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BackgroundAdherence to antiretroviral therapy (ART) is essential for allowing persons living with HIV to live longer, healthier lives. However, a large portion of this population has suboptimal adherence and are not virally suppressed. Conventional interventions aimed at improving ART adherence lack portability and scalability, and improvements in adherence are not often sustained. Mobile health (mHealth) ART interventions offer a low-cost and accessible method of improving adherence, but many have limited functionality and do not offer comprehensive support. The combination of an mHealth intervention with a face-to-face adherence intervention and interactive health coaching feature may offer sufficient support in a manner that is sensitive to resource limitations that are often found in HIV treatment settings. This paper details the protocol of a study designed to evaluate the potential of an enhanced mHealth intervention for improving ART adherence. ObjectiveThe primary objective of this study is to assess the feasibility and acceptability of the Fitbit Plus app enhanced with a face-to-face LifeSteps session (Fitbit Plus condition) for improving ART adherence. In addition, we will determine the preliminary efficacy of the intervention by calculating treatment effect sizes. MethodsThis study will be conducted in 2 phases. The intervention will be developed and piloted with a small group of participants during phase 1. Pilot participants will provide feedback that will be used to refine the intervention for phase 2. In phase 2, a preliminary randomized controlled trial (RCT) comparing Fitbit Plus with a condition that approximates the standard of care (SOC) will be conducted with 60 persons living with HIV. Interviews will be conducted with RCT participants at baseline, and follow-up interviews will be conducted at 1, 3, 6, and 12 months. ART adherence is the primary outcome and will be monitored throughout the study via electronic pill boxes. Effect sizes will be generated using a fractional logit model estimated by generalized estimating equations. ResultsPhase 1 of this trial is complete; data collection for phase 2 is ongoing. Follow-ups with enrolled participants will conclude in January 2020. ConclusionsThis study will contribute to the literature on ART adherence and may produce an efficacious intervention. Owing to a small sample size, there may be insufficient power to detect statistically significant differences between Fitbit Plus and SOC. However, if Fitbit Plus is found to be acceptable and feasible and yields promising effect size estimates, this pilot study could serve as the foundation for a larger, fully powered trial of Fitbit Plus. Trial RegistrationClinicalTrials.gov NCT02676128; https://clinicaltrials.gov/ct2/show/NCT02676128 International Registered Report Identifier (IRRID)DERR1-10.2196/15356

Introduction: Behavioral crises are increasingly prevalent in health care settings. Existing programs, however, include procedures that lack adaptability, omit critical components, and deviate from clinical best-practice recommendations. Health care employees also continue to report lacking confidence for safely managing behavioral crises. Aims: We described the development and acceptability of a comprehensive crisis prevention program and its modification for a large pediatric health care system to help remediate the limitations of existing programs. Method: Chi-square analyses evaluated the acceptability of the crisis prevention program pre- versus post-training and at 3- and 6-month follow-up times. For insignificant outcomes, logistical regressions identify whether responses differed between emergency-department and nonemergency-department employees. Results: Chi-square analyses were significant for 10 of 15 questions suggesting that employees were more confident in managing and communicating during behavioral crises post-training, and that this confidence was maintained. Logistic regressions found that emergency-department employees differed in some responses to the acceptability questionnaire than nonemergency-department employees over time Conclusion: The present crisis prevention program is adaptable to various settings and patients, and it is well received overall by employees. The safety of patients and employees is integral to the delivery of quality care and improving patient-provider relations. [ABSTRACT FROM AUTHOR]

Background: Nearly two million adults in the US currently live with an Opioid Use Disorder (OUD) diagnosis. Recent efforts have encouraged and facilitated widespread adoption of empirically supported medications for opioid use disorder (MOUD), yet MOUD and OUD behavioral health interventions remain dramatically underutilized. Fear of discrimination and judgment, compounded by systemic and regulatory barriers, hinder individuals' access to specialty treatment.Objectives: The goal of the current study was to (1) reveal how perspectives toward OUD treatment may differ across medication types, program settings, and drug use history; (2) address systemic and regulatory components that potentially foster and propagate positive or negative attributions to OUD; and (3) understand how experiences reduce patients' willingness to pursue and/or maintain long term treatment.Methods: Twenty-four adults engaged in buprenorphine treatment at two outpatient addiction treatment centers participated in in-depth, qualitative interviews between 2019 and 2020 in Providence, Rhode Island.Results: Thematic analysis revealed negative attributions toward OUD across all participants. Three key themes developed from the coding and analysis: (1) differential perceptions of therapeutic medications (2) negative perceptions of treatment programs and (3) perceptions of drugs and people who use drugs.Conclusions: Stigmatizing language remains a major public health issue that needs to be addressed to facilitate treatment for individuals for OUD and other drug use disorders. Incorporating strategies targeting labeling across medication types, program settings, and drug use may improve treatment outcomes by reducing the inaccurate beliefs surrounding OUD and connecting patients to evidence-based support. [ABSTRACT FROM AUTHOR]

Introduction Case definitions form an important part of standardized systems for public health surveillance. They can be used in the reporting of the conditions under surveillance, the monitoring of geographical [...], The formulation of accurate clinical case definitions is an integral part of an effective process of public health surveillance. Although such definitions should, ideally, be based on a standardized and fixed collection of defining criteria, they often require revision to reflect new knowledge of the condition involved and improvements in diagnostic testing. Optimal case definitions also need to have a balance of sensitivity and specificity that reflects their intended use. After the 2009- 2010 H1N1 influenza pandemic, the World Health Organization (WHO) initiated a technical consultation on global influenza surveillance. This prompted improvements in the sensitivity and specificity of the case definition for influenza--i.e. a respiratory disease that lacks uniquely defining symptomology. The revision process not only modified the definition of influenza-like illness, to Include a simplified list of the criteria shown to be most predictive of influenza infection, but also clarified the language used for the definition, to enhance interpretability. To capture severe cases of influenza that required hospitalization, a new case definition was also developed for severe acute respiratory infection in all age groups. The new definitions have been found to capture more cases without compromising specificity. Despite the challenge still posed In the clinical separation of influenza from other respiratory infections, the global use of the new WHO case definitions should help determine global trends in the characteristics and transmission of influenza viruses and the associated disease burden. La formulation de definitions precises de cas cliniques fait partie integrente d'un processus efncace de surveillance de la sante publique. Alors que ees definitions devraient, dans l'ideal, s'appuyer sur un ensemble standardise et fixe de criteres de definition, elles necessitent souvent une revision pour tenir compte des nouvelles connaissances relatives a la maladie concernee et des ameliorations apportees aux tests diagnostiques. Pour etre optimales, les definitions de cas doivent aussi etablir un equilibre entre sensibilite et specificite qui reflete leur utilisation aux fins prevues. A la suite de la pandemie de grippe H1N1 de 2009-2010, l'Organisation mondiale de la Sante (OMS) a lance une consultation technique sur la surveillance mondiale de la grippe. Cela a conduit a des ameliorations concernant la sensibilite et la specificite de la definition de cas pour la grippe--c'est-a-dire une maladie respiratoire dont seule la symptomatologie reste a definir. Le processus de revision n'a pas seulement modifie la definition du syndrome de type grippal pour indure une liste simplifiee des criteres le mieux a meme de predire une infection grippale, il a egalement permis de clarifier le langage utilise dans la definition pour en ameliorer Interpretation. Par ailleurs, afin de tenir compte des cas severes de grippe qui necessitaient une hospitalisation, une nouvelle definition de cas a ete introduite concernant l'infection aigue severe des voies respiratoires dans tous les groupes d'age. Il a ete constate que les nouvelles definitions refletaient davantage de cas, sans pour autant compromettre la specificite. S'il est vral que la distinction clinique de la grippe des autres infections respiratoires continue de poser probleme, l'utilisation mondiale des nouvelles definitions de cas de l'OMS devralt permettre de degager des tendances mondiales concernant les caracteristiques et la transmission des virus grippaux ainsi que la charge de morbidite qui leur est associee. La elaboracion de definiciones precisas de los casos clinicos es una parte fundamental de un proceso efectivo de la vigilancia de la salud publica. Aunque tales definiciones deberian, idealmente, estar basadas en una recopilacion estandarizada y fija de criterios de definicion, a menudo necesitan una revision para reflejar el nuevo conocimiento de la enfermedad existente y las mejoras en las pruebas de diagnostico. Las definiciones optimas de los casos tambien deben tener un equilibrio entre sensibilidad y especificidad que refleje su uso previsto. Despues de la pandemia de gripe H1N1 en 2009-2010, la Organizacion Mundial de la Salud (OMS) inicio una consulta tecnica para la vigilancia mundial de la gripe. Esto dio lugar a mejoras en la sensibilidad y la especificidad de las definiciones de los casos de gripe, es decir, una enfermedad respiratoria que carece de una sintomatologia definitoria singular. El proceso de revision no solo modifico la definicion de las enfermedades similares a la gripe para incluir una lista simplificada de los criterios que demostraron ser mas predictivos de la infeccion por gripe, sino que tambien aclaro el lenguaje utilizado para la definicion, con el fin de mejorar su interpretacion. Para englobar los casos graves de gripe que requirieron hospitalizacion, tambien se desarrollo una nueva definicion de los casos de la infeccion respiratoria aguda grave en todos los grupos de edad. Se ha descubierto que las nuevas definiciones engloban mas casos sin comprometer la especificidad. A pesar del desafio que todavia plantea la separacion clinica de la gripe de otras infecciones respiratorias, el uso global de las nuevas definiciones de los casos de la OMS deberia ayudar a determinar las tendencias mundiales en las caracteristicas y transmision de los virus de la gripe y la carga de la enfermedad asociada.

Objectives: Before the coronavirus disease 2019 pandemic, federal law required in-person evaluation before buprenorphine initiation. Regulatory changes during the pandemic allow for buprenorphine initiation by audio-only or audiovisual telehealth. Little is known about treatment engagement after buprenorphine initiation conducted via audio-only telehealth. Methods: A retrospective cohort study of 94 individuals who received initial treatment through an audio-only encounter between April 2020 and February 2021 was performed. Participant demographics, substance use history, withdrawal symptoms, 30-day treatment engagement, and adverse outcomes were determined by an electronic chart and REDcap database review. Subsequent buprenorphine prescriptions filled within 30 days of the initial encounter were tracked through the Rhode Island Prescription Drug Monitoring Program. Results: Buprenorphine was prescribed for 94 individuals. Most (92 of 94 [97.9%]) filled their prescription within 30 days. Most had previously taken buprenorphine, including prescribed (42 of 92 [45.7%]) and nonprescribed (58 of 92 [63.0%]). Two thirds were in opioid withdrawal at the time of the call (61 of 92 [66.3%]) with a mean Subjective Opioid Withdrawal Scale of 26.8 (range, 4–57). Four individuals experienced precipitated withdrawal (4 of 94 [4.3%]), and 2 reported persistent withdrawal at their follow-up visit (2 of 94 [2.1%]). More than 70% filled a subsequent prescription for buprenorphine within 30 days of the end of their hotline prescription (65 of 92 [70.7%]), on average of 5.88 days (range, 0–28) after completion of their telehealth prescription. Conclusions: Expanding telehealth-delivered buprenorphine care has the potential to address treatment gaps and facilitate delivery of on-demand services during peak motivation. This evaluation of audio-only buprenorphine initiation found high rates of unobserved buprenorphine initiation and treatment continuation with low rates of complications. [ABSTRACT FROM AUTHOR]

Studies on preference assessments have shown that when both edible and leisure items are compared, edible items tend to displace leisure items in preference hierarchies. However, the mechanisms behind this process are currently unclear. One possibility is that displacement may be a product of the relatively brief periods of access to leisure items typically used in preference assessments. The purpose of the current investigation was to examine whether the duration of access to leisure items affects displacement. In this study, participants chose between preferred leisure items and the edible items that had previously been shown to displace those leisure items in a preference hierarchy. Duration of access to the leisure item was systematically increased across series to identify the magnitude at which leisure items became more preferred than edible items. Results indicate that as the duration of access to leisure items increases, displacement decreases. [ABSTRACT FROM AUTHOR]

Renewal is defined as the reemergence of a previously eliminated behavior following a context change. Determining the prevalence of this effect in clinical practice would allow clinicians to better anticipate the reemergence of problem behavior, such as when a patient is discharged from a treatment facility to return to their home. The current consecutive, case‐series analysis determined the prevalence and magnitude of renewal when implementing behavioral treatments for problem behavior. Across 182 context changes, renewal was observed 77 times (42.3%). In the first session following the context change, problem behavior rates increased by a factor of 3 and then decreased across successive sessions. These results indicated that renewal effects may be common, but are also transient and return to rates observed before context changes. [ABSTRACT FROM AUTHOR]

Common approaches to pica treatment involve intensive staffing and near continuous behavioral monitoring to proactively disrupt any attempts at this potentially life threatening behavior. Including differential reinforcement of discarding pica items as a contingency in such interventions has been suggested as a more practical treatment model, but the evidence base for this approach is limited. We replicated this work by evaluating differential reinforcement for discarding pica items in conjunction with response blocking and differential reinforcement of other behavior in the treatment of pica exhibited by two children. We extended this work by evaluating sustained reductions when therapist and caregiver monitoring was reduced. [ABSTRACT FROM AUTHOR]

Odanacatib (ODN), a selective oral inhibitor of cathepsin K, was an investigational agent previously in development for the treatment of osteoporosis. In this analysis, the effects of ODN on bone remodeling/modeling and structure were examined in the randomized, double‐blind, placebo‐controlled, event‐driven, Phase 3, Long‐term Odanacatib Fracture Trial (LOFT; NCT00529373) and planned double‐blind extension in postmenopausal women with osteoporosis. A total of 386 transilial bone biopsies, obtained from consenting patients at baseline (ODN n = 17, placebo n = 23), month 24 (ODN n = 112, placebo n = 104), month 36 (ODN n = 42, placebo n = 41), and month 60 (ODN n = 27, placebo n = 20) were assessed by dynamic and static bone histomorphometry. Patient characteristics at baseline and BMD changes over 5 years for this subset were comparable to the overall LOFT population. Qualitative assessment of biopsies revealed no abnormalities. Consistent with the mechanism of ODN, osteoclast number was higher with ODN versus placebo over time. Regarding bone remodeling, dynamic bone formation indices in trabecular, intracortical, and endocortical surfaces were generally similar in ODN‐treated versus placebo‐treated patients after 2 years of treatment. Regarding periosteal modeling, the proportion of patients with periosteal double labels and the bone formation indices increased over time in the ODN‐treated patients compared with placebo. This finding supported the observed numerical increase in cortical thickness at month 60 versus placebo. In conclusion, ODN treatment for 5 years did not reduce bone remodeling and increased the proportion of patients with periosteal bone formation. These results are consistent with the mechanism of action of ODN, and are associated with continued BMD increases and reduced risk of fractures compared with placebo in the LOFT Phase 3 fracture trial. © 2020 American Society for Bone and Mineral Research. [ABSTRACT FROM AUTHOR]

The article focuses on the U.S. has documented its deadliest year of overdoses (ODs) in May 2020 with lives lost to drug overdoses and Rhode Island (RI) remains one of the most severely impacted states, with annual OD deaths expected to exceed 400 for the first time in 2020. Topics include the Rhode Island Department of Health (RIDOH) has released fatal overdose data.

Purpose: This study sought to examine the correspondence between brief functional analyses and more thorough functional analyses as described in the model of functional assessment proposed by Vollmer et al.1Methods: A panel of trained clinicians indicated the presence/absence of specific functions of problem behavior based on graphic results from brief functional analyses and functional analyses conducted with 19 participants. These conclusions were compared across assessments. Results: The functions identified by the panel based on results of brief functional analyses had low correspondence with those of the more thorough functional analysis conducted with the same participants. Conclusions: Although brief-functional analyses appear regularly in clinical practice and the literature, findings from this study suggest that results may differ from those of more thorough functional analyses. Additional study is necessary to determine the cause of discrepant results between these two methodologies. [ABSTRACT FROM AUTHOR]

It has been suggested that reinforcing problem behavior during functional analyses (FAs) may raise ethical questions, such as resulting in an increase in problem behavior outside of FA sessions. The current translational study assessed whether conducting an FA resulted in increases in problem behavior outside of the FA setting for six participants using a nonconcurrent multiple baseline across participants design. The rate of problem behavior was measured outside the FA setting prior to and during an FA. Idiosyncratic results suggest that problem behavior outside of the FA setting may increase, decrease, or be unaffected by conducting an FA. [ABSTRACT FROM AUTHOR]

Objectives: The current paper describes the use of token systems in a behavioral day-treatment unit for severe challenging behavior using a consecutive case review spanning three years. Methods: Experimenters reviewed 96 patient case files, 24 of which implemented some token system as a component of the individual's treatment package. Aspects of each token system (including schedules of token delivery and exchange; inclusion of token training and response cost; and types of backup reinforcers delivered), and participant characteristics were coded. Results: Token systems were most frequently employed during differential reinforcement for alternative behavior (DRA, most commonly for compliance) or differential reinforcement of other behavior (DRO). Tokens were most frequently used in an instructional context. Several commonalities were identified (e.g. restriction of backup reinforcers between token exchanges and initial dense schedules of reinforcement). Compared to past reviews, this sample had an over-representation of individuals with challenging behavior maintained by escape, multiply maintained challenging behavior, and individuals for which the function was not identified in a functional analysis. Treatment packages including token systems resulted in a reduction in challenging behavior for 91.67% of participants, with 70.83% exhibiting at least an 80% reduction. Conclusion: Our findings suggest that token systems may be a beneficial component of treatment plans used to address challenging behavior. Some common components should likely be included in all token systems and specific client variables may guide decisions related to idiosyncratic treatments. [ABSTRACT FROM AUTHOR]

An essay on the profound confusion that fuels the actions, paranoia and eventual fall of the title character in William Shakespeare's tragedy "Macbeth" is presented. It discusses the contradictions of people around Macbeth, his misunderstanding of his role as an active and inactive military general, his justification for killing King Duncan, and his inability to stop killing after he assumed the throne. It also cites Macbeth's evil nature and internal conflict and Shakespeare's vision of evil.

False negative functional analysis (FA) results may be less likely when caregivers serve as therapists, as problem behavior may be more likely to occur in the presence of a caregiver than with a novel therapist. This case study both replicated and extended prior research on this topic. It provides an example of FA results differing between a caregiver and novel therapist and also showed that FA results may differ across caregivers when they serve as therapists. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Pica displayed by two individuals with autism was decreased by a treatment involving differential reinforcement and response interruption that altered the chain of behavior involved in pica (i.e., picking up items and placing them in the mouth). The treatment involved establishing prompts to 'clean-up' as a new discriminative stimulus (SD) for picking up items from the floor; and holding potential pica items was established as an SD for discarding those items in a trash receptacle, putting them away, or using them appropriately. After demonstrating the effectiveness of the treatment in an analog setting, the treatment package was systematically generalized to community settings. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Despite its proven efficacy, buprenorphine remains dramatically underutilized for management of opioid use disorder largely due to onerous barriers to treatment initiation. During the COVID-19 pandemic, many substance use disorder treatment facilities have reduced their hours and services, exacerbating existing barriers. To this end, the U.S. Drug Enforcement Administration and Substance Abuse Mental Health Services Administration adjusted their guidelines to allow for new buprenorphine prescriptions following audio-only telehealth encounters, no longer requiring an in-person evaluation prior to treatment initiation. Under this new guidance, we established a 24/7 telephone hotline to function as a "tele-bridge" clinic where people with opioid use disorder can be linked with a buprenorphine prescriber in real-time for OUD assessment and unobserved buprenorphine initiation with connection to follow-up if appropriate. Additionally, we developed an ED callback protocol to reach patients recently seen for opioid overdose and facilitate their entry into care if interested. In this commentary we describe our hotline and ED callback protocols, discuss theoretical and anecdotal benefits to this approach, and advocate for continuation of current regulatory changes post-COVID-19 to maintain expanded access to novel treatment approaches. [ABSTRACT FROM AUTHOR]

Objectives: To examine the same-day associations between substance use and objectively measured antiretroviral therapy (ART) nonadherence among persons living with HIV (PLWH). Methods: PLWH (N = 53) were given an electronic pill box (EPB), and their ART adherence was monitored for 14 days. During a follow-up interview, participants were asked about any alcohol or drug use that occurred during those same 14 days. Results: Daily heavy drinking (⩾5 drinks for males and ⩾4 drinks for females) was associated with a nearly five times greater likelihood of same-day ART nonadherence (OR = 4.90, 95% CI = 1.79-13.36, P =.002). Further, drug use was associated with a nearly two times greater likelihood of ART nonadherence on the same day (OR = 1.80, 95% CI = 1.14-2.85, P =.012). Conclusions: These results highlight the importance of continuing to pursue interventions to effectively address heavy drinking and drug use among PLWH in order to improve ART adherence. [ABSTRACT FROM AUTHOR]

ST segment elevation is associated with non-cardiac pathologies but is not as well reported as myocardial infarction. We present a case of a 63-year-old man who was admitted for an overdose on cyclobenzaprine with signs of anti-cholinergic toxicity. He developed signs of ileus on imaging and became progressively obtunded. He was noted to have ST segment elevations on electrocardiogram (EKG) with no troponin elevation. Patient required urgent catheterization which showed normal coronary arteries. His bowel was decompressed subsequently resulting in resolution of the ST segment changes. Other cases of ST segment elevations with gastrointestinal pathologies including cholecystitis, pancreatitis and gastric dilation have been reported but the etiology is still unclear. This case illustrates the importance of understanding EKGs in the clinical context. ST segment elevation on EKG, if there is contradicting symptomology and lab reports, should be further investigated to prevent unnecessary work-up and potentially dangerous therapies. [ABSTRACT FROM AUTHOR]

Expanding addiction treatment services in Rhode Island has never been more urgent. Today, we face colliding syndemics of COVID-19, preventable drug overdoses, and HIV, with another year of record overdoses. While the treatment of substance use disorder (SUD) is an essential component of general medical care, numerous barriers prevent broader treatment access for patients in Rhode Island. Buprenorphine and methadone therapy have restrictions that are not applied to other areas in medicine, including for more dangerous medications. In this piece, we highlight existing barriers to care, applaud current progress being made in our state, and provide recommendations for next steps to turn the tide of this deadly epidemic. We hope that these proposed changes will help develop a robust treatment landscape for all patients with SUD in Rhode Island. [ABSTRACT FROM AUTHOR]

Low dose buprenorphine initiation (LDBI) is a dosing strategy used to transition patients from full opioid agonists to buprenorphine. The purpose of LDBI is to circumvent obstacles associated with disruption in analgesia, precipitated withdrawal, and prerequisite opioid withdrawal prior to initiating buprenorphine, as not all patients are able to tolerate physical withdrawal symptoms recommended by national guidelines. No literature exists directly comparing traditional buprenorphine initiation to LDBI. Until information on long-term outcomes is available, these dosing strategies should be reserved for patients unable to tolerate traditional buprenorphine initiation. Available published research suggests LDBI strategies will allow some patients to successfully transition to buprenorphine with minimal or no symptoms of withdrawal. Ensuring access to pharmacotherapy during hospital admission is a crucial time for potential intervention and should be considered when appropriate. This narrative review discusses the background of LDBI strategies as well as practical clinical and operational considerations for the inpatient clinician., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Acroangiodermatitis (AAD), also known as pseudo-Kaposi's sarcoma, is an uncommon benign angioproliferative condition most commonly seen in the lower extremities. This condition often presents as discolored patches that progress to painful ulcerations. The list of vascular conditions associated with this diagnosis is vast. Acroangiodermatitis presents similarly to more aggressive conditions such as Kaposi's sarcoma, making histopathologic examination helpful in its diagnosis. We present two cases of AAD in the setting of chronic venous insufficiency.