The mobile emergency recovery intervention trial (MERIT): Protocol for a 3-year mixed methods observational study of mobile recovery outreach teams in Nevada's emergency departments.

BACKGROUND: The Substance Abuse and Mental Health Administration awarded State Targeted Response grants to support states' efforts to address the opioid epidemic. In Nevada, one component of this grant was mobile recovery outreach teams (MROTs) that utilized peer recovery support specialists to provide care for qualifying patients in emergency departments (EDs). The Mobile Emergency Recovery Intervention Trial (MERIT) is a mixed methods study to assess the feasibility/acceptability and effectiveness of the MROT intervention. This protocol mainly describes the R33 research activities and outcomes. The full protocol can be found protocols.io. METHODS: Data will be derived from state-level data sets containing de-identified emergency department visits, substance use disorder treatment records, and mortality files; in-person mixed methods interviews; participant observation; and self-report process evaluation forms. Primary outcomes include Medication Assisted Treatment (MAT) initiation and non-fatal overdose; secondary outcomes include MAT retention and fatal overdose. Quantitative hypotheses will be tested using generalized linear mixed effects models, Bayesian hierarchical models, and marginal Cox models. Qualitative interview data will be analyzed using an inductive thematic analysis procedure. DISCUSSION: It is impossible to conduct a randomized controlled trial of the effectiveness of the MROTs, given the ethical and logistical considerations of this intervention.This study's innovative design employs a mixed methods formative phase to examine feasibility and acceptability, and a quasi-experimental outcomes evaluation phase employing advanced statistical methods to mitigate bias and suggest causal inference regarding the effectiveness of the MROTs.Innovative interventions have been deployed in many states; evidence regarding their effectiveness is lacking, but critical to informing an effective public health response to the opioid epidemic

Capability engineering -an analysis of perspectives

The terms "capability" and "capability engineering" are now widely used across industry and in government procurement, but it is clear that different communities use the terms with similar, but distinctly different meanings. Using a soft systems methodological approach, an INCOSE UK working group has identified eight perspectives of capability, which have been related to Ring"s value cycle and the Hitchins" five layer model of systems engineering. It is asserted that capability is the ability to do something and that capability engineering is the overarching approach that links value, purpose, and solution of a systems problem. It is equivalent to layers 1-4 of Hitchins" Five Layer Model and is equivalent to an holistic perspective of systems engineering. There are significant practice and examples of capability engineering from (at least) the UK rail provision, defence, and Information Services and it is the view of the working group that further INCOSE guidance may be needed to ensure engineers are properly equipped to deal with capability and capability engineering.©2011 by Michael Henshaw, Duncan Kemp, Peter Lister, Andrew Daw, Alan Harding, Andrew Farncombe, Malcolm Touchin. Published and used by INCOSE with permission

The influence of parental smoking and family type on saliva cotinine in UK ethnic minority children: a cross sectional study

Background In the United Kingdom, there has been an increase in cigarette smoking in ethnic minority adults since the 1970s; in some groups levels are now similar to that of White British people. We aimed to examine the determinants of exposure to secondhand smoke in ethnic minority children. We hypothesised that exposure to secondhand smoke in children will vary across ethnic groups, but that the correlates of exposure would be similar to that of Whites. Methods The Determinants of Adolescent Social well-being and Health sample comprises 3468 White United Kingdom and ethnic minority (Black Caribbean, Black African, Indian, Pakistani, Bangladeshi) pupils aged 11-13 yrs. Outcome was saliva cotinine concentration. Explanatory variables collected by self-complete questionnaire included ethnicity, child reported household smoking and socio-economic circumstances. Data were analysed using linear regression models with a random intercept function. Results Ethnic minority children had lower saliva cotinine than Whites, partly explained by less smoking among parents. White and Black Caribbean children had higher cotinine levels if they lived in a household with a maternal smoker only, than with a paternal smoker only. Living in a lone compared to a dual parent household was associated with increased cotinine concentration of 45% (95%CI 5, 99%) in Whites, 27% (95%CI 5,53%) in Black Caribbeans and 21% (95%CI 1, 45%) in Black Africans after adjusting for household smoking status. Material disadvantage was a significant correlate only for White children (40% (95%CI 1, 94%) increase in cotinine in least compared to most advantaged group). Conclusions Ethnic minority children were less exposed to secondhand smoke than Whites, but the variations within groups were similarly patterned. These findings suggest that it is important not to be complacent about low smoking prevalence in some minority groups

Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial

BACKGROUND: Waiting lists for treatment are common in outpatient and community services, Existing methods for managing access and triage to these services can lead to inequities in service delivery, inefficiencies and divert resources from frontline care. Evidence from two controlled studies indicates that an alternative to the traditional &quot;waitlist and triage&quot; model known as STAT (Specific Timely Appointments for Triage) may be successful in reducing waiting times without adversely affecting other aspects of patient care. This trial aims to test whether the model is cost effective in reducing waiting time across multiple services, and to measure the impact on service provision, health-related quality of life and patient satisfaction. METHODS/DESIGN: A stepped wedge cluster randomised controlled trial has been designed to evaluate the impact of the STAT model in 8 community health and outpatient services. The primary outcome will be waiting time from referral to first appointment. Secondary outcomes will be nature and quantity of service received (collected from all patients attending the service during the study period and health-related quality of life (AQOL-8D), patient satisfaction, health care utilisation and cost data (collected from a subgroup of patients at initial assessment and after 12&nbsp;weeks). Data will be analysed with a multiple multi-level random-effects regression model that allows for cluster effects. An economic evaluation will be undertaken alongside the clinical trial. DISCUSSION: This paper outlines the study protocol for a fully powered prospective stepped wedge cluster randomised controlled trial (SWCRCT) to establish whether the STAT model of access and triage can reduce waiting times applied across multiple settings, without increasing health service costs or adversely impacting on other aspects of patient care. If successful, it will provide evidence for the effectiveness of a practical model of access that can substantially reduce waiting time for outpatient and community services with subsequent benefits for both efficiency of health systems and patient care.<br /

Immunoparesis defined by heavy plus light chain suppression is a novel marker of long-term outcomes in cardiac AL amyloidosis

Cardiac involvement and presenting dFLC (difference between involved and uninvolved free light chains) are independent predictors of outcome in systemic AL amyloidosis. These markers have limited prognostic utility in patients surviving the initial months following diagnosis. Here we assessed immunoparesis, as determined by novel heavy+light chain (HLC) immunoassays, as a prognostic marker for survival in AL amyloidosis. HLC measurements identified immunoparesis of at least one immunoglobulin (Ig) isotype in 145 (85%) patients; and severe immunoparesis (≥2 Ig isotypes suppressed by >50% below normal levels) in 29 (17%) patients. Median overall survival (OS) on intention to treat (ITT) analysis was 26·2 months. In the ITT cohort, dFLC >180 mg/l was associated with shorter OS (P = 0·05); whereas HLC immunoparesis was not prognostic. On a landmark analysis of 127 patients alive at 6 months, presenting dFLC was not prognostic for OS (P = 0·33) and severe HLC immunoparesis trended towards poorer survival (20·2 vs. 42·8 months; P = 0·09). In the subset of patients with cardiac involvement, severe HLC immunoparesis conferred very poor outcome (median OS 8·8 vs. 29·9 months, P = 0·007). In conclusion, severe HLC immunoparesis is an independent marker of long-term poor prognosis in AL patients with cardiac involvement. The pathophysiological significance of this observation needs further study