Prisma Health

Medications for opioid use disorder (MOUD) are effective in reducing opioid use, but retention to buprenorphine remains suboptimal among OUD patients. Integration of computer-based cognitive behavioral therapy (CBT4CBT) and utilization of recovery coaches (RCs), called RC+CBT4CBT-Buprenorphine, into OUD care could improve drug use and retention in care among patients taking buprenorphine. The OVERCOME II (OUD Intervention Recovery Coach CBT and OUD Medications II) study is a three-arm 1:1:1 randomized clinical trial designed to test the remotely delivered RC+CBT4CBT-Buprenorphineintervention as an adjunct to buprenorphine treatment for patients with OUD, and to compare it with both CBT4CBT-Buprenorphine alone and the treatment as usual (TAU). Patients (n=90) who have newly initiated buprenorphine in the past 90days are planned to be recruited. Comprehensive measures on demographics, various conditions/constructs, and outcomes will be collected from medical charts and survey instruments. Additionally, neurophysiological outcomes and neurocognitive inhibitory controls will be measured using the NEXUS-10-MKII physiological system with BioTrace+ software and computerized Drug Go/NoGo Task, respectively. Qualitative analysis of interviews with N=2 RCs and N=15 participants will also be conducted. The study will be the first to examine the effectiveness of the remotely delivered RC+CBT4CBT-Buprenorphine intervention on drug use (during the first 8weeks and follow-up) and retention in care, as well as on various neurophysiological and cognitive performances in comparison to CBT4CBT-Buprenorphine alone and TAU. Clinical Trial Registration: This study was registered at ClinicalTrials.gov (NCT06102200, www.clinicaltrials.gov/) on August 31, 2023, with a title, An Integrated Intervention Involving Recovery Coaching and Cognitive Behavioral Therapy for Opioid Use Disorder (OVERCOME 2).

In the PROACTIVE-HF trial, remote heart failure (HF) management using comprehensive vital signs and seated mean pulmonary artery pressure (mPAP) was safe and resulted in a low reported rate of HF hospitalization (HFH) and all-cause mortality (HFH/D) through 12 months. In this report, we extend the results from the PROACTIVE-HF study through 2 years, stratified by ejection fraction (EF). PROACTIVE-HF was a prospective, multicenter, open-label, single-arm trial evaluating the safety and efficacy of patient management using the Cordella PA pressure sensor system in patients with New York Heart Association class III symptoms, regardless of EF. In the first 24 months, the incidence of HF events (HFE)/D was 0.89 (95% CI 0.81-0.99) events per patient, driven by HFH. Patients with HF with reduced EF had greater HFE/D rates than those with HF with preserved EF (1.0 vs 0.8 events per patient, P = .048). For patients with HF experiencing moderate-to-severe symptoms, management using the Cordella PA sensor system was associated with low event rates and improved health status at 2 years, regardless of EF. Comprehensive remote monitoring of vital signs, seated PAP, and patient-reported symptoms via a digital platform supports sustained benefit for high-risk patients with HF.

Introduction: Sinus of Valsalva aneurysms are rare cardiac anomalies, typically congenital but occasionally acquired, that may remain asymptomatic until rupture. Rupture can lead to acute hemodynamic instability, heart failure, or death. Diagnosis can be particularly challenging in pediatric patients, especially when presenting with non-specific symptoms or misleading history. We report a case of a ruptured sinus of Valsalva aneurysm in an adolescent, initially misattributed to substance ingestion. Description: A 15-year-old female presented with altered mental status, seizure-like activity, and desaturations after reportedly ingesting a cannabis edible at school. Narcan was administered with minimal improvement. She was tachycardic and mydriatic on arrival. Her mental status normalized in the emergency department. Initial workup revealed mild hyponatremia, metabolic acidosis, anemia (Hgb 6.5), and QT prolongation. Head CT was unremarkable. The patient was initially believed to be stable for PICU transfer for ingestion monitoring. However, she decompensated prior to transfer, developing persistent hypotension and desaturations despite supportive measures, requiring intubation and urgent PICU admission. In the PICU, chest radiograph revealed cardiomegaly. Echocardiogram showed aortic insufficiency, mitral regurgitation, pericardial effusion, reduced ejection fraction, and a ruptured subvalvular aneurysm. She underwent surgical repair of a ruptured sinus of Valsalva and posterior aortic root reconstruction. Intraoperative findings were consistent with infective endocarditis. She was discharged but readmitted the following day with fever. Imaging showed a mitral valve mass and rim-enhancing pericardial effusion requiring washout. Postoperatively, she developed right-sided weakness and facial droop. MRI confirmed a left MCA infarct, and she underwent thrombectomy. Progressive systolic dysfunction led to ultimately receiving an orthotopic heart transplant. Discussion: This case highlights the diagnostic challenge of serious cardiac pathology in adolescents presenting with neurologic or toxicologic symptoms. This case explains the importance of avoiding anchoring bias. Early cardiac imaging in the setting of unexplained hypoxia, hypotension, or anemia may identify rare but life-threatening conditions.

ObjectiveRefractory pain of the shoulder hinders independence and decreases quality of life. Sixty-day peripheral nerve stimulation (PNS) treatment has shown the ability to provide substantial and sustained relief in patients with chronic shoulder pain. The present study aims to identify key patient and treatment characteristics that may be utilized by physicians to optimize patient outcomes.DesignAn institutional review board–approved retrospective chart review evaluated patients who previously underwent 60-day PNS treatment for their chronic shoulder pain. Patient and treatment characteristics were extracted from electronic medical records and analyzed alongside patient-reported outcomes provided at the end of treatment.ResultsOverall, 221 patients were included in the study. Of patients with available outcomes, 75% (n = 132/176) reported substantial (i.e., ≥50%) pain relief at end of treatment. PNS treatment effectiveness was consistent when stratified by several factors, including the chronicity of pain, patient age, and the cause of pain. Regression analyses identified characteristics associated with successful outcomes.ConclusionsThe study highlights the effectiveness of 60-day peripheral nerve stimulation treatment across a variety of shoulder pain types and medical histories. These findings complement previous studies and real-world evidence supporting PNS in the management of chronic shoulder pain and provide insights that may inform patient selection and optimization of 60-day PNS treatment.

Background: Opioid medications are prescribed for pain management including headache treatment; recent study suggests its association with cardiovascular disease including stroke. We investigated the relationship between oral opioid use and incident ischemic stroke within the Atherosclerosis Risk in Communities (ARIC) study. Methods: We analyzed data from 11,668 ARIC participants (mean age 60 ± 6 years, 78% white and 56% female) at Visit 3 (1993–1995), including 390 opioid users, followed for ischemic stroke events. Oral opioid medication use was not assessed directly; instead, opioids would have been captured through the comprehensive medication inventory if participants brought relevant medication containers to the visit. Cox proportional hazards regression models estimated hazard ratios (HRs) for incident ischemic stroke associated with opioid use, adjusting for demographic and vascular risk factors (age, sex, race, hypertension, diabetes, smoking). Kaplan–Meier survival curves and log-rank tests compared event-free survival. Results: During follow-up, 1,011 ischemic strokes occurred, including 46 among opioid users. In univariate Cox models, opioid use was significantly associated with higher stroke risk (HR 1.59; 95% CI, 1.19–2.14; p = 0.002). In multivariable models adjusting for age, sex, race, hypertension, diabetes, smoking and atrial fibrillation, opioid use remained independently associated with incident ischemic stroke (HR 1.55; 95% CI, ~1.15–2.09; p = 0.004). Kaplan–Meier analysis ( Figure ) demonstrated significantly lower cumulative stroke-free survival among opioid users compared with non-users (log-rank χ 2 = 9.72, p = 0.002) . Conclusions: In ARIC, oral opioid use was independently associated with a ~50% increased risk of incident ischemic stroke after adjustment for established vascular risk factors. These findings highlight the need for careful risk–benefit assessment when prescribing opioids, particularly in populations with elevated cardiovascular risk.