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States With Substantial Increases In Buprenorphine Uptake Did So With Increased Medicaid Prescribing, 2018–24
No full textMultiple federal policy changes since 2018 have been intended to increase buprenorphine prescribing in response to a persistent treatment gap for opioid use disorder in the US. Anticipated national increases did not occur, but highly variable state-level trends provide important insights. We used IQVIA data to examine all-payer and per payer prescribing across states during the period 2018-24. All-payer prescriptions per 1,000 residents increased by more than 60 percent in ten states while decreasing by more than 10 percent in eight states. States expanding Medicaid during this period increased all-payer prescribing by 27.3 percent; those that had expanded earlier increased prescribing by 11.6 percent, whereas in nonexpansion states, prescribing declined by 2.1 percent. All-payer rates ranged thirty-eight-fold in 2024 (varying from 9.3 to 355.5 per 1,000; lowest quintile, 15.7 per 1,000; highest quintile, 118.6 per 1,000). Medicaid prescribing changes were key drivers of all-payer changes. In 2024, Medicaid prescribing ranged from 0.50 per 1,000 to 217.26 per 1,000, and from 3.6 percent to 66.8 percent of all-payer buprenorphine prescriptions. The self-pay proportion ranged from 0.7 percent to 30.8 percent, and this proportion was strongly associated with the Medicaid proportion. Highly disparate state-level changes suggest that federal policy impacts were mediated by state-specific factors. Medicaid's key role in driving overall prescribing highlights the public health urgency of maintaining expansions and sustaining enrollment for the single adult population
Benefits of enhanced recovery after surgery in robotic nephrectomy
No full textPurpose: Enhanced recovery after surgery (ERAS) is an evidence-based perioperative care approach aimed at attenuating surgical stress response and facilitating patient recovery. This study compared postoperative outcomes between an ERAS perioperative model to a traditional, unstandardized perioperative care practice in patients undergoing robotic nephrectomy.
Materials and methods: A total of 206 patients who underwent robotic renal surgery were stratified into traditional and ERAS cohorts. In total, 111 patients received the ERAS pathway, and 95 received traditional care. Data was collected through a retrospective review of electronic medical records. The primary outcome was length of hospital stay (LOS). The secondary outcomes included patient recovery milestones, pain scores, opioid use, patient complications, 30-day readmission rates, incidence of surgical site infection, and total hospital costs.
Results: Implementation of the ERAS pathway was associated with shorter hospital stay (median LOS 2.2 days vs. 2.3 days p = 0.011), lower post-operative pain scores and lower total opioid requirements at all analyzed time points (0-1, 1-24, and 24-48 h). No statistically significant differences were observed in adverse events, rates of ileus, time to first flatus, surgical site infection, or oral intake. Hospital costs were similar between groups. 30-day readmission was higher in the traditional care cohort (9% vs. 2% p = 0.035).
Conclusions: ERAS was associated with reduced length of hospital stay, improved pain scores, reduced opioid use, and lower incidence of hospital readmission in patients undergoing robotic nephrectomy
"Star of the snowbelt": On the Genealogy of Indianapolis Charter Schools
No full textIUIThis thesis traces the ideological genealogy of the charter schools Indianapolis from the 1980s to the mid-2010s, examining how power over public education shifted from democratic school boards to a complex network of political, philanthropic, and market actors. Using archival research from the Indianapolis Mayoral Archives and a historical genealogical approach, this study reveals how national reform discourse materialized into distinctive local governance structures that fundamentally reconfigured educational power relationships.
The analysis unfolds in three parts. First, it examines how the 1983 “A Nation at Risk” government report created a crisis narrative that enabled educational alternatives. Second, it analyzes how charter school legislation proliferated across states. Each state adapted the concept to local political contexts while federal administrations from Clinton through Obama provided bipartisan support through different governance mechanisms. Third, Indianapolis is used as a case study of how this mechanism evolved in Indiana’s capital city.
The Indianapolis landscape reveals unique factors that shaped charter development: Unigov’s exclusion of school districts created institutional space for mayoral intervention; demographic transformation of Indianapolis Public Schools following white flight provided the crisis narrative for reform; and intermediary organizations like The Mind Trust channeled philanthropic capital into local charter expansion. The city developed distinctive features including mayoral authorization of charter school and Innovation network Schools that hybridized charter autonomy with district oversight.
Qualitative analysis empirical data on school outcomes reveals the contradictions in charter reform. While Herron High School achieved success, Flanner House Elementary perpetrated systemic fraud, and approximately one-third of Indianapolis charter school shutter due to financial and administrative failures. Such divergent outcomes demonstrate that reconfigured educational governance created possibilities for both innovation and exploitation.
This thesis concludes that charter school reform in Indianapolis represents neither simple privatization nor democratic renewal. Rather, it is a fundamental reconfiguration of who, or what, has power over educational governance, one that blurs boundaries between public and private control. This transformation illustrates how neoliberal reforms operate through local adaptation rather than wholesale replacement of public institutions, raising questions about democratic accountability in public education
Voices from the Hallway: School Staff Perspectives on Building Healthier School Communities
No full textInnovative Web-Based Future Planning and Well-Being for Caregivers of Individuals With Intellectual and Developmental Disabilities: Protocol of a Pragmatic Randomized Controlled Trial
No full textBackground: Nearly three-quarters of the estimated 4.9 million people with intellectual and developmental disabilities (IDDs) in the United States live with family caregivers, 25% of whom are aged older than 60 years. People with IDDs experience disproportionately high rates of mortality, morbidity, and acute care use, often due to a lack of accessible, tailored resources to support them throughout the lifespan. Few caregivers engage in long-term care (LTC) planning, often due to a lack of information and support.
Objective: This protocol describes the design and methods of the Future Planning and Well-Being for Individuals with Intellectual Disabilities and Family Caregivers study, a randomized controlled trial evaluating the effectiveness of the Map Our Life web-based LTC planning tool compared to an attention control website on caregiver-reported burden, caregiver-reported well-being, and progress in and communication of future plans for the individual with an IDD.
Methods: The Future Planning and Well-Being for Individuals with Intellectual Disabilities and Family Caregivers study is a national, multisite, randomized controlled clinical trial with a target enrollment of 1050 family caregivers of individuals with IDDs at 6 sites across the United States. Participants are randomly assigned (1:1) to either the Map Our Life web-based LTC planning tool plus enhanced usual care or an attention control group consisting of a Centers for Disease Control and Prevention-sponsored health promotion website for people with disabilities plus enhanced usual care. Primary outcomes, including caregiver-reported burden, caregiver-reported well-being, and LTC planning behaviors, are assessed at baseline and at 1, 6, and 18 months. Data will be analyzed using mixed-effects models to accommodate the repeated measures design.
Results: This study was funded in July 2022, received initial Institutional Review Board approval in August 2023, and was registered on ClinicalTrials.gov in December 2023. Recruitment began in December 2023 and is scheduled to conclude in December 2025. Primary outcome analyses will commence immediately following the completion of final follow-up surveys.
Conclusions: LTC planning is an important component of addressing health disparities among individuals with disabilities and their family caregivers. By focusing on using an innovative and accessible tool for LTC planning, the study addresses a critical gap in available resources with the potential to improve quality of life and reduce caregiver burden
Integrated single-cell multiomic profiling of caudate nucleus suggests key mechanisms in alcohol use disorder
No full textAlcohol use disorder (AUD) induces complex transcriptional and regulatory changes across multiple brain regions including the caudate nucleus, which remains understudied. Using paired single-nucleus RNA-seq and ATAC-seq on caudate samples from 143 human postmortem brains, including 74 with AUD, we identified 17 distinct cell types. A significant portion of the alcohol-related differences in gene expression were accompanied by a corresponding difference in chromatin accessibility within the gene. We observed transcriptional differences in medium spiny neurons that impact RNA metabolism and immune response pathways. A small cluster of D1/D2 hybrid neurons showed AUD-induced differences distinct from the D1 and D2 types, suggesting a unique role in AUD. Those with AUD had a higher proportion of microglia in an inflammatory state; astrocytes entered a reactive state partially regulated by JUND. Oligodendrocyte dysregulation was driven in part by OLIG2 activity and increased TGF-β1 signaling from microglia and astrocytes. We also observed increased microglia-astrocyte communication via the IL-1β pathway. These findings provide valuable insights into the genetic and cellular mechanisms in the caudate related to AUD. They also demonstrate the broader utility of large-scale multiomic studies in uncovering complex gene regulation across diverse cell types, which has implications beyond the substance use field
Blood Pressure Effects and Risk of Hypotension due to Intravenous Furosemide in Acute Decompensated Heart Failure
No full textObjective: We quantified the magnitude of systolic blood pressure (SBP) adverse effects associated with intravenous furosemide (IVFu), compared to other factors, during treatment for acute decompensated heart failure (ADHF).
Methods: Continuous BP monitoring (598.2 person-hours, 91,210 observations) before and after IVFu was performed in a prospective multicenter ADHF cohort (n = 253). Multivariable-adjusted mixed effects regression was used to determine the amount of SBP reduction and the risk of hypotension attributable to IVFu administration, as opposed to confounders (e.g., non-IVFu treatments and baseline patient characteristics).
Results: Median SBP was 124 mmHg (IQR: 105-149) at baseline. Hypotension occurred in 5515 observations (6.0%). The multivariable models explained 79.6% and 58.1% of variance in SBP and risk of hypotension, respectively. Only 1.4% of variance in SBP and 1.7% of hypotension risk were related to IVFu, with the remainder accounted for by confounders. After multivariable adjustment, SBP dropped -11.9 mmHg on average after 80 mg IVFu, reaching a nadir at 147 min (-15.2 mmHg) and partial return to baseline by 6 h (-8.5 mmHg). IVFu-related risk of hypotension after multivariable adjustment depended predominantly on baseline SBP and dose. Risk of hypotension associated with 80 mg IVFu was ≤ 2% with baseline SBP ≥ 120 mmHg. For 40 mg, IVFu-associated hypotensive risk was ≤ 2% with SBPs of 90-100 mmHg, and < 1% with SBP ≥ 110 mmHg. IVFu-associated risk of hypotension returned to zero at 6 h after administration, regardless of dose.
Conclusions: Blood pressure reductions after IVFu during ADHF treatment are modest, and hypotension is rare and transient. Most variance in SBP during ADHF treatment is due to other factors
Predicting Pancreatic Ductal Adenocarcinoma Occurrence Up to 10 Years in Advance Using Features of the Main Pancreatic Duct in Pre-Diagnostic CT Scans
No full textBackground/Objectives: Pancreatic ductal adenocarcinoma (PDAC) prediction in high-risk individuals is essential for early detection and improved outcome. While prior studies have utilized pancreatic radiomics for PDAC prediction, the added value of main pancreatic duct (MPD) features remains unclear. This study aims to assess the additional value of features of the main pancreatic duct (MPD) for predicting PDAC occurrence across different timeframes in advance. Methods: In total, 321 contrast-enhanced CT scans of the MPD and pancreas carried out across control, pre-diagnostic, and diagnostic cohorts were segmented, and radiomics were extracted. A support vector machine (SVM) classifier was used to classify the control and pre-diagnostic cohorts, with model performance assessed using area under the receiver operating characteristic (ROC) curves (AUCs) Results: The MPD diameter and volume significantly increased from the control to the pre-diagnostic and diagnostic CT scans (p < 0.05). The addition of features of the MPD to the pancreas improved the PDAC prediction AUC from 0.83 to 0.96 for subjects 6 months to 3 years in advance, from 0.81 to 0.94 for 3-6 years in advance, and 0.75 to 0.84 for 6-10 years in advance of diagnosis. Additionally, integrating MPD radiomics with diameter and volume significantly improved the AUC from 0.81 to 0.88 for subjects 6 months to 3 years in advance. Conclusions: Radiomic features from abdominal CT scans allow PDAC prediction up to 10 years in advance. Integrating MPD features, including diameter and volume, significantly improves PDAC prediction compared to using radiomics of the pancreas alone
A novel commensal Neisseria species harboring the gonococcal diagnostic marker DR-9 causes false-positive Roche cobas NAAT results
No full textNeisseria gonorrhoeae (Ng), the etiologic agent of gonorrhea, is the second most reported bacterial sexually transmitted infection globally. In the USA, nucleic acid amplification tests (NAATs) are considered the gold standard for diagnosis. Although NAATs are sensitive and offer high throughput, cross-reactivity with commensal Neisseria can compromise specificity. Here, we report the isolation and characterization of a novel commensal Neisseria sp. from the oropharynx of a patient with suspected gonococcal treatment failure. An initial diagnosis was made using the Roche cobas CT/NG test on the cobas 8800 system, which repeatedly yielded positive results post-treatment. A confirmatory Aptima Combo 2 (AC2, Hologic) test was negative, and multiple culture attempts failed to isolate Ng. Instead, a commensal Neisseria strain was recovered. Whole-genome sequencing revealed this isolate shared partial genomic identity with several Neisseria spp., including Ng, and carried a distinct region encoding the gonococcal diagnostic marker DR-9, the target of cobas assays. Cross-reactivity was confirmed with the cobas 4800 and 6800 platforms, but not with the AC2 assay targeting 16S rRNA. We discuss the possible origins of the DR-9 marker on this strain as well as examine its antimicrobial susceptibility profile and genomic resistance markers. These findings highlight the potential for misdiagnosis and unnecessary treatment when commensal Neisseria species harbor Ng diagnostic targets. Our study underscores the need for genomic surveillance of Ng and commensal Neisseria, not only to monitor diagnostic performance but also to track commensals that may serve as reservoirs of antimicrobial resistance determinants and contribute to the spread of resistance.IMPORTANCEAccurate diagnosis of gonorrhea is critical for effective treatment and antimicrobial stewardship. Nucleic acid amplification tests, the mainstay of gonococcal diagnostic testing, can yield false-positive results due to genetic overlap between Neisseria gonorrhoeae and commensal Neisseria species, especially from extragenital sites like the oropharynx. Prior studies, such as Hopkins et al. (2023), have recognized this limitation and proposed supplemental tests to improve specificity for oropharyngeal specimens. Here, we describe a novel commensal Neisseria strain isolated from a patient with suspected treatment failure that harbors the gonococcal diagnostic marker DR-9. This case highlights the need for confirmatory testing using an alternate gene target in cases where repeated positive tests are obtained with extragenital specimens and demonstrates the need for improved test specificity, particularly for anatomical sites such as the pharynx, which has high commensal diversity. Enhanced molecular surveillance of commensal Neisseria populations will be vital for understanding and minimizing diagnostic cross-reactivity