No Patient Left Behind: A Novel Paradigm to Fulfill Hepatitis C Virus Treatment for Rural Patients.

Background: This study evaluates a novel multidisciplinary program providing expanded access to hepatitis C virus (HCV) treatment for rural Appalachian patients in South Carolina. This program identified patients via an opt-out emergency department screening program, and it aimed to achieve HCV cure by using community paramedics (CPs) to link and monitor patients from treatment initiation through 12-week sustained virologic response (SVR). Methods: Patients aged ≥18 years who were HCV RNA positive were eligible for enrollment if they failed to appear for a scheduled HCV appointment or reported barriers to accessing office-based treatment. CPs provided home visits (initial and 4, 12, and 24 weeks) using a mobile Wi-Fi hotspot to support telemedicine appointments (compliant with the Health Insurance Portability and Accountability Act) and perform focused physical assessments, venipuncture, and coordinated home delivery of medications. Statistics described participant characteristics, prevalence of SVR, and patient satisfaction results at 12 weeks posttreatment. Results: Thirty-four patients were eligible for SVR laboratory tests by 31 August 2023; the majority were male (61.7%) and White (64.7%) with an average age of 56 years (SD, 11.7). Twenty-eight (82.4%) completed treatment and achieved 12-week SVR. Six (17.6%) were lost to follow-up. Two-thirds strongly agreed that they were satisfied with the overall care that they received, and half strongly agreed that their overall health had improved. Conclusions: This CP-augmented treatment program demonstrated success curing HCV for rural patients who lacked access to office-based treatment. Other health care systems may consider this novel delivery model to treat hard-to-reach individuals who are HCV positive.

Recovery Barrier Characterizations by Hospitalized Patients with Substance Use Disorders: Results from a Randomized Clinical Study on Inpatient Peer Recovery Coaching.

Patients hospitalized with medical complications from substance use disorder (SUD) encounter unique health problems that may complicate their recovery. Recovery barriers are not well understood in this population. The study objective is to characterize recovery barriers in this patient population. Participants (n = 96) in this six-month longitudinal study were randomized to a peer recovery coaching intervention or standard of care. The primary outcome measures were qualitative, open-ended questions addressing factors interfering with participants' recovery. Data were analyzed using content analysis. Themes were identified a priori using past research on recovery capital domains; these seven barriers were (1) psychological health difficulties, (2) physical health challenges, (3) lack of social support, (4) insufficient treatment or recovery support to maintain sobriety, (5) environmental and housing concerns, (6) deficits in coping skills, and (7) lack of meaningful activities. At baseline, the most common recovery barriers were in the environment and housing (28.1%), psychological health (27.1%), and social support (22.9%) domains. At six-month follow-up, participants were asked to describe barriers they felt they had made improvement in over the last six months. The primary themes that participants reported improvements in were treatment and recovery support to maintain sobriety (52.1%), coping skills (35.4%), and social support (27.1%). Hospitalization and participation in a randomized controlled trial may be a turning point in which to address recovery barriers for patients hospitalized with complications from SUD.

Detection of Mpox Virus Using Microbial Cell-Free DNA: The Potential of Pathogen-Agnostic Sequencing for Rapid Identification of Emerging Pathogens.

BACKGROUND: The 2022 global outbreak of Monkeypox virus (MPXV) highlighted challenges with polymerase chain reaction detection as divergent strains emerged and atypical presentations limited the applicability of swab sampling. Recommended testing in the United States requires a swab of lesions, which arise late in infection and may be unrecognized. We present MPXV detections using plasma microbial cell-free DNA (mcfDNA) sequencing. METHODS: Fifteen plasma samples from 12 case-patients were characterized through mcfDNA sequencing. Assay performance was confirmed through in silico inclusivity and exclusivity assessments. MPXV isolates were genotyped using mcfDNA, and phylodynamic information was imputed using publicly available sequences. RESULTS: MPXV mcfDNA was detected in 12 case-patients. Mpox was not suspected in 5, with 1 having documented resolution of mpox >6 months previously. Six had moderate to severe mpox, supported by high MPXV mcfDNA concentrations; 4 died. In 7 case-patients, mcfDNA sequencing detected coinfections. Genotyping by mcfDNA sequencing identified 22 MPXV mutations at 10 genomic loci in 9 case-patients. Consistent with variation observed in the 2022 outbreak, 21 of 22 variants were G > A/C > T. Phylogenetic analyses imputed isolates to sublineages arising at different time points and from different geographic locations. CONCLUSIONS: We demonstrate the potential of plasma mcfDNA sequencing to detect, quantify, and, for acute infections with high sequencing coverage, subtype MPXV using a single noninvasive test. Sequencing plasma mcfDNA may augment existing mpox testing in vulnerable patient populations or in patients with atypical symptoms or unrecognized mpox. Strain type information may supplement disease surveillance and facilitate tracking emerging pathogens.

Implementation of a mobile health clinic framework for Hepatitis C virus screening and treatment: a descriptive study.

Background: Although treatment for Hepatitis C Virus (HCV) is effective, individuals face access barriers. The utility of mobile health clinics (MHC), effective mechanisms for providing healthcare to underserved populations, is understudied for HCV-related interventions. We aimed to describe implementation of, and factors associated with, screening and treatment via MHCs. Methods: Clemson Rural Health implemented a novel MHC program to reach and treat populations at-risk for HCV with a focus on care for uninsured individuals. We examined HCV screening and treatment initiation/completion indicators between May 2021 and January 2023. Findings: Among 607 individuals screened across 31 locations, 94 (15.5%) tested positive via antibody and viral load testing. Treatment initiation and completion rates were 49.6% and 86.0%, respectively. Among those screened, the majority were male (57.5%), White (61.3%; Black/Hispanic: 28.2%/7.7%), and without personal vehicle as primary transportation mode (54.4%). Injection drug use (IDU) was 27.2% and uninsured rate was 42.8%. Compared to HCV-negative, those infected included more individuals aged 30-44 (52.1% vs. 36.4%, p = 0.023), male (70.2% vs. 55.2%, p = 0.009), White (78.5% vs. 60.2%, p < 0.0001), without personal vehicle (58.5% vs. 43.5%, p = 0.028), IDU (83.7% vs. 21.0%, p < 0.0001), and uninsured (61.2% vs. 48.8%, p = 0.050). Uninsured rates were higher among those initiating compared to not initiating treatment (74.5% vs. 45.3%, p = 0.004). Interpretation: The MHC framework successfully reaching its target population: at-risk individuals with access barriers to healthcare. The high HCV screening and treatment initiation/completion rates demonstrate the utility of MHCs as effective and acceptable intervention settings among historically difficult-to-treat populations. Funding: Gilead Sciences, Inc., and SC Center for Rural and Primary Healthcare.

Inpatient Low-dose Transitions From Full Agonist Opioids Including Methadone Onto Long-acting Depot Buprenorphine: Case Series From a Multicenter Clinical Trial.

OBJECTIVES: Persons with opioid use disorder (OUD) suffer disproportionately from morbidity and mortality related to serious addiction-related infections requiring hospitalization. Long-acting buprenorphine (LAB) is an underused medication for OUD that may facilitate linkage to care and treatment retention when administered before hospital discharge. Transition onto buprenorphine in the inpatient setting is often complicated by pain, active infection management, potential surgical interventions, and risk of opioid withdrawal in transition from full agonists to a partial agonist. METHODS: The COMMIT Trial is a randomized controlled trial evaluating LAB administered by infectious disease physicians and hospitalists compared with treatment as usual for persons with OUD hospitalized with infections. We report a case series of participants on full agonist opioids including methadone who were transitioned to sublingual buprenorphine using low-dose ( microdosing ) strategies followed by LAB injection. RESULTS: Seven participants with current opioid use disorder and life-threatening infections, all with significant concurrent pain and many requiring surgical intervention, underwent low-dose transitions starting at buccal buprenorphine doses ranging from 225 µg to 300 µg 3 times a day on the first day. All were well tolerated with average time to LAB injection of 7.5 days (range, 5-10 days). CONCLUSIONS: Inpatient low-dose buprenorphine transition from full agonist opioids including methadone onto LAB is feasible even in those with complex hospitalizations for concurrent infections and/or surgery. This strategy facilitates dosing of LAB before hospital discharge when risk of opioid relapse and overdose are significant.

Using Community Paramedicine to Treat Hepatitis C Virus in Upstate South Carolina.

OBJECTIVES: Hepatitis C virus (HCV) is an infection of the liver that can lead to significant liver damage and hepatocellular carcinoma. Individuals born between 1945 and 1965 and individuals with intravenous drug use represent the largest HCV demographics and often experience barriers to treatment. In this case series, we discuss a novel partnership between community paramedics (CPs), HCV care coordinators, and an infectious disease physician to provide HCV treatment to individuals with barriers accessing care. METHODS: Three patients tested positive for HCV within a large hospital system in the upstate region of South Carolina. All of the patients were contacted to discuss their results and scheduled for treatment by the hospital's HCV care coordination team. Patients who expressed barriers to attending in-person appointments or were lost to follow-up were offered a telehealth appointment facilitated by CPs performing a home visit with the added ability to draw blood and perform a physical assessment guided by the infectious disease physician. All of the patients were eligible for and prescribed treatment. The CPs assisted with follow-up visits, blood draws, and other patient needs. RESULTS: Two of the three patients connected to care had an undetectable HCV viral load following 4 weeks of treatment, whereas the third was undetectable after 8 weeks. Only one patient reported a mild headache that was potentially linked to the medication, whereas the others did not report any adverse effects. CONCLUSIONS: This case series highlights the barriers experienced by some HCV-positive patients and a distinctive plan to address impediments to access for HCV treatment.

Missed opportunities for diagnosis of HIV in the emergency department using non-risk-based testing strategy.

Objectives: The objective of this study was to identify the number of missed opportunities (MO) for human immunodeficiency virus (HIV) diagnoses within our emergency departments (EDs) and assess any significant associated patient characteristics. Following current Centers for Disease Control guidelines, an opt-out HIV screening program was implemented in 2 of 7 EDs within a large Southern healthcare system. This study sought to differentiate the risk of MO in opt-out compared to clinician-initiated, risk-based ED screening protocols. Methods: A retrospective analysis was conducted from August 2019 to March 2022 of adult patients (≥18 years old) screened for HIV, comparing the ED screening method and characterization of all MOs. MO was defined as any ED visit, before HIV seropositivity, that included sexually transmitted infection screening and/or treatment with no HIV screening. Two EDs implemented generalized opt-out screening for all adult patients (>18 years old); whereas, the remaining 5 sites relied on clinician-initiated screening. Patient characteristics associated with an MO were evaluated by χ2, t tests, and multivariable logistic regression. Results: In total, 19,423 patients were screened for HIV, 142 of who tested positive. Of the 142 HIV-positive individuals, 12 (8.5%) had 1 MO and 3 of 12 (25%) had 2. The proportion of patients with a MO was significantly higher at clinician-initiated EDs as compared opt-out EDs (41.7% vs 13.9%, P = 0.01). After adjusting for demographics, individuals seen at clinician-initiated EDs were more likely to have a MO compared opt-out EDs (adjusted odds ratio, 4.64; 95% confidence interval, 1.18-18.27; P = 0.02). Conclusion: This novel study highlights the success and overall high positivity (0.7%) of an ED-based opt-out screening program. Taken together, the implementation of generalized opt-out screening within a large Southern healthcare system can rapidly increase overall screening, uncover a surprisingly high positivity rate, and decrease MOs for HIV diagnosis.

HIV Pre-Exposure Prophylaxis in the Emergency Department: A Systematic Review.

STUDY OBJECTIVE: Many emergency departments (EDs) have identified the importance of HIV prevention and have implemented steps to screen and offer preexposure prophylaxis (PrEP). The objective of this study was to systematically review existing literature that identifies PrEP eligibility in the ED and summarize outcomes along the PrEP cascade of care (awareness, interest, linkage to treatment, initiation, and retention) for patients in ED. METHODS: Four databases captured all PrEP-related studies in EDs from January 1, 2013 to January 27, 2022. Data were extracted on study characteristics and outcomes, and study quality was assessed using a modified quality assessment tool by the Effective Public Health Practice Project. RESULTS: Of the 218 articles, 16 were subjected to full-text review, and 7 met inclusion criteria. Although most studies identified patients who were PrEP eligible using criteria adapted from the 2017 Centers for Disease Control and Prevention PrEP guidelines, the number and time frame for each criterion varied. Six studies reported outcomes on the PrEP cascade of care, showing a relatively high prevalence of awareness and interest but a very low prevalence of linkage and uptake. No studies documented retention in PrEP treatment. CONCLUSION: Although up to a third of patients in ED assessed in the current study were PrEP eligible, less than half of PrEP-eligible participants had prior knowledge of PrEP, and very few who expressed interest in the ED were ultimately linked to PrEP treatment or initiated PrEP. Future research is necessary to identify strategies to increase PrEP education, interest, and linkage to care from the ED.

Examining Internalizing Mental Health Correlates of Addiction Severity in Patients Hospitalized With Medical Complications From Substance Use Disorder.

Background: Comorbidities between Substance Use Disorder (SUD) and mental health disorders are highly prevalent, yet there remains a lack of information regarding how mental health conditions may affect addiction severity. Consequently, this study sought to investigate the relationship between internalizing disorders (anxiety and mood disorders) and addiction severity in patients hospitalized for SUD-related medical complications. Individual difference predictors and history of prior treatment for SUD were also examined. Methods: Participants (N = 200) were hospitalized patients who consented to receive peer-based recovery support services for their SUD. To be eligible for the study, participants needed to have a SUD diagnosis due to alcohol, opioids, methamphetamine, cocaine, or a combination of these substances (polysubstance use). Participants completed self-report questionnaires regarding demographics, mental health history, prior SUD treatment, and addiction severity (Drug and Alcohol Screening Test; DAST-10) during their hospitalization. Results: Results showed that patients with Generalized Anxiety Disorder (GAD) (M = 6.68, SD = 2.97) had greater addiction severity compared to those without GAD (M = 5.41, SD = 3.34), P = .016. Addiction severity results stratified by SUD type showed that the relationship was significant among patients with Alcohol Use Disorder (P = .014), but not among those with other SUD types (Ps > .27). Major Depressive Disorder (MDD) and Post-Traumatic Stress Disorder (PTSD) were not linked to addiction severity. Among those with GAD, 81.4% had previously been to treatment compared to only 53.1% of those without GAD, P = .010. The only participant characteristic linked with addiction severity was insurance status. Conclusions: GAD may represent a risk factor for advanced alcohol addiction trajectories, including greater addiction severity and severe health complications requiring inpatient hospitalization.

Changes in alcohol use during hepatitis C treatment in persons who inject drugs.

People who inject drugs (PWID) are a vulnerable population at high risk for acquiring hepatitis C virus (HCV) and frequently suffer from comorbid alcohol use. This study examines the characteristics and correlates of alcohol use among study participants, the association between alcohol consumption and sustained virologic response (SVR) in patients receiving HCV treatment, changes in drinking behaviours during HCV treatment and associations of drinking over time with specific models of HCV treatment. Participants were 150 PWID with HCV who were receiving opioid agonist therapy (OAT) and enrolled in a randomized clinical trial exploring the effectiveness of three models of care for HCV treatment. The addiction severity index was the primary measure of alcohol consumption. Days of alcohol intake were evaluated longitudinally and across three treatment groups. At baseline, 31% (47/150) reported having at least one drink in the last 30 days including 24% (36/150) who reported drinking to intoxication in the last 30 days. There was no difference in SVR rates between groups. There was a significant decrease in overall days of drinking from baseline (7.78 ± 7.86) to follow-up at Week 24 (5.78 ± 8.83) (p = 0.041), but there were no significant changes among those who drank to intoxication; modified directly observed therapy (mDOT) was the only group with a significant decline in days of alcohol consumption (p = 0.041). In this cohort of PWID on OAT, baseline alcohol consumption did not affect SVR rates. HCV treatment was overall associated with decreased alcohol consumption. In particular, mDOT was associated with decreased alcohol consumption. Given the additive effect of alcohol and HCV on the development of cirrhosis, studies should be done to investigate the complimentary effects of the mDOT model of care on alcohol cessation.

Acute Care Utilization After Recovery Coaching Linkage During Substance-Related Inpatient Admission: Results of Two Randomized Controlled Trials.

BACKGROUND: For patients with substance use disorder (SUD), a peer recovery coach (PRC) intervention increases engagement in recovery services; effective support services interventions have occasionally demonstrated cost savings through decreased acute care utilization. OBJECTIVE: Examine effect of PRCs on acute care utilization. DESIGN: Combined results of 2 parallel 1:1 randomized controlled trials. PARTICIPANTS: Inpatient adults with substance use disorder INTERVENTIONS: Inpatient PRC linkage and follow-up contact for 6 months vs usual care (providing contact information for SUD resources and PRCs) MAIN MEASURES: Acute care encounters (emergency and inpatient) 6 months before and after enrollment; encounter type by primary diagnosis code category (mental/behavioral vs medical); 30-day readmissions with Lace+ readmission risk scores. KEY RESULTS: A total of 193 patients were randomized: 95 PRC; 98 control. In the PRC intervention, 66 patients had a pre-enrollment acute care encounter and 56 had an encounter post-enrollment, compared to the control group with 59 pre- and 62 post-enrollment (odds ratio [OR] = -0.79, P = 0.11); there was no significant effect for sub-groups by encounter location (emergency vs inpatient). There was a significant decrease in mental/behavioral ED visits (PRC: pre-enrollment 17 vs post-enrollment 10; control: pre-enrollment 13 vs post-enrollment 16 (OR = -2.62, P = 0.02)) but not mental/behavioral inpatient encounters or medical emergency or inpatient encounters. There was no significant difference in 30-day readmissions corrected for Lace+ scores (15.8% PRC vs 17.3% control, OR = 0.19, P = 0.65). CONCLUSIONS: PRCs did not decrease overall acute care utilization but may decrease emergency encounters related to substance use. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04098601, NCT04098614).

HIV Preexposure Prophylaxis Care Continuum Among Individuals Receiving Medication for Opioid Use Disorder, South Carolina, 2020-2021.

We implemented the HIV preexposure prophylaxis (PrEP) care continuum among individuals receiving medication for opioid use disorder (MOUD). We screened HIV-negative MOUD participants for PrEP eligibility by assessing injection drug use risk factors and sexual behaviors. Implementation of the PrEP care continuum was challenging; less than a third of MOUD participants were aware of PrEP, and very few initiated PrEP. Findings should promote the development of effective interventions to increase engagement in PrEP during MOUD treatment. (Am J Public Health. 2022;112(1):34-37. https://doi.org/10.2105/AJPH.2021.306566).

Case Series of Three Patients with Disseminated Gonococcal Infection and Endocarditis.

INTRODUCTION: The increasing incidence of Neisseria gonorrhoeae infections and emergence of cephalosporin-resistant strains means the threat of disseminated gonococcal infection and endocarditis needs to be reimagined into the differential diagnosis for patients treated in the emergency department (ED) for sexually transmitted infections and for endocarditis itself. Only 70 cases of disseminated gonococcal infection (DGI) with endocarditis had been reported through 2014.1-4 In 2019, however, an outbreak of DGI with one case of endocarditis was reported.5 This case series of three patients with DGI and endocarditis, in addition to the recent outbreak, may represent a warning sign for reemergence of this threat. CASE REPORT: We describe three cases within a recent three-year period of gonococcal endocarditis as seen and treated at our institution. These cases show divergent presentations of this insidious disease with both classical and atypical features. One case displayed a classic migratory rash with positive urine testing and a remote history of sexually transmitted infections, while another patient developed isolated culture-confirmed endocarditis with negative cervical testing and imaging, and the final case was a male patient who presented to the ED with fulminant endocarditis as the first ED presentation of infection. CONCLUSION: Secondary to an overall rise in incidence and possibly due to increasing antibiotic-resistance patterns, gonococcal endocarditis should be included in the differential diagnosis of any case of endocarditis. Reciprocally, increased vigilance should surround the evaluation of any patient for sexually transmitted diseases while in the ED for both the development of DGI and endocarditis.

Design and methods of a multi-site randomized controlled trial of an integrated care model of long-acting injectable buprenorphine with infectious disease treatment among persons hospitalized with infections and opioid use disorder.

BACKGROUND: Hospitalization with co-occurring opioid use disorder (OUD) and infections presents a critical time to intervene to improve outcomes for these intertwined epidemics that are typically managed separately. A surge in life-threatening infectious diseases associated with injection drug use, including bacterial and fungal infections, HIV, and HCV accounts for substantial healthcare utilization, morbidity, and mortality. Infectious Disease (ID) specialists manage severe infections that require hospitalization and are a logical resource to engage patients in medication treatment for OUD (MOUD). An injectable long-acting monthly formulation of buprenorphine (LAB) has a potential advantage for initiating MOUD within hospital settings and bridging to treatment after discharge. METHODS: A randomized multi-site trial tests a new model of care (ID/LAB) in which OUD and infections are managed by ID specialists and hospitalists using LAB coupled with referrals to community resources for long-term MOUD. A sample of 200 adults admitted to three U.S. hospitals for OUD and infections are randomly assigned 1:1 to ID/LAB or treatment as usual (TAU). The primary outcome measure is the proportion of patients enrolled in effective MOUD at 12 weeks after randomization. Secondary outcomes include relapse to opioid use, adherence to infectious disease treatment, infection morbidity and mortality, and drug overdose. RESULTS: We describe the design, procedures, statistical analysis, and early implementation issues of this randomized trial. CONCLUSIONS: Study findings will provide insight into the feasibility and effectiveness of integrated treatment of OUD and serious infections and have the potential to reduce morbidity and mortality in this vulnerable population.

Leveraging Public and Private Funding to Implement Opt-out HIV Screening Programs in Rural and Urban Emergency Departments in South Carolina Discovered a High Rate of Human Immunodeficiency Virus (HIV) Infection in Black Patients.

The new epicenter of the ongoing HIV epidemic in the United States is the South. Specifically, South Carolina (SC) is listed a priority state as part of the CDC's Ending the Epidemic Plan for America. A novel opt-out HIV screening program was implemented in one rural and one urban Emergency Department (ED) within a large SC health system. Leveraging both public and private funding sources, which made both the testing and linkage processes cost neutral, ED based screening was provided for 2304 Black patients which represents an 44% increase. As part of this screening program a total of 50 individuals were linked to care of which 29 were Black. The rate of HIV positivity for Black patients using this ED based screening program was nearly double that of the baseline health system screening. This program's utilization of the health system electronic health record (EHR) and funding from various sources may provide a model for legislative and public health entities to combat the HIV epidemic in the South.

Isolated COVID-19 Infection Precipitates Myasthenia Gravis Crisis: A Case Report.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has spread around the world and caused hundreds of thousands of fatalities across a wide spectrum of patients with varying severity and presenting complaints. The discussion of the ability of this disease to cause significant illness in patients with various risk factors such as myasthenia gravis is important to help guide physicians on recognition and treatment options as the pandemic matures. CASE REPORT: Here we discuss a single case of isolated COVID-19 infection that precipitated a myasthenic crisis with no other clinical sequelae in a patient who presented to the emergency department (ED). This report highlights some of the initial difficulties and delay in diagnosis encountered earlier in the pandemic with limited testing supplies and processing labs; however, prompt ED recognition and treatment still led to a favorable outcome. CONCLUSION: The patient recovered during this initial presentation and was successfully treated with plasma exchange and steroids only. It is important to recognize that myasthenia gravis patients may represent a uniquely vulnerable population that requires enhanced surveillance and screening to prevent significant morbidity and mortality. This case describes how even a mild infection with no significant clinical sequelae or significant signs on imaging studied can precipitate a crisis event.

Inpatient link to peer recovery coaching: Results from a pilot randomized control trial.

BACKGROUND: Few individuals hospitalized with Substance Use Disorder (SUD) complications participate in recovery support services after discharge. Peer recovery coaching represents one potential new method for promoting recovery. METHODS: A six-month prospective randomized controlled trial compared outcomes between the standard of care and a physician-initiated recovery coaching intervention. The primary outcome measure was engagement in recovery support services, and the secondary outcome measures were substance use frequency and self-reported physical and mental health using the SF-12 survey. Participants (N = 98) were eligible if they were identified by a healthcare provider as having a SUD and were hospitalized due to SUD complications. RESULTS: Engagement rate over the six-month post-discharge time period was higher for participants in the recovery coaching intervention (84 %, 95 % CI: 78%-91%) compared to the standard of care control condition (34 %, 95 % CI: 25 %-44 %), log OR = 28.59, p < .001. No overall group differences in substance use frequency (p = .80), self-reported physical (p = .69) or mental (p = .89) health were observed. CONCLUSION: An inpatient linkage to recovery coaching services improves engagement rates and can feasibly be implemented in a single-center inpatient service. This intervention is promising for promoting both short-term and long-term engagement in recovery support services.

Factors associated with mortality in febrile patients in a government referral hospital in the Kenema district of Sierra Leone.

There is a paucity of data on the etiologies and outcomes of febrile illness in rural Sierra Leone, especially in the Lassa-endemic district of Kenema. We conducted a retrospective study of patients with subjective or documented fever (T ≥ 38.0°C) who were admitted to a rural tertiary care hospital in Kenema between November 1, 2011 and October 31, 2012. Of 854 patients admitted during the study period, 429 (50.2%) patients had fever on admission. The most common diagnoses were malaria (27.3%), pneumonia (5.1%), and Lassa fever (4.9%). However, 53.4% of febrile patients had no diagnosis at discharge. The in-hospital mortality rate was 18.9% and associated with documented temperature ≥ 38.0°C (adjusted odds ratio [AOR] = 2.89, P = 0.001) and lack of diagnosis at discharge (AOR = 2.04, P = 0.03). Failure to diagnose the majority of febrile adults and its association with increased mortality highlight the need for improved diagnostic capacity to improve patient outcomes.