Literature Collection

OBJECTIVES: To evaluate the prevalence of the Determinants of Malnutrition in Aged Persons (DoMAP) and identify determinants of malnutrition among older adults attending primary healthcare. DESIGN AND SETTING: Prospective, observational, monocentric study in primary healthcare. PARTICIPANTS: 500 older adults. MEASUREMENTS: Malnutrition was diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Potential causes of malnutrition were assessed by the attending physician using the DoMAP model with a 1:1 recruitment of malnourished and non-malnourished older persons. RESULTS: Malnourished individuals (mean age 81.7 ± 5.0 years; 59% women) exhibited a significantly higher prevalence of almost all DoMAP determinants compared to non-malnourished persons, particularly low intake (88 vs. 11%), high requirements (83 vs. 49%), poor appetite (73 vs. 9%), shopping difficulties (59 vs. 26%), inflammation (81 vs. 49%), gastrointestinal disease (17 vs. 2%), cancer (11 vs. 1%), depression (35 vs. 19%), dementia (21 vs. 6%), polypharmacy (60 vs. 38%), and hospitalization (27 vs. 4%). The mean total determinants count was significantly higher in malnourished participants (14.9 ± 5.0) than in non-malnourished ones (6.8 ± 4.4; p < 0.001). Regression analysis revealed low intake as the strongest determinant at Level1; poor appetite, forgetting to eat, shopping difficulties and inflammation at Level2; gastrointestinal disease, cancer and depression at Level3, and frailty and hospitalization at Level4. CONCLUSION: This study highlights the complex multifactorial nature of malnutrition in older adults attending primary healthcare, confirming the superior role of low intake and poor appetite among other determinants. The DoMAP model offers a structured framework for potential causative factors of malnutrition in older subjects.

In recent years, neonatal abstinence syndrome (NAS) rates have increased rapidly across the United States, rising from 1.2 (2000) to 5.8 (2012) per 1000 hospital births annually. Because most NAS infants are treated in an intensive care setting, associated hospital charges are high and continue to escalate, rising on average from $39,400 in 2000 to $66,700 in 2012. An innovative NAS treatment program, which includes early-initiated methadone therapy, rooming-in, and combined inpatient/outpatient weaning in a low-acuity nursery, has been in place since 2003 at a large Southeastern hospital. The program has proven safe, effective and low cost for treating infants of >/=35 weeks gestational age whose mothers used long-acting opioids. Given that 81% of NAS cases in the United States are funded by Medicaid programs and that the cost burden is rising rapidly, researchers considered the potential saved charges associated with implementing the same program in other hospitals state- and nationwide. Researchers used regression models to project state and national NAS birth rates from 2015-2025 and to predict future NAS charges under current treatment protocols. Three scenarios were developed to compare the potential saved charges of implementing the innovative NAS treatment program across the state and nation with assumptions related to the percent of NAS infants eligible for the program, percent funded by Medicaid, and fluctuations in average length of stay. The potential saved charges are substantial, creating a compelling case for policy makers and hospitals in the pursuit of safe, effective, and cost-conscious NAS care.

BACKGROUND: To synthesise recent empirical evidence for the prevention and management of respiratory function in children. METHODS AND FINDINGS: We searched the PubMed, Cochrane Library, Embase and Web of Science databases for studies published from inception to 16 September 2024. Two authors independently selected eligible studies, evaluated the quality of the included studies and assessed bias based on the Cochrane Collaboration tool for assessing the risk of bias. First, 968 studies that met the inclusion criteria were selected. We stratified all studies into three groups: asthma (n=50), pneumonia (n=4) and other respiratory diseases (n=15). We performed bias evaluations and summarised the paediatric respiratory function on a pathway based on probable aetiology. We determined that household and communal management schemes for different age groups were based on different types of diseases. We divided the children into the infant group (0-3 years old), preschool age (4-6 years old), school-going age (7-13 years old) and adolescents (14-18 years old) and summarised the appropriate management schemes according to the different characteristics of each group. CONCLUSION: Effective prevention and management strategies implemented at both the family and community levels can significantly enhance the quality of life for children with respiratory disorders. Our summary highlights the importance of these strategies throughout the preadult lifecycle. We emphasise the need for future research employing rigorous and advanced methodologies to explore and address prevention and management practices across varying severity levels of respiratory conditions.

IMPORTANCE: There have only been 3 efficacy trials reporting head-to-head comparisons of pharmacotherapy and trauma-focused psychotherapy for posttraumatic stress disorder (PTSD), and none were conducted in primary care. In addition, few trials have examined treatment sequences for patients not responding to an initial treatment. OBJECTIVE: To test the hypothesis that (1) brief trauma-focused psychotherapy (written exposure therapy [WET]) is more effective than a choice of 3 selective serotonin reuptake inhibitors (SSRIs; ie, sertraline, fluoxetine, or paroxetine) and (2) WET augmentation is more effective than switching to the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine for those not responding to an SSRI. DESIGN, SETTING, AND PARTICIPANTS: This was a pragmatic comparative effectiveness trial conducted from April 2021 to June 2024 that randomized primary care patients to 1 of 3 treatment sequences: (1) SSRI followed by WET augmentation, (2) SSRI followed by switch to SNRI, or (3) WET followed by SSRI. Effectiveness in this pragmatic trial depends on treatment engagement and treatment fidelity. The study included patients meeting clinical criteria for PTSD from primary care clinics of 7 federally qualified health centers and 8 Department of Veterans Affairs medical centers. INTERVENTIONS: SSRI followed by WET augmentation, SSRI followed by switch to SNRI, or WET followed by SSRI. MAIN OUTCOMES AND MEASURES: PTSD symptom severity, as measured by the DSM-5 PTSD Checklist (PCL-5). RESULTS: A total of 700 patients (mean [SD] age, 45.1 [15.4] years; 368 men [62.1%]). The mean (SD) baseline PCL-5 score was 52.8 (11.1), indicating considerable symptom severity. At 4 months, 144 of 278 patients (51.8%) randomized to an SSRI were adherent and reported a 14.0-point PCL-5 decrease, whereas 111 of 352 patients (31.5%) randomized to WET completed all sessions and reported a 12.1-point decrease. There was no significant between-group difference (adjusted mean difference [MD], 1.79; 95% CI, -0.76 to 4.34; P = .17). For the 122 of 295 patients (41.4%) randomized to an SSRI who did not respond to treatment, those randomized to switch to the SNRI reported a 9.2-point PCL-5 decrease compared with a 2.3-point decrease for those randomized to WET augmentation, which was a statistically significant between-group difference (adjusted MD, 10.19; 95% CI, 4.97-15.41; P < .001). CONCLUSIONS AND RELEVANCE: Study results showed that treatment of PTSD in primary care with either SSRIs or WET was feasible and effective. For patients not responding to an SSRI, switching to an SNRI may be more effective than WET augmentation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04597190.

BACKGROUND: The United States faces a growing challenge with over 6.5 million people living with dementia (PLwD). PLwD and their caregivers struggle with cognitive, functional, behavioral, and psychosocial issues. As dementia care shifts to home settings, caregivers receive inadequate support but bear increasing responsibilities, leading to higher healthcare costs. In response, the Centers for Medicare & Medicaid Services (CMS) introduced the Guiding an Improving Dementia Experience (GUIDE) Model. The study explores the real-world implementation of the Cedars-Sinai C.A.R.E.S. Program, a pragmatic dementia care model, detailing its recruitment process and initial outcomes. METHODS: The Cedars-Sinai C.A.R.E.S. Program was integrated into the Epic electronic health record system and focused on proactive patient identification, engagement, interdisciplinary collaboration, care transitions, and ongoing care management. Eligible patients with a dementia diagnosis were identified through electronic health record and invited to join the program. Nurse practitioners with specialized training in dementia care performed comprehensive assessments using the CEDARS-6 tool, leading to personalized care plans developed in consultation with primary care providers. Patients benefited from a multidisciplinary team and support from care navigators. RESULTS: Of the 781 eligible patients identified, 431 were enrolled in the C.A.R.E.S. PROGRAM: Enrollees were racially diverse, with lower caregiver strain and patient behavioral and psychological symptoms of dementia (BPSD) severity compared to other programs dementia care programs. Healthcare utilization, including hospitalizations, emergency department (ED) admissions, and urgent care visits showed a downward trend over time. Completion of advanced directives and Physician Order of Life-Sustaining Treatment (POLST) increased after enrollment. CONCLUSION: The Cedars-Sinai C.A.R.E.S. Program offers a promising approach to dementia care. Its real-world implementation demonstrates the feasibility of enrolling a diverse population and achieving positive outcomes for PLwD and their caregivers, supporting the goals of national dementia care initiatives.

Introduction: Access to prenatal care offers the opportunity for providers to assess for substance use disorders (SUDs) and to offer important treatment options, but utilization of treatment during pregnancy has been difficult to measure. This study presents pre-COVID trends of a subset of SUD diagnosis at the time of delivery and related trends in treatment utilization during pregnancy. Materials and Methods: A retrospective cohort design was used for the analysis of West Virginia Medicaid claims data from 2016 to 2019. Diagnosis of SUDs at the time of delivery and treatment utilization for opioid use disorder (OUD) and non-OUD diagnosis during pregnancy across time were the principal outcomes of interest. This study examined data from n = 49,398 pregnant individuals. Results: Over the 4-year period, a total of 2,830 (5.7%) individuals had a SUD diagnosis at the time of delivery. The frequency of opioid-related diagnoses decreased by 29.3%; however, non-opioid SUD diagnoses increased by 55.8%, with the largest increase in the diagnosis of stimulant use disorder (30.9%). Treatment for OUD increased by 13%, but treatment for non-opioid SUD diagnoses during pregnancy declined by 41.1% during the same period. Conclusions: Interventions enacted within West Virginia have improved access and utilization of treatment for OUD in pregnancy. However, consistent with national trends in the general population, non-opioid SUD diagnoses, especially for stimulants, have rapidly increased, while treatment for this group decreased. Early identification and referral to treatment by OB-GYN providers are paramount to reducing pregnancy and postpartum complications for the mother and neonate.

Behavioral health conditions are disproportionately experienced by people living with Human immunodeficiency virus (HIV), including young Black gay, bisexual, and other men who have sex with men (GBMSM). Left unaddressed, these symptoms can adversely impact HIV care outcomes. Improving the integration of behavioral health and HIV care services has been proposed as a strategy to address this challenge. To conduct a pre-implementation study exploring barriers and facilitators to improving HIV and behavioral health care integration at two HIV clinics in Atlanta, Georgia. We conducted a mixed-methods study guided by the Consolidated Framework for Implementation Research (CFIR). Sixty (60) HIV care providers, behavioral health care providers, and social service providers participated in cross-sectional surveys, and a subset of survey participants (15) also participated in a qualitative in-depth interview to explore CFIR constructs in greater depth. We focused on Intervention Characteristics, Outer Setting, and Inner Setting as the most relevant CFIR domains. Within each of these domains, we identified both facilitators and barriers to improving HIV and behavioral care integration in the two clinics. Participants agreed that enhancing integration would provide a relative advantage over current practice, would address young Black GBMSM and other patient needs, and would be compatible with the organizational mission. However, they also expressed concerns about complexity, resource availability, and priority relative to other clinic initiatives. Participants were enthusiastic about improving care integration but also invoked practical challenges to translating this idea into practice. Future research should test specific implementation strategies and their potential effectiveness for improving the integration of behavioral health and HIV care, as a strategy for improving well-being among young Black GBMSM and other people living with HIV.; People living with Human immunodeficiency virus (HIV), including young Black gay, bisexual, and other men who have sex with men, often experience challenges related to behavioral health. We did a study to explore barriers and facilitators to improving the integration of behavioral health and HIV services at two HIV clinics in Atlanta, Georgia. Our study included interviews and surveys with sixty care providers. Participants shared that improving care integration was a good idea and would address patients’ needs. However, they also expressed concerns about challenges that might get in the way of integrating care effectively. Future research should test different ways of improving care integration in these types of settings.; eng