Referral Treatment Research Articles

Clinical pattern and burden of strabismus in a teaching institute of Northeast India

ABSTRACT Purpose: To determine the clinical pattern and burden of strabismus in a teaching institute of Northeast (NE) India. Methods: In this hospital-based, cross-sectional study, detailed clinical evaluation of patients with manifest strabismus was carried out for a period of one and half years. Results: Out of the 7222 new outpatient department attendances, a total of 110 new patients with manifest strabismus were found, with a hospital-based burden of 1.52% [95% confidence interval: 1.3–1.8]. Comitant strabismus was seen in 84.55%, and incomitant in 15.45%. Exotropia comprised 70%, esotropia 26.36%, hypertropia 10%, and hypotropia 2.72%. The angle of deviation was large in most of the participants (69.09%) with a mean of 34.90 ± 17.08 PD for horizontal and 13.29 ± 8.97 PD for vertical deviations. A cause of strabismus could be identified in 30.91%. Paralytic strabismus was seen in 15.45%, sensory in 11.82%, infantile in 1.82%, and accommodative in 1.82%. Amblyopia was found in 5.45%. In our study, 25.45% patients underwent strabismus surgery, while 74.55% patients either needed conservative management or were being worked up for surgery till the end of this study. Conclusion: This study determined the pattern and burden of strabismus in a teaching institute of NE India. Since the institute caters to patients from different states of NE India, this study gives an indirect picture of the burden of strabismus of the whole of NE India. It is hoped that these data will aid in determining the overall burden of strabismus in the country. They will also help the family medicine and primary care physicians to have an idea about the burden and pattern of strabismus in the community, thus enabling them to create awareness about strabismus, remove the undue apprehensions of patients, and do timely referrals for treatment and prevent irreversible visual loss.

Referrals and Black-White Coronary Heart Disease Treatment Disparities: A Qualitative Study of Primary Care Physician Perspectives.

Black-White coronary heart disease (CHD) treatment disparities are well documented, especially regarding the use of high-quality hospitals. Physician referral networks may play a role. To understand how primary care physicians (PCPs) make specialty referrals for CHD treatment and how referrals may contribute to treatment disparities. Qualitative study using semi-structured interviews and focus group discussions. We purposively recruited 45 PCPs (50 invited, 90% response rate) in three metro areas with high Black-White segregation of cardiac care networks (New York City; Chicago; Atlanta). We developed the focus group discussion guide from interviews and current literature. We conducted two focus groups per metro area via Zoom. Two expert team members independently coded the transcripts using inductive techniques and analyzed focus group content and themes using Dedoose. Most participants were male (62.2%), White (57.8%), and practiced for at least 23years. We identified several recurrent themes for factors influencing cardiology referrals. The most frequently mentioned themes were heavy reliance on professional networks, specialist availability, timeliness, communication style, patient geographic and economic constraints, and patient preferences. PCPs used anecdotal and not data-driven evidence to assess hospital quality and viewed Black-White differences in high-quality hospital use as due to patient economic status and preferences or differences in hospital access and provider referral bias. PCPs' referral decisions for CHD treatment are primarily driven by access to specific professional networks and the socioeconomic circumstances of their patients. Nevertheless, PCPs strive to make the best available decisions, leaning into their networks and honoring patient preferences. While PCPs acknowledged existing disparities, they attributed them to patient and system factors rather than provider referral bias. Mitigating disparities will require interventions to improve minority-serving providers' formal and informal connections with high-quality specialists and hospitals, address patient socioeconomic constraints, and train providers to recognize their potential biases and misconceptions.

Exploring the feasibility of Recovery Management Checkups for Primary Care in a Federally Qualified Health Center.

Primary care settings present an opportunity for alcohol and substance use disorder (A/SUD) screening and treatment referral. However, there are recognized deficiencies in widely used treatment referral approaches, including acute care connections, vs. those that can support longer-term recovery. Recovery Management Checkups for Primary Care (RMC-PC) is an intervention with an evidence base for improving treatment referral and subsequent recovery for primary care patients; however, the intervention has never been fully implemented outside of a research context. We conducted a feasibility study to inform a future hybrid study of RMC-PC that will test the implementation and effectiveness of the intervention in primary care practice. We used a convergent mixed method design. The study's setting was a Federally Qualified Health Center (FQHC) located in a large midwestern city. RMC-PC linkage services were administered by one of two treatment linkage managers: an FQHC linkage manager (F-LM) and a research staff linkage manager (R-LM). Quantitative data included (a) rates of positive A/SUD screening among a group of FQHC patients and (b) linkage manager service data (e.g., rate of successful meeting completion and days to completing of key events). Qualitative data included (c) an assessment of linkage manager's motivational interviewing performance and (d) a focus group with FQHC staff focused on their perspectives on RMC-PC implementation determinants. Quantitative data were summarized using descriptive statistics, and linkage manager performance was compared. Qualitative data were analyzed using a hybrid deductive-inductive process. Fifty percent of patients screened met moderate-high A/SUD risk. Eleven of 16 recruited patients completed at least one linkage manager meeting, with 63% completing both meetings. The F-LM delivered RMC-PC services alongside other duties successfully; however, three primary barriers to FQHC implementation were identified (difficulties applying motivational interviewing, incompatibilities of screening with FQHC technology and workflow, and lack of billing mechanism to support services). RMC-PC is feasible for FQHC staff to deliver, though issues identified must be considered to ensure successful and sustainable implementation. Knowledge gained will inform a packaged implementation strategy that will be used in a future hybrid trial.

An Urgent Need to Promote Equitable Buprenorphine Administration for Opioid Use Disorder in the Emergency Department.

In recent years, there has been a marked surge in opioid overdose deaths among Black, Latino, and Native American populations. The emergency department (ED) represents a crucial opportunity to address these racial and ethnic inequities by initiating buprenorphine and providing referral for ongoing addiction treatment. Yet Black, Latino, and Native American populations encounter substantial inequities in ED-based addiction treatment access. Within this context, Koeber et al conducted their cross-sectional study of ED patients who screened positive for opioid misuse to evaluate inequities in buprenorphine administration. The authors found that Black ED patients were less likely (odds ratio, 0.56; 95% confidence interval, 0.35-0.88) to receive buprenorphine. There is an urgent need for mixed methods research to understand the drivers of these inequities and interventions to address the multilevel factors across the opioid use disorder care continuum to promote equitable, accessible, person-centered opioid use disorder treatment.

Changes in legal referrals to specialty substance use disorder treatment from 2015–2019

BackgroundThe policy landscape around substance use has changed dramatically in the past decade, which may have affected the number and characteristics of treatment episodes for substance use disorder (SUD). In this study, we examine changes in the volume of SUD treatment referrals from the legal system and compare changes in the composition of substances used by referral source. We used publicly available discharge data on specialty SUD treatment episodes in the U.S. from 2015–2019 and included episodes involving adults that are discharged from specialty SUD treatment facilities during the study. We calculated descriptive statistics of specialty SUD treatment discharges in each year and aggregated across all years by referral source and substance(s) reported upon admission. To test differences by year and referral source, we conducted z-tests of proportions.ResultsThe proportion of referrals to specialty SUD treatment from the legal system declined between 2015 and 2019 (p < 0.001). However, referrals from probation/parole and diversionary programs grew over time (p < 0.001) in number and proportion over time. Legal referrals were most often associated with alcohol or cannabis use, though referrals for these substances declined from 2015–2019.ConclusionsThis research lays the groundwork for future investigations to evaluate the effect of important policy changes on referral sources to specialty SUD treatment and the quality and outcomes associated with referrals to treatment from the legal system.

Certificate in Advanced Behavioral Interventions Among Multiple Populations

This manuscript describes the curricular and instructional approaches utilized in the composition and delivery of the Certificate in Advanced Behavioral Interventions Among Multiple Populations (CABISAM) created by the School of Social Work at Loyola University Chicago. CABISAM is a social work led interprofessional education (IPE) model where students from social work, nursing, and medicine engage in didactic and experiential activities to advance clinical and leadership knowledge of interprofessional approaches to screening, brief intervention, and referral for treatment (SBIRT) with diverse populations. An interprofessional team of faculty from each discipline was involved throughout the development and planning process to consider accreditation, cultural, and logistical issues unique to each profession. CABISAM engages students in an evidenced-based interprofessional education (IPE) experience with exposure to cutting-edge topics relevant to health professionals: training in interprofessional practice, substance use in unique settings with diverse populations, and clinical implementation skills. This manuscript presents an adaptable and generalizable interprofessional education approach to other undergraduate and graduate programs across disciplines.

Optimizing Colorectal Screening in Portugal with Process Mining

Abstract Background Efficient healthcare screening programs management influences patient outcomes. Process mining has emerged as a powerful tool to enhance these programs by refining complex workflows and pinpointing operational deviations. Objectives This study utilizes process mining techniques to analyze the colorectal cancer screening program in Northern Portugal, focusing on detecting deviations and performance bottlenecks in process models. Methods This screening program started in March 2018, but process mining was only used on data posterior to 2020. Over 1 million case observations from administrative data were included in the process model analysis, involving more than six key process activities and numerous resources. We used new software and statistical tools for process mining to rapidly compute observations and filter for different operational needs and monitor interventions. Results The discovery analysis identified deviations, such as unexpected performance issues and irregular activity sequences. Although over 100 traces were identified, fewer than five traces accounted for more than 90% of all case paths, indicating the most common traces that have a true impact in participation rates, referral rates, and treatment rates. Notable differences in resource performance during specific periods, such as COVID-19 or seasonal events, were also observed. These findings provided insights for adjusting resource allocation and improving coordination, with impact in minimizing seasonal phenomena or peak production periods. Lessons Process mining offers actionable insights for effective health program coordination, enabling the monitoring and timely response to process deviations. With key areas for action identified in a more timely and precise manner, we can enhance efficiency, and expand population coverage and treatment referral. Future initiatives will focus on further process optimization and national coverage expansion using these management tools. Key messages • Process mining revolutionizes healthcare by enabling the strategic management of complex oncological screening program workflows. • Comprehensive data analysis across the patient pathway enhances program efficiency and expands treatment access.

The TELEhealth Shared decision-making COaching and navigation in Primary carE (TELESCOPE) intervention: a study protocol for delivering shared decision-making for lung cancer screening by patient navigators.

Lung cancer screening (LCS) can reduce lung cancer mortality but has potential harms for patients. A shared decision-making (SDM) conversation about LCS is required by the Centers for Medicare & Medicaid Services (CMS) for LCS reimbursement. To overcome barriers to SDM in primary care, this protocol describes a telehealth decision coaching and navigationintervention for LCS in primary care clinics delivered by patient navigators. The objective of the study is to evaluate the effectiveness of the intervention and its implementation potential, compared with an enhanced usual care (EUC) arm. Patients (n = 420) of primary care clinicians (n = 120) are being recruited to a cluster randomized controlled trial. Clinicians are randomly assigned to 1) TELESCOPE intervention: prior to an upcoming non-acute clinic visit, patients participate in a telehealth decision coaching and navigationsession about LCS delivered by trained patient navigators and nurse navigators place a low-dose CT scan (LDCT) order for each TELESCOPE patient wanting LCS, or 2) EUC: patients receive enhanced usual care from a clinician. Usual care is enhanced by providing clinicians in both arms with access to a Continuing Medical Education (CME) webinar about LCS and an LCS discussion guide. Patients complete surveys at baseline and 1-week after the scheduled clinic visit to assess quality of the SDM process. Re-navigation is attempted with TELESCOPE patients who have not completed the LDCT within 3months. One month before being due for an annual screening, TELESCOPE patients whose initial LCS showed low-risk findings are randomly assigned to receive a telehealth decision coaching booster session with a navigator or no booster. Electronic health records are abstracted at 6, 12 and 18months after the initial decision coaching session (TELESCOPE) or clinic visit (EUC) to assess initial and annual LCS uptake, imaging results, follow-up testing for abnormal findings, cancer diagnoses, treatment, and tobacco treatment referrals. This study will evaluate factors that facilitate or interfere with program implementation using mixed methods. We will assess whether a decision coaching and patient navigation intervention can feasibly and effectivelysupport high-quality SDM for LCS and guideline-concordant LCS uptake for patients in busy primary care practices serving diverse patient populations. This study was registered at ClinicalTrials.gov (NCT05491213) on August 4, 2022. Version 1, April 10, 2024.

Controversies in our understanding of extreme hyperbilirubinemia in glucose-6-phosphate dehydrogenase-deficient neonates.

Despite declarations that kernicterus should be a "never-event", the condition continues to occur, glucose-6-phosphate dehydrogenase (G6PD)-deficiency being a leading cause. In this paper, we address some controversies regarding the pathophysiology and the potential for extreme hyperbilirubinemia associated with G6PD-deficiency. We present evidence to demonstrate that G6PD-deficiency-associated neonatal hyperbilirubinemia is no longer limited to countries and geographic regions to which the condition was indigenous, but is also encountered in North America and other Western countries with a low inherent G6PD-deficiency frequency. Pathophysiologically, while a diminished bilirubin conjugative component is undoubtedly present, we present evidence that there is a component of increased hemolysis as well, contributing to the extreme, exponential hyperbilirubinemia associated with G6PD-deficiency. Extreme hyperbilirubinemia in G6PD heterozygotes, while less frequent than in male hemizygotes or female deficient homozygotes, has been reported, suggesting previous underestimation of the risks of heterozygosity. Universal neonatal screening for G6PD-deficiency, while not expected to prevent acute, episodic hyperbilirubinemia, should increase awareness, thereby facilitating earlier referral for treatment, prior to the onset of bilirubin encephalopathy. Finally, we speculate as to what the future looks like for babies with G6PD-deficiency, potential therapeutic stratagems, and the effect of G6PD-deficiency on medical conditions beyond the realm of neonatal hyperbilirubinemia. IMPACT STATEMENTS: G6PD-deficiency is encountered in North America and Western countries previously thought to have a low frequency of the condition. Extreme, sudden neonatal hyperbilirubinemia is due, in the main, to increased hemolysis, an independent risk factor for neurotoxicity. Extreme hyperbilirubinemia may follow apparently resolved neonatal hyperbilirubinemia which had been treated by phototherapy. Female G6PD heterozygotes, previously thought to be unaffected clinically by G6PD-deficiency, while at low risk, may, nevertheless, develop extreme hyperbilirubinemia. Universal neonatal G6PD screening should be aimed towards increasing caretaker awareness and facilitating referral for treatment prior to the onset of bilirubin encephalopathy.

Utilizing Academic Detailing Intervention to Increase Screening, Referral, and Treatment for Opioid Use Disorder Among Primary Care Providers in Randolph County.

Opioid use disorder is a national epidemic that has killed over one million United States residents since 1999. Randolph County, North Carolina (NC) has a significantly higher rate of drug overdose and emergency-department-related visits than the NC state average. Primary care providers are well positioned to intervene and offer screening, referral, and treatment of opioid use disorder, yet this does not often occur. This quality improvement project serves as a pilot to evaluate the effectiveness of academic detailing (AD) to increase screening, referral, and treatment of opioid use disorder as well as to increase knowledge of community resources available. Face-to-face one-to-one AD was provided to primary care providers. Content included an overview of the diagnosis, standardized screening tools, management, and community resources available for referral. Assessments pre and post were conducted to evaluate screening, referral and treatment practices, knowledge of available community resources, barriers to providing services, and satisfaction with the AD event. AD did not result in change in frequency of screening or referral for treatment for OUD. None of the providers who participated in the intervention were prescribing buprenorphine prior to the event, nor were they after the event. Results indicated that there was an increase in the knowledge level of providers after AD with a change in median knowledge level from "I know about some resources in the area" to "I am very knowledgeable about area resources." Barriers to screening, referral, and treatment were identified, with lack of time being the most frequently cited. AD did not increase screening, referral, or treatment of OUD in this pilot project. However, there was an increase in knowledge of community resources related to OUD. AD is labor and time intensive and may be difficult to scale. Providers are well positioned to impact patient lives and increase screening, referral, and treatment for OUD in primary care settings. Continued work is needed to overcome barriers for getting patients adequate OUD treatment. Additional research is needed to ascertain if varied forms of AD would be more time and cost effective.

Working towards health: A model of cervical cancer screening and treatment for factory employees in Haiti.

In Haiti, cervical cancer continues to cause high levels of mortality and morbidity due to lack of resources and political unrest. Haitian women employed in factories are especially vulnerable because they are unable to take time away from work to access health resources. We aimed to describe a low-cost intervention which successfully addressed this need. We present a retrospective review of data gathered through a public-private partnership, in which women working in garment factories near Port-au-Prince, Haiti, were offered health education, clinical breast exam, and free human papillomavirus (HPV) self-swab testing at their place of employment. Women testing positive for HPV were subsequently tested using visual inspection with acetic acid (VIA) to inform treatment referrals, and treated with mobile thermocoagulation in factory infirmaries. Factory-employed healthcare workers were trained on cancer screening, including VIA and clinical breast exam. A total of 6843 out of 6983 (98%) female factory employees attended free reproductive health education sessions, and 4005 out of 4153 eligible women (97%) were screened using HPV self-swab testing; 5176 women received a clinical breast exam. Of the women screened for HPV, 1001 (25%) tested positive and 905 (90%) of HPV-positive women received VIA testing and thermocoagulation. The intervention had a total cost of US$76 000, over half of which was spent on an HPV testing machine. Innovative approaches to the prevention of cervical cancer are especially necessary in very low-resource, politically unstable environments like Haiti. Self-swab and screen-and-treat programs in the workplace were acceptable to employees and factory owners. This low-cost model was reached vulnerable women through a public-private partnership, and tracked them through screening and treatment. It could be implemented elsewhere or extended to include other health services.

Abstract C177: Increasing cervical cancer screening among women living with HIV (WLWH) in Jamaica

Abstract Background: Cervical cancer (CCA) is the third most common cancer and the third leading cause of cancer deaths among women in Jamaica. Although human papilloma virus (HPV), the primary risk factor for CCA, has a prevalence of 54% among sexually active Jamaican women, HPV vaccination uptake is low, and CCA is often diagnosed at advanced stages due to inadequate screening. Women comprise 50% of persons living with HIV in Jamaica and are about six times more likely to develop cervical cancer than women without HIV. However, despite national guidelines requiring annual screenings, a national audit found that fewer than one-third of eligible WLWH underwent a Pap smear in the past year. Objective: We aimed to address gaps in CCA screening among WLWH attending four large HIV treatment sites in Jamaica through programmatic and operational support integrated into HIV care. Method: Working through the UCSF Jamaica Country Programme, funded by PEPFAR, clinical advisors completed site reviews to identify gaps in the CCA screening process. Critical gaps identified at the four sites included insufficient supplies (speculums, slides, cytology brushes, fixative, Pap smear jackets, and bed rolls), limited provider knowledge, delays in sample processing, and the delayed return of results from the national public health lab. From January 2023 to May 2024, our team provided technical assistance and resources for sample collection, private laboratory testing, delivery of samples, and collection and review of results. Results: Cervical cancer modules were integrated into an ongoing clinical management training series that reached 33 clinicians across multiple sessions. With supportive supervision, the sites strengthened patient notification and sample transportation, that facilitated appointment adherence, timely sample delivery, and prompt collection of results. Clinical advisors further supported site teams to identify abnormal results and ensure timely and appropriate follow-up diagnostic tests and treatment referrals. This intervention supported 656 eligible WLWH to complete Pap smears, with 614 timely results returned to the sites by May 2024. Conclusion: Targeted programmatic interventions can increase CCA screening by improving the availability of Pap supplies, clinic workflow, and operational efficiency within HIV care clinics thereby reaching a population at high risk for CCA. Technical and financial support from donors can be expanded to explore clinic-based models for improving and integrating HPV screening and vaccine uptake among vulnerable WLWH. The impact of these interventions can be tested through quality improvement and implementation science frameworks. Citation Format: Sharlene T Beckford Jarrett, Sasha-Kaye Blackwood, Kimlin Tam Ashing, Kamelia Bryan, Tyrone O Ellis, Jeffrey Edwards, Willi McFarland, Nicola Skyers. Increasing cervical cancer screening among women living with HIV (WLWH) in Jamaica [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C177.

Investigating the service utilization and pathways of patients with alcohol use disorders.

Process mining was widely used in healthcare settings to analyse patient pathways, providing insights about patient care and resource allocation. This study aimed to apply process mining to explore service utilization and pathways of patients with alcohol use disorders in receiving the community-based Drug and Alcohol Service to establish a baseline for evaluating improvement initiatives. Patients' encounters with the Drug and Alcohol Service and their direct care activities (i.e. Intake, Assessment, and treatment service activities) that occurred in these encounters were analysed to depict the actual pathways. Patterns were uncovered from these actual pathways using a process mining tool Disco. Patients with alcohol use disorders were divided into two groups-patients who use polysubstance and those who do not-to compare their service utilization and pathway patterns. Five hundred seventy-one patients with alcohol use disorders incurred 1447 encounters, comprising 13,974 activities. The top three actual pathways with at least three activities were: (i) pathway 'Intake-> Withdrawal Management-> Withdrawal Management' (170 (11.7%) encounters and 130 (22.8%) patients); (ii) pathway 'Intake-> Adult Counselling-> Adult Counselling' (161 (11.1%) encounters and 126 (22.1%) patients); and (iii) pathway 'Intake-> Assessment-> Withdrawal Management' (155 (10.7%) encounters and 129 (22.6%) patients). However, 313 (21.6%) encounters did not proceed beyond the Intake stage. When the patients started their pathways from Intake, their immediate next activities were frequently Withdrawal Management, Assessment or Adult Counselling. Compared to those who do not use polysubstance, patients who use polysubstance had a higher proportion of Intake (19.3% vs 11.8%, P < .001), Involuntary Treatment (4.0% vs 1.0%, P < .001) and Magistrate Early Referral into Treatment (6.4% vs .3%, P < .001), but a lower proportion of Withdrawal Management (31.2% vs 39.0%, P < .001) and Adult Counselling (27.8% vs 37.6%, P < .001). This study contributes to an in-depth understanding of service utilization and pathways of patients with alcohol use disorders within the community-based Drug and Alcohol Service. Future studies should investigate their reasons for dropping out after Intake.

Buprenorphine prescription and treatment initiation through preemptive outreach and telehealth consultation with emergency medicine providers

Background Persons with opioid use disorder (OUD) urgently need improved access to medications for opioid use disorder (MOUD) and long-term treatment. Promising options include initiating buprenorphine in the emergency department (ED), telemedicine, and proactive treatment referrals before overdose events. Objective(s) We describe the process and outcomes of a novel referral path utilizing preemptive outreach and telemedicine to facilitate rapid access to MOUD and long-term treatment. Methods Participants were referred to telemedicine appointments with ED providers for buprenorphine initiation and to treatment agencies via an electronic referral network. Administrative data tracked participation at each stage of the process. Independent samples t-tests and chi-square tests assessed differences in process completion based on demographics. Results 163 persons with OUD or recent opioid overdose were referred, with high rates of participant follow-through, resulting in 126 new buprenorphine prescriptions and 114 linkages to long-term treatment. Of the 163 patients referred, 114 (69.9%) completed all steps. Participant demographics were not associated with significantly different completion rates. Conclusions This model serves as a viable pathway to link people to treatment resources and MOUD, and novelly combines prospective client outreach with telemedicine to reach persons before they arrive in the ED following an overdose. Future studies should examine the impact of similar programs on subsequent opioid use rates and treatment retention.

Managing Pediatric Hip Pain Patients with Precision.

Pediatric hip pain can have orthopedic, infectious, inflammatory, neoplastic, or nonmusculoskeletal etiologies. Organizing the differential diagnosis by symptom chronicity and a determination of intraarticular versus extraarticular pain, as well as the age at pain onset, can be helpful to hone in on the cause. Clinicians should consider plain radiographs in cases of acute trauma, with concern for bony pathology, or in patients with unexplained limp or hip pain, with musculoskeletal ultrasound and magnetic resonance imaging used as advanced imaging when indicated. Relative rest with subsequent strengthening and stretching should be prescribed in nonoperative conditions, though several pediatric hip pain diagnoses require orthopedic or other specialty referral for definitive treatment. This article is a comprehensive review of hip pain etiologies in the pediatric population.

Moving Beyond Referrals: Addressing Multilevel Barriers to Substance Use Treatment Engagement Through Police-Led Recovery Management Check-Ups.

The opioid epidemic in the United States (US) has prompted innovative responses from law enforcement agencies including specialized units to refer overdose survivors to substance use treatment following an overdose. However, traditional law enforcement outreach does not address the multilevel barriers to treatment engagement that lead to repeat overdose-related calls for service. The current evaluation explored the process components and outcomes of a Comprehensive Opioid Abuse Program (COAP) initiative within a local law enforcement agency in the Southeast US. COAP funding supported a police-led recovery management team (RMT) to connect overdose survivors to substance use treatment. The RMT also utilized recovery management check-ups (RMCs) to provide sustained support to enhance substance use treatment engagement beyond the initial treatment referral. A mixed-methods approach was employed to examine participant demographic, substance use, mental health, treatment, and criminal justice characteristics (N = 65) and explore perceptions of programmatic strengths and potential areas for improvement (N = 15). The quantitative and qualitative analyses were informed by the Recovery Capital Model. Quantitative analysis revealed that the RMT connected many participants with various support services, notably including housing assistance and health insurance. Qualitative findings highlight program effectiveness in improving social, community, and personal recovery capital. These findings contribute to expanding research on police-led post-overdose initiatives and suggest that police-led RMCs can address multilevel barriers to treatment engagement and minimize law enforcement stigma.

The need for primary care providers in the clinical management of hypermobility spectrum disorders and ehlers-danlos syndrome: a call to action.

Patients with joint-hypermobility and joint-hypermobility spectrum disorders (HSD), including hypermobile Ehlers-Danlos Syndromes (EDS) present numerous co-morbid concerns, and multidisciplinary care has been recommended. The complexity of these patient's needs and increased demand for medical services have resulted in long delays for diagnosis and treatment and exhausted extant clinical resources. Strategies must be considered to ensure patient needs are met in a timely fashion. This opinion piece discusses several potential models of care for joint-hypermobility disorders, several ways in which primary providers can be involved, and argues that primary providers should be an essential and integrated part of the management of these patients, in collaboration with multidisciplinary teams and pediatric subspecialists. We review several strategies and educational opportunities that may better incorporate primary providers into the care and management of these patients, and we also discuss some of the limitations and barriers that need to be addressed to improve provision of care. This includes establishing primary care physicians as the medical home, providing initial diagnostic and treatment referrals while connecting patients with specialty care, and collaboration and coordination with multi-disciplinary teams for more complex needs. Several barriers exist that may hamper these efforts, including a lack of available specialty trainings for providers interested in providing care to patients with EDS and HSD, a lack of expertly derived consensus guidelines, and limited time resources in extant primary care practices. Also, primary providers should have an active voice in the future for the further consideration and development of these presented strategies.

The Intersection of Intimate Partner Violence, Strangulation, and Brain Injury Screening: A Pilot Project.

Survivors of intimate partner violence are at a high risk for having a brain injury because of high rates of strangulation and head and face injuries sustained from physical abuse. In addition to acute physical injuries, survivors experience various health complications. Many survivors do not seek medical attention for their injuries, and when they do, their brain injury often goes unrecognized and untreated. Research indicates that screening for brain injury can be an effective intervention to increase the identification of brain injuries and medical referrals for diagnosis and treatment. Unfortunately, brain injury screening is not a standard of care. Shelter-seeking clients were routinely screened for brain injury using a modified HELPS screening tool. A positive screen prompted a medical referral. A modified HELPS screening tool was utilized with permission for the project. Before implementation, 36 individuals entered shelter, 0 were screened for brain injury, and the medical referral rate was 19.4% (n = 7). After implementation, 40 clients entered shelter, 36 were screened for brain injury, 77.8% (n = 28) screened positive, and the medical referral rate was 80.6% (n = 29). Brain injury screening may be an effective evidence-based intervention for shelter-seeking survivors of intimate partner violence to increase medical referrals.

Knowledge, Attitudes, and Challenges: Irish General practitioners’ preparedness for publicly funded Assisted reproductive technologies

ObjectivesGlobal access to assisted reproductive technologies (ART) remains highly inequitable. Until recently, access to ART in Ireland was solely available through private fertility clinics. Publicly funded ART was introduced in September 2023 but eligibility requires patients to meet strict access criteria that include referral by their primary care general practitioner (GP) to the local fertility service. Previous studies report that fertility training amongst doctors, including GPs, is variable and an obstetrics and gynaecology (O&G) rotation is not mandatory for GP trainees in Ireland. This study aimed to investigate GPs’ knowledge of fertility investigations and management, as well as attitudes towards publicly funded ART access criteria. Study DesignA cross-sectional online survey was distributed to GPs working in Ireland between September 2023 and January 2024. The survey questionnaire explored attitudes to, and knowledge of, ART including the publicly funded access criteria. Responses to free-text questions were qualitatively analysed using content analysis. ResultsThe study had 154 respondents, representing approximately 4 % of GPs in Ireland. Three quarters (n = 120, 78 %) of respondents were female, 68 % (n = 105) had completed an O&G training rotation and 72 % (n = 111) had further O&G qualifications. However, 69 % (n = 107) reported that they had no training in subfertility investigation and management, and 34 % (n = 53) were not aware of the access criteria for publicly funded ART prior to completing the survey. Almost all GPs (97 %, n = 149) felt that they would benefit from more education on fertility. Qualitative content analysis generated two themes regarding publicly funded ART: (i) the access criteria are too restrictive and (ii) the workload for GPs will increase. ConclusionsGPs in Ireland are now being tasked with managing infertility and fertility treatment referrals, but most have not been provided with sufficient training. Our study shows that GPs in Ireland desire broader access criteria for publicly funded ART and better fertility training and education for their own clinical practice.

Superiorly Based Preauricular Flap for Total Ear Lobe Reconstruction Following a Large Keloid Excision.

A large keloid on the right earlobe that extended to the infraauricular region was the reason for the 42-year-old woman's referral for treatment. The entire thickness of the earlobe was implicated in the surgical defect that resulted from the severe keloid excision. We employed a straightforward technique to provide a pleasing appearance while repairing the entire lobe in a single stage without the need for grafts. In addition to being ornamental, ear lobules provide a crucial point of reference for facial symmetry while wearing earrings. It is obviously unnatural from an aesthetic standpoint to lose them. Numerous techniques created to reconstruct this deformity have offered a range of benefits and drawbacks. A case of big ear lobe keloid with whole ear lobe reconstruction employing a new, single-stage, superiorly based Preauricular flap technique that is easy to master and produces good results in terms of absence of recurrence or no any deformity even after a lengthy follow-up period has been presented.