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Background: Research on adolescent heroin use has focused on national surveillance, access, prevalence of use, and overdose deaths, however, to our knowledge, no study has examined local-level differences in the prevalence of adolescent heroin use in the context of nonmedical prescription opioid (NMPO) use. This study characterizes heroin and NMPO use among US high school students in select urban areas by sex and race/ethnicity., Methods: Data are from 21 urban school districts that participate in CDC's Local Youth Risk Behavior Surveillance System. We describe 2017 prevalence estimates (and 95 % confidence intervals) of lifetime heroin and NMPO use among youth stratified by sex and race/ethnicity (i.e., White, Black, Hispanic/Latino)., Results: The highest estimates of heroin use were in Baltimore, MD (7.6 %), Shelby County, TN (6.3 %), and Duval County, FL (6.1 %), whereas NMPO use was highest in Duval County, FL (18.1 %), Cleveland, OH (18.0 %), and Shelby County, TN (16.8 %). Heroin use was higher among boys than girls, especially among Hispanic/Latino boys in Duval County (12.3 %) and Black boys in Baltimore (10.9 %). NMPO use was highest among Hispanic/Latino girls (21.3 %) and White girls (19.9 %) in Duval County., Discussion: While some cities and subpopulations with high levels of adolescent heroin use also had elevated levels of NMPO use, others did not, illustrating the complexities of this opioid epidemic., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Age-related decline in muscle oxidative capacity reduces muscle function and physical performance, leading to disability and frailty. Whether age-related decline in oxidative capacity is modified by exercise and other lifestyle practices is unclear. Therefore, we tested the hypothesis that physical activity is associated with better oxidative capacity, independent of age., Design: Cross-sectional study performed in the Baltimore Longitudinal Study of Aging, conducted by the Intramural Research Program (IRP) of the National Institute on Aging (NIA)., Setting: NIA IRP Clinical Research Unit, Baltimore, MD., Participants: Participants included 384 adults (54.7% women), aged 22 to 92 years, seen between 2013 and 2017., Measurements: Muscle oxidative capacity was measured in vivo using phosphorous magnetic resonance spectroscopy. We determined the postexercise time constant (τ PCr ; in seconds) for phosphocreatine (PCr) recovery, with lower values of τ PCr, (ie, more rapid recovery of PCr levels after exercise) reflecting greater oxidative capacity. Time spent in moderate-to-vigorous physical activity (MVPA) was assessed using wearable accelerometers that participants wore 5.9 ± 0.9 consecutive days in the free-living environment., Results: In linear regression models, higher τ PCr was associated with older age (standardized β = .39; P < .001) after adjusting for sex, race, height, and weight. After including MVPA as an independent variable, the standardized regression coefficient of age decreased by 40%, but remained associated with τ PCr (β age = .22; P < .001) and had a smaller standardized regression coefficient than MVPA (β MVPA = -.33; P < .001). After adjusting for health status, education, and smoking history, the standardized regression coefficient for age decreased 12% (β age = .20; P = .003), while the standardized coefficient for MVPA decreased only 3% (β MVPA = -.32; P < .001)., Conclusion: Study findings suggest that MVPA is strongly associated with muscle oxidative capacity, independent of age, providing mechanistic insights into the health benefits of exercise in older age. J Am Geriatr Soc 67:1695-1699, 2019., (© 2019 The American Geriatrics Society.)

This article reports on the impact of the Experience Corps® (EC) Baltimore program, an intergenerational, school-based program aimed at improving academic achievement and reducing disruptive school behavior in urban, elementary school students in Kindergarten through third grade (K-3). Teams of adult volunteers aged 60 and older were placed in public schools, serving 15 h or more per week, to perform meaningful and important roles to improve the educational outcomes of children and the health and well-being of volunteers. Findings indicate no significant impact of the EC program on standardized reading or mathematical achievement test scores among children in grades 1-3 exposed to the program. K-1st grade students in EC schools had fewer principal office referrals compared to K-1st grade students in matched control schools during their second year in the EC program; second graders in EC schools had fewer suspensions and expulsions than second graders in non-EC schools during their first year in the EC program. In general, both boys and girls appeared to benefit from the EC program in school behavior. The results suggest that a volunteer engagement program for older adults can be modestly effective for improving selective aspects of classroom behavior among elementary school students in under-resourced, urban schools, but there were no significant improvements in academic achievement. More work is needed to identify individual- and school-level factors that may help account for these results.

Adolescents and young adults living with HIV (YLHIV) face numerous stresses that affect their care and medication adherence. The clinic social environment may play an important supportive role for YLHIV, influencing health outcomes. The aim of this article is to explore how YLHIV in Baltimore, Maryland understand the various forms of social support provided within the social environment of their HIV clinic. We used qualitative research methods including iterative, semi-structured in-depth interviews with 20 YLHIV interviewed up to three times each to explore HIV stressors, support systems, and medication adherence. We employed thematic content analysis to systematically code and synthesize textual interview data. We found that YLHIV experienced social embeddedness with their healthcare teams and through clinic activities. Participants largely perceived these social connections as support, acknowledging that these supports are available to them when needed. Support was enacted through the provision of instrumental support for issues outside of the young person's medical care (i.e., finding a crib for a participant's baby), appraisal (i.e., through respect of the young person's agency and decision making), and information about their HIV care and medication. Support was not always well received, however, as some young people found the support from clinicians demeaning. Limitations of the clinic social support environment included concerns about trust and privacy, and perceiving support as inappropriate or unwanted. Participants identified a number of ways in which the clinic provided meaningful social support. Future research should explore how these supports may improve care and medication adherence of YLHIV.

Background: Sex partner meeting places may be important locales to access men who have sex with men (MSM) and implement targeted HIV control strategies. These locales may change over time, but temporal evaluations have not been performed., Methods: The objectives of this study were to describe the frequency of report of MSM sex partner meeting places over time and to compare frequently reported meeting places in the past 5 years and past year among newly HIV-diagnosed MSM in Baltimore City, Maryland. Public health HIV surveillance data including partner services information were obtained for this study from the Baltimore City Health Department from May 2009 to June 2014., Results: A total of 869 sex partner meeting places were reported, including 306 unique places. Bars/clubs (31%) and Internet-based sites (38%) were the most frequently reported meeting place types. Over the 5-year period, the percentage of bars/clubs decreased over time and the percentage of Internet-based sites increased over time. Among bars/clubs, 4 of 5 of those most frequently reported in the past 5 years were also most frequently reported in the most recent year. Among Internet-based sites, 3 of 5 of those most frequently reported in the past 5 years were also in the top 5 most frequently reported in the past year., Conclusion: This study provides a richer understanding of sex partner meeting places reported by MSM over time and information to health departments on types of places to access a population at high risk for HIV transmission.

Background: Patients continue to suffer preventable harm from the omission of evidence-based therapies. To remedy this, The Joint Commission developed core measures for therapies with strong evidence and, through the Top Performer on Key Quality Measures program, recognize hospitals that deliver those therapies to 95% of patients. The Johns Hopkins Medicine board of trustees committed to high reliability and to providing > or = 96% of patients with the recommended therapies., Methods: The Armstrong Institute for Patient Safety and Quality coordinated the core measures initiative, which targeted nine process measures for the 96% performance goal: eight Joint Commission accountability measures and one Delmarva Foundation core measure. A conceptual model for this initiative included communicating goals, building capacity with Lean Sigma methods, transparently reporting performance and establishing an accountability plan, and developing a sustainability plan. Clinicians and quality improvement staff formed one team for each targeted process measure, and Armstrong Institute staff supported the teams work. The primary performance measure was the percentage of patients who received the recommended process of care, as defined by the specifications for each of The Joint Commission's accountability measures., Results: The > or = 96% performance goal was achieved for 82% of the measures in 2011 and 95% of the measures in 2012., Conclusions: With support from leadership and a conceptual model to communicate goals, use robust improvement methods, and ensure accountability, The Johns Hopkins Hospital achieved high reliability for The Joint Commission accountability measures.

Background: Although cancer outcomes have improved in recent decades, substantial disparities by race, ethnicity, income, and education persist. Increasingly, patient navigation services are demonstrating success in improving cancer detection, treatment, and care and in reducing cancer health disparities. To advance progress in developing patient navigation programs, extensive descriptions of each component of the program must be made available to researchers and health service providers., Objective: We sought to describe the components of a patient navigation program designed to improve cancer screening based on informed decision making on cancer screening and cancer treatment services among predominantly Black older adults in Baltimore City., Methods: A community-academic participatory approach was used to develop a patient navigation program in Baltimore, Maryland. The components of the patient navigation system included the development of a community academic (advisory) committee (CAC); recruitment and selection of community health workers (CHWs)/navigators and supervisory staff, initial training and continuing education of the CHWs/navigators, and evaluation of CHWs/navigators. The study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board., Conclusions: The incorporation of community-based participatory research principles into each facet of this patient navigation program facilitated the attainment of the intervention's objectives. This patient navigation program successfully delivered cancer navigation services to 1,302 urban Black older adults. Appropriately recruited, selected and trained CHWs monitored by an experienced supervisor and investigators are the key elements in a patient navigation program. This model has the potential to be adapted by research and health service providers.

Background: Endovascular technologies represent major advancements in treating descending thoracic aortic aneurysms (DTAA). We compared hospital charges of open thoracic aortic replacement (OTAR) with endovascular repair of thoracic aortic aneurysms (TEVAR)., Methods: Retrospective analysis of hospital charges related to repair of DTAA (2000-2009). Charges were inflation adjusted for dollars in 2009., Results: There were 50 OTAR and 50 TEVAR patients. Open thoracic aortic replacement charges were $64 531 (interquartile range [IQR]: 49 000-108 515) versus $61 909 (IQR: 41 307-92 109) for TEVAR(P = .4). A total of 10 patients (10%) died before discharge, with 0 TEVAR deaths (P < .05). For OTAR, supply charges ($9167) accounted for 13% of total charges versus 56% for TEVAR ($40 468), P < .01. Open thoracic aortic replacement length of stay (LOS) was 12 days (6 days intensive care unit [ICU] stay); bed charges comprised 40% of the total charges. Thoracic endovascular aneurysm repair had lower LOS (5days with 2 days ICU stay, P < .001)., Conclusions: Descending thoracic aortic aneurysm repair remains a formidable operation with significant resource utilization. Thoracic endovascular aneurysm repair does not significantly reduce overall hospital charges due to device costs but demonstrates improved mortality, ICU, and total LOS.

It has been reported that germline mutations in the palladin gene (PALLD) cause the familial aggregation of pancreatic cancer, but the evidence is weak and controversial. We sequenced the coding regions of PALLD in 48 individuals with familial pancreatic cancer. We did not find any deleterious mutations and find no evidence to implicate mutations in PALLD as a cause of familial pancreatic cancer.

Background and Aims: Physician reimbursement for services and thus income are largely determined by the Medicare Resource-Based Relative Value Scale. Patients' assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients' valuation of health-care services to Medicare's relative value unit (RVU) assessments and to discover patients' perceptions about the relative differences in incomes across physician specialties., Design: Cross-sectional survey., Participants and Setting: Individuals in select outpatient waiting areas at Johns Hopkins Bayview Medical Center., Methods: Data collection included the use of a visual analog 'value scale' wherein participants assigned value to 10 specific physician-dependent health-care services. Informants were also asked to estimate the annualized incomes of physicians in specialties related to the above-mentioned services. Comparisons of (i) the 'patient valuation RVUs' with actual Medicare RVUs, and (ii) patients' estimations of physician income with actual income were explored using t-tests., Outcomes: Of the 206 eligible individuals, 186 (90%) agreed to participate. Participants assigned a significantly higher mean value to 7 of the 10 services compared with Medicare RVUs (P<0.001) and the range in values assigned by participants was much smaller than Medicare's (a factor of 2 vs. 22). With the exception of primary care, respondents estimated that physicians earn significantly less than their actual income (all P<0.001) and the differential across specialties was thought to be much smaller (estimate: $88,225, actual: $146,769)., Conclusion: In this pilot study, patients' estimations of the value health-care services were markedly different from the Medicare RVU system. Mechanisms for incorporating patients' valuation of services rendered by physicians may be warranted.

Background: Patient safety rounds were implemented in a pediatric tertiary care setting. Completed patient safety issues from three years of pediatric patient safety rounds and nine months of pediatric surgical safety rounds were analyzed. Completed issues were categorized into both Modified Vincent and University HealthSystem Consortium (UHC) categorization schemes to compare and contrast their attributes., Findings: From January 2003 through January 2006, there were 159 completed patient safety issues, 148 (93%) from general pediatric safety rounds and 11 (7%) from pediatric surgical safety rounds. Using the UHC classification scheme, 35.8% of the issues were classified as care coordination/records, 27.0% as equipment safety situation/preventive maintenance, 21.4% as equipment/supplies/devices, 3.8% as error related to procedure/ treatment/test, and 3.8% as medication error. In the Modified Vincent classification scheme, 63.5% of the issues were classified as environmental factors, 23.3% as team factors, 6.9% as individual factors, 3.1% as task factors, and 1.9% as patient characteristics. Pediatric safety rounds were well received by both frontline staff and senior executives., Discussion: The use of pediatric safety rounds is a low-cost intervention that helps to partner senior leaders and frontline staff on patient safety and is an effective tool for improving patient safety in a pediatric setting.

This paper explores adolescents' definitions of what it means to be a man and a woman, the psycho-social context surrounding the formation of gender ideologies and their relationship to HIV/STI prevention. Semi-structured, in-depth interviews were conducted with fifty African-American adolescents living in Baltimore, Maryland. Female gender ideologies included economic independence, emotional strength and caretaking. Male gender ideologies emphasized financial responsibility, toughness and sexual prowess. Findings suggest that stronger adherence to male gender ideologies related to toughness and sexual prowess is influenced by male participants' perceived inability to fulfill their primary gender role as economic providers and the importance of gaining approval from male peers in the absence of adult male role models. Stronger adherence to female gender ideologies related to emotional strength and caretaking may be linked to a heightened desire for male intimacy and tolerance of male sexual risk behavior. Implications of the gender ideologies documented and their commonalities are discussed in terms of HIV/STI prevention.

Substance use is significantly associated with physical injury, yet relatively little is known about the prevalence of specific substance use disorders among trauma patients, or their associated sociodemographic characteristics. We evaluated these issues in an unselected sample of 1,118 adult inpatients at the University of Maryland Shock Trauma Center, Baltimore, MD, who were interviewed with the psychoactive substance use disorder section of the Structured Clinical Interview for DSM-III-R. Among trauma inpatients, lifetime alcohol users (71.8% of subjects) were more likely male; users of illegal drugs (45.3%) were also more likely to be younger, unmarried, and poor. Patients with current drug abuse/dependence (18.8%) were more likely to be non-white, less educated, and poor; those with current alcohol abuse/dependence (32.1%) were also more likely male, unmarried, and older. These findings highlight the need for screening for substance use disorders in trauma settings and referral of patients to substance abuse treatment programs.

The technology of intravenous catheter access ports has evolved from open ports covered by removable caps to more-sophisticated, closed versions containing mechanical valves. We report a significant increase in catheter-related bloodstream infections after the introduction of a new needle-free positive-pressure mechanical valve intravenous access port at our institution.

Substance abuse and HIV infection are important medical problems that receive comparatively little attention in residency training programs and residents often feel unprepared to deal with them. We developed a month-long rotation that combined outpatient care for patients with HIV infection and addiction, with inpatient care for medically-ill patients on a detoxification unit. At the end of the rotation, residents reported greater comfort with caring for these patients and improved self-rated competence. They also rated the rotation highly. Our experience shows that a rotation combining inpatient and outpatient substance abuse and HIV care was valued by residents and increased their comfort and proficiency with caring for these underserved and stigmatized populations.

Background: At The Johns Hopkins Hospital (JHH), a culture of safety refers to the presence of characteristics such as the belief that harm is untenable and the use of a systems approach to analyzing safety issues., Patient Safety as a Leadership and Organizational Priority: The leadership of JHH provides strategic planning guidance for safety and improvement initiatives, involves the patient safety committee in capital investment allocation decisions and in designing and planning new hospital facilities, and ensures that safety and quality head the agenda of board-of-trustees meetings. Although JHH takes a systems approach, structures such as monitoring staff behavior trends are used to hold people accountable for job performance., Challenges and Lessons Learned: JHH encountered three major hurdles in implementing and sustaining a culture of safety. First, JHH's decentralized organizational structure contributes to a silo effect that limits the spread of ideas, practices, and culture. JHH intends to create an internal collaborative of departmental safety initiatives to foster opportunities for units to share ideas and results. Second, in response to the challenge of encouraging teams to think and act in an interdisciplinary fashion, communication and teamwork training are being used to enhance the effectiveness of interdisciplinary teams. Further development of valid and meaningful safety-related measurement and data collection methodologies is JHH's largest remaining challenge.

Satisfaction with health care was compared for dually eligible older beneficiaries receiving care in three settings: a managed care organization (MCO) that is at risk for providing Medicare and Medicaid benefits (n = 200); the fee-for-service (FFS) sector in the same ZIP Code (n = 201); and respondents to the national Medicare Current Beneficiary Survey (MCBS) (n = 531). Patients in the MCO were more likely to be highly satisfied in three domains--global quality, access to care, and technical skills--compared with patients in the local and national FFS study groups but fewer were highly satisfied with the interpersonal manner of their providers.

Objective: To examine the association between occupational physical activity and self-reported disability., Design: Population-based case control analysis of a longitudinal population-based study in east Baltimore. Eligible participants were aged 18 to 29 yr in 1981, had complete information on occupation in 1981, no disability with tasks related to the domain of mobility in 1981, and complete information on mobility function in 1993 (n = 174). Occupations were divided into low, moderate, and high metabolic equivalents based on job category in 1981. The main outcome measure was disability defined by self-report of difficulty in one or more of five exercise mobility tasks in 1993., Results: Of 174 eligible participants, 45 (26%) reported the onset of disability at follow-up in 1993. A crude odds ratio of 0.25 (95% confidence interval, 0.06, 0.82) was found for the association of moderate compared with low occupational physical activity and the risk of incident disability in mobility tasks. After adjustments to control for possible confounders, moderate job metabolic activity (1.8-2.9 Mets) was independently protective against disability in this cohort (odds ratio = 0.25; 95% confidence interval = 0.083, 0.783)., Conclusion: In this cohort of people aged 18 to 29 yr, a moderate amount of occupational physical activity was protective against disability in mobility tasks.

The Hill-Bone Compliance to High Blood Pressure Therapy Scale assesses patient behaviors for three important behavioral domains of high blood pressure treatment: 1) reduced sodium intake; 2) appointment keeping; and 3) medication taking. This scale is comprised of 14 items in three subscales. Each item is a four point Likert type scale. The content validity of the scale was assessed by a relevant literature review and an expert panel, which focused on cultural sensitivity and appropriateness of the instrument for low literacy. Internal consistency reliability and predictive validity of the scale were evaluated using two community based samples of hypertensive adults enrolled in clinical trials of high blood pressure care and control. The standardized alpha for the total scale were 0.74 and 0.84, and the average interitem correlations of the 14 items were 0.18 and 0.28, respectively. The construct and predictive validity of the scale was assessed by factor analysis and by testing of theoretically derived hypotheses regarding whether the scale demonstrated consistent and expected relationships with related variables. In this study, high compliance scale scores predicted significantly lower levels of blood pressure and blood pressure control. Moreover, high compliance scale scores at the baseline were significantly associated with blood pressure control at both baseline and at follow up in the two independent samples. This brief instrument provides a simple method for clinicians in various settings to use to assess patients' self reported compliance levels and to plan appropriate interventions.

Objective: Guided by a social influence and empowerment framework, peer leaders in the injecting drug user (IDU) community were trained to promote human immunodeficiency virus (HIV) prevention among their contacts within and beyond their sex and drug networks., Methods: From 1994 to 1995 in Baltimore, Maryland, 36 peer leaders who participated in the 10-session training program were administered pretest and posttest surveys. Evaluation included leaders' self-reported HIV-related behaviors and outreach activities. Survey data also were collected from 78 of the leaders' risk network members., Results: Peer leaders reported a significant increase in condom use and in cleaning used needles with bleach. The leaders' risk network members, compared with controls, were significantly more likely to report greater needle hygiene. In an assessment of diffusion of information, the majority of risk network members who were current injectors reported receiving needle-cleaning materials from the leaders, and the majority of risk network members were able to correctly identify the HIV prevention slogans that had been taught to the leaders. The leaders documented 2165 HIV prevention interactions, of which 84% were with active drug users., Conclusions: The results from this study suggest that, in the IDU community, training peer leaders as HIV educators may promote HIV prevention among the leaders' risk network members and others at risk of acquiring and transmitting HIV. This training also may provide the leaders with effective prosocial roles.

Objective: Although lowering incidence rates of human immunodeficiency virus (HIV) transmission is the primary goal of needle exchange programs (NEPs), other desirable outcomes are possible. Referring exchange participants to more comprehensive drug abuse treatment programs has the potential to reduce or eliminate the use of drugs. This possibility was evaluated by comparing the treatment responses of new admissions with an outpatient opioid agonist treatment program in Baltimore, Maryland., Methods: New admissions (1994 - 1997) to an opioid agonist treatment program were first grouped by referral source (needle exchange, n = 82 vs. standard referrals, n = 243) and then compared on admission demographic and clinical variables and response to treatment during the first three months. Outcome measures included retention rates, self-reported drug use and injecting frequencies, self-reported illegal activities for profit, and results from weekly urinalysis testing for opioids and cocaine., Results: Patients from the NEP were significantly older and more likely to be male, African American, and unemployed than standard referral patients. Needle exchange patients also had a greater baseline severity of drug use than patients in the standard referral group. Despite these baseline differences, both groups achieved comparably good short-term treatment outcomes (including reduced drug use and criminal activity for profit); treatment retention was also good, although slightly better in the standard referral group (88% vs. 76%)., Conclusion: These data demonstrate the feasibility and merits of creating strong linkages between NEPs and more comprehensive drug abuse treatment clinics.

Quality clinical experiences are a critical component of advanced practice nursing (APN) curricula. Historically, nursing instructors coordinated both the didactic and clinical components of a course. Increasingly, course coordinators organize the didactic component, and external preceptors working in the clinical setting function as practicum teachers. Both scenarios involve labor-intensive processes, and neither facilitate the scheduling of clinical experiences that build on progressive learning across the student's curriculum. A centralized, computerized, relational data base for efficient management of APN preceptors and students across the curriculum was designed. One master's-prepared clinical coordinator maintains the data base and performs all related functions. This system offers numerous benefits to students, preceptors, ] faculty, and nursing school, including balanced and progressively complex clinical learning experiences for students from competent preceptors: consistent interface with students and preceptors; faculty relief from time-consuming tasks; rapid generation of a variety of tables, rosters, and reports; consistent tracking of preceptor evaluations; timely acknowledgment of preceptor assistance; and efficient communication among students, preceptors, faculty, and school administration.

Both hepatitis B virus (HBV) and human immunodeficiency virus (HIV) type 1 seroconversions have been considered as outcome measures to evaluate the effectiveness of needle exchange programs. To assess the relationships between incident HBV and HIV infections among injecting drug users (IDUs), seroconversions were prospectively studied among a cohort of 240 HBV- and HIV- seronegative IDUs. The incidence of HBV seroconversion declined from 24.41/100 person-years in 1988 to 0 seroconversions in 1992. In contrast, HIV seroconversion rates varied little from the overall rate of 3.29/100 person-years. HBV seroconversion predicted subsequent HIV seroconversion among male IDUs (relative incidence [RI]= 4.23) but not among female IDUs (RI=0.86). Because of different transmission dynamics, HBV seroconversion probably has limited utility as a surrogate outcome measure for incident HIV. However, HBV seroconversion itself is an appropriate and important outcome measure for evaluation of prevention programs among IDUs.