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IMPORTANCE Timely initiation and referral to treatment for patients with opioid use disorder seen in the emergency department is associated with reduced mortality. It is not known how often commercially insured adults obtain follow-up treatment after nonfatal opioid overdose. OBJECTIVE To investigate the incidence of follow-up treatment following emergency department discharge after nonfatal opioid overdose and patient characteristics associated with receipt of follow-up treatment.

BackgroundMental health problems are commonly encountered in primary care, with primary care providers (PCPs) experiencing challenges referring patients to specialty mental health care. Electronic consultation (eConsult) is one model that has been shown to improve timely access to subspecialty care in a number of medical subspecialties. eConsults generally involve a PCP-initiated referral for specialty consultation for a clinical question that is outside their expertise but may not require an in-person evaluation.ObjectiveOur aim was to describe the implementation of eConsults for psychiatry in a large academic health system.MethodsWe performed a content analysis of the first 50 eConsults to psychiatry after program implementation. For each question and response, we coded consults as pertaining to diagnosis and/or management as well as categories of medication choice, drug side effects or interactions, and queries about referrals and navigating the health care system. We also performed a chart review to evaluate the timeliness of psychiatrist responses and PCP implementation of recommendations.ResultsDepression was the most common consult template selected by PCPs (20/50, 40%), followed by the generic template (12/50, 24%) and anxiety (8/50, 16%). Most questions (49/50, 98%) pertained primarily to management, particularly for medications. Psychiatrists commented on both diagnosis (28/50, 56%) and management (50/50, 100%), responded in an average of 1.4 days, and recommended in-person consultation for 26% (13/50) of patients. PCPs implemented psychiatrist recommendations 76% (38/50) of the time.ConclusionsFor the majority of patients, psychiatrists provided strategies for ongoing management in primary care without an in-person evaluation, and PCPs implemented most psychiatrist recommendations. eConsults show promise as one means of supporting PCPs to deliver mental health care to patients with common psychiatric disorders.

Following a tidal disruption event (TDE), the accretion rate can evolve from quiescent to near-Eddington levels and back over timescales of months to years. This provides a unique opportunity to study the formation and evolution of the accretion flow around supermassive black holes (SMBHs). We present 2 yr of multiwavelength monitoring observations of the TDE AT2018fyk at X-ray, UV, optical, and radio wavelengths. We identify three distinct accretion states and two state transitions between them. These appear remarkably similar to the behavior of stellar-mass black holes in outburst. The X-ray spectral properties show a transition from a soft (thermal-dominated) to a hard (power-law-dominated) spectral state around L bol ∼ few × 10−2 L Edd and the strengthening of the corona over time ∼100–200 days after the UV/optical peak. Contemporaneously, the spectral energy distribution (in particular, the UV to X-ray spectral slope α ox) shows a pronounced softening as the outburst progresses. The X-ray timing properties also show a marked change, initially dominated by variability at long (>day) timescales, while a high-frequency (∼10−3 Hz) component emerges after the transition into the hard state. At late times (∼500 days after peak), a second accretion state transition occurs, from the hard into the quiescent state, as identified by the sudden collapse of the bolometric (X-ray+UV) emission to levels below 10−3.4 L Edd. Our findings illustrate that TDEs can be used to study the scale (in)variance of accretion processes in individual SMBHs. Consequently, they provide a new avenue to study accretion states over seven orders of magnitude in black hole mass, removing limitations inherent to commonly used ensemble studies.

Background The majority of individuals with opioid use disorder (OUD) face access barriers to evidence-based treatment, and the COVID-19 pandemic has exacerbated the United States (US) opioid overdose crisis. However, the pandemic has also ushered in rapid transitions to telehealth in the USA, including for substance use disorder treatment with buprenorphine. These changes have the potential to mitigate barriers to care or to exacerbate pre-existing treatment inequities. The objective of this study was to qualitatively explore Philadelphia-based low-barrier, harm-reduction oriented, opioid use disorder (OUD) treatment provider perspectives about and experiences with telehealth during the COVID-19 pandemic, and to assess their desire to offer telehealth to patients at their programs in the future. Methods We interviewed 22 OUD treatment prescribers and staff working outpatient programs offering OUD treatment with buprenorphine in Philadelphia during July and August 2020. All participants worked at low-barrier treatment programs that provide buprenorphine using a harm reduction-oriented approach and without mandating counseling or other requirements as a condition of treatment. We analyzed the data using thematic content analysis. Results Our analysis yielded three themes: 1/ Easier access for some: telehealth facilitates care for many patients who have difficulty attending in-person appointments due to logistical and psychological barriers; 2/ A layered digital divide: engagement with telehealth can be seriously limited by patients’ access to and comfort with technology; and 3/ Clinician control: despite some clinic staff beliefs that patients should have the freedom to choose their treatment modality, patients’ access to treatment via telehealth may hinge on clinician perceptions of patient “stability” rather than patient preferences. Conclusions Telehealth may address many access issues, however, barriers to implementation remain, including patient ability and desire to attend healthcare appointments virtually. In addition, the potential for telehealth models to extend OUD care to patients currently underserved by in-person models may partially depend on clinician comfort treating patients deemed “unstable” via this modality. The ability of telehealth to expand access to OUD care for individuals who have previously struggled to engage with in-person care will likely be limited if these patients are not given the opportunity to receive treatment via telehealth.

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We present the results of a large multi-wavelength follow-up campaign of the Tidal Disruption Event (TDE) AT 2019dsg, focusing on low to high resolution optical spectroscopy, X-ray, and radio observations. The galaxy hosts a super massive black hole of mass $\rm (5.4\pm 3.2)\times 10^6\, M_\odot$ and careful analysis finds no evidence for the presence of an Active Galactic Nucleus, instead the TDE host galaxy shows narrow optical emission lines that likely arise from star formation activity. The transient is luminous in the X-rays, radio, UV and optical. The X-ray emission becomes undetected after ∼100 days, and the radio luminosity density starts to decay at frequencies above 5.4 GHz by ∼160 days. Optical emission line signatures of the TDE are present up to ∼200 days after the light curve peak. The medium to high resolution spectra show traces of absorption lines that we propose originate in the self-gravitating debris streams. At late times, after ∼200 days, narrow Fe lines appear in the spectra. The TDE was previously classified as N-strong, but after careful subtraction of the host galaxy’s stellar contribution, we find no evidence for these N lines in the TDE spectrum, even though O Bowen lines are detected. The observed properties of the X-ray emission are fully consistent with the detection of the inner regions of a cooling accretion disc. The optical and radio properties are consistent with this central engine seen at a low inclination (i.e., seen from the poles).

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