Background: Opioid-related deaths have risen dramatically in rural communities. Prior studies highlight few medication treatment providers for opioid use disorder in rural communities, though literature has yet to examine rural-specific treatment barriers. Objectives: We conducted a systematic review to highlight the state of knowledge around rural medication treatment for opioid use disorder, identify consumer-and provider-focused treatment barriers, and discuss rural-specific implications. Methods: We systematically reviewed the literature using PsycINFO, Web of Science, and PubMed databases (January 2018). Articles meeting inclusion criteria involved rural samples or urban/rural comparisons targeting outpatient medication treatment for opioid use disorder, and were conducted in the U.S. to minimize healthcare differences. Our analysis categorized consumer-and/or providerfocused barriers, and coded barriers as related to treatment availability, accessibility, and/or acceptability. Results: Eighteen articles met inclusion, 15 which addressed consumer-focused barriers, while seven articles reported provider-focused barriers. Availability barriers were most commonly reported across consumer (n = 10) and provider (n = 5) studies, and included the lack of clinics/providers, backup, and resources. Acceptability barriers, described in three consumer and five provider studies, identified negative provider attitudes about addiction treatment, and providers' perceptions of treatment as unsatisfactory for rural patients. Finally, accessibility barriers related to travel and cost were detailed in four consumer-focused studies whereas two provider-focused studies identified time constraints. Conclusions: Our findings consistently identified a lack of medication providers and rural-specific implementation challenges. This review highlights a lack of rural-focused studies involving consumer participants, treatment outcomes, or barriers impacting underserved populations. There is a need for innovative treatment delivery for opioid use disorder in rural communities and interventions targeting provider attitudes.

Dual-energy CTPA with image reconstruction at 50 keV allows a significant reduction in iodine load while improving intravascular signal intensity, maintaining SNR and with comparable radiation dose.

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Objective: To determine the test performance characteristics of serial creatine kinase-MB (CK-MB) mass measurements for acute myocardial infarction (MI) in patients presenting to the ED with chest pain and nondiagnostic ECGs. Methods: A prospective, observational test performance study was conducted. Hemodynamically stable patients aged 2 2 5 years with chest discomfort, but without ECGs diagnostic for MI, were enrolled at 7 university teaching hospitals. Presenting ECGs showing >1 -mV ST-segment elevation in 2 2 electrically contiguous leads were considered diagnostic for MI; patients with diagnostic ECGs on presentation were excluded. Real-time, serial CK-MB mass levels were obtained using a rapid serum immunochernical assay at the time of ED presentation (0-hour) and 3 hours later (3-hour). The following testing schemes were evaluated for their sensitivity and specificity for detection of MI during patient evaluation in the ED: 1) an elevated ( 2 8 ng/mL) presenting CK-MB level; 2) an elevated presenting and/or 3-hour CK-MB level; 3) a significant increase (i.e., 2 3 ng/mL) within the range of normal limits for CK-MB concentrations during the 3-hour period (A CK-MB); andor 4) development of ST-segment elevation during the 3 hours (second ECG). Results: Of the 1,042 patients enrolled, 777 (74.6%) were hospitalized, including all 67 MI patients (8.6% of admissions). As a function of duration of time in the ED, the test performance characteristics of serial CKMBs for MI ( Conclusion: Serial CK-MB monoclonal antibody mass measurements in the E D can identify MI patients with initially nondiagnostic ECGs. CK-MB sensitivity significantly increases over 3 hours of observation of stable chest discomfort patients in the ED; it also increases as a function of the total interval from onset until enzyme measurement.

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