Initiating oral or injectable Naltrexone at Discharge equally effective for reducing heavy drinking in AUD: JAMA

Researchers have found in a hospital-based randomized trial that Initiating oral or injectable naltrexone at hospital discharge significantly reduced heavy drinking in patients with alcohol use disorder (AUD) . It is strange that despite its effectiveness, fewer than 2% of hospitalized patients with alcohol-related illnesses are offered medication. The study highlights the hospital as a critical opportunity for identifying and treating AUD, with both daily oral and monthly injectable naltrexone proving similarly effective.

Alcohol use disorder (AUD) is common in hospital patients. AUD medications are not typically initiated in that setting. The comparative effectiveness between initiation of oral naltrexone and extended-release injectable naltrexone in the hospital is not known. A study was done to compare the effectiveness of initiating oral naltrexone vs extended-release injectable naltrexone on reduction in alcohol use and health care utilization among medical inpatients with AUD. The Alcohol Disorder Hospital Treatment (ADOPT) study is a randomized clinical trial conducted at an urban teaching hospital in the US, with enrollment between June 2016 and March 2020. Inpatients were screened for eligibility, and those with AUD and recent heavy drinking (defined as 5 or more drinks for men and 4 or more drinks for women) were enrolled. Outcomes were assessed at 3-month follow-up; assessors were not blinded to treatment assignment. Data were analyzed from May 2021 to September 2023. Participants received either daily oral naltrexone or monthly extended-release injectable naltrexone. All received medical management with a research nurse who specialized in addiction. The primary outcome was change in percentage of heavy drinking days (HDDs) over the past 30 days from baseline to 3-month follow-up, assessed by validated instrument. The secondary outcome was any acute health care utilization (emergency department or hospitalization) at 3-month follow-up over the past 90 days. Results Of 248 participants, 199 (80.2%) were male, and the mean (SD) age was 49.4 (10.4) years. The baseline median (IQR) percentage of HDDs in the past 30 days was 80.0% (43.3-100). At 3-month follow-up, the mean percentage of HDDs in the past 30 days was reduced in both groups (oral naltrexone: baseline, 66.7% HDDs; 3-month follow-up, 27.4% HDDs; difference, −38.4 percentage points; 95% CI, −125.0 to 48.2; extended-release injectable naltrexone: baseline, 70.7% HDDs; 3-month follow-up, 23.8% HDDs; difference, −46.4 percentage points; 95% CI, −123.4 to 30.6; P = .14). At follow-up, 59 of 109 in the oral naltrexone arm (54.1%) and 66 of 108 in the extended-release injectable naltrexone arm (61.1%) reported acute health care utilization in the prior 3 months; the odds of this utilization were not significantly different between groups (adjusted odds ratio, 1.34; 95% CI, 0.77-2.33). In this randomized clinical trial, when initiated at hospital discharge, oral and extended-release injectable naltrexone did not differ in effectiveness. Participants had substantial reductions in HDDs in both treatment groups; however, there was not a significant difference in the reduction of percentage of HDDs in the past 30 days or acute health care utilization between groups. Hospitalization represents an opportunity to start AUD pharmacotherapy; choice of oral naltrexone vs extended-release injectable naltrexone should be directed by factors such as patient preference and insurance.

Reference:

Magane KM, Dukes KA, Fielman S, et al. Oral vs Extended-Release Injectable Naltrexone for Hospitalized Patients With Alcohol Use Disorder: A Randomized Clinical Trial. JAMA Intern Med. Published online April 21, 2025. doi:10.1001/jamainternmed.2025.0522

Keywords:

Magane KM, Dukes KA, Fielman S, Initiating, oral, injectable, Naltrexone, Discharge, equally, effective, reducing, heavy, drinking, AUD, JAMA

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Atopic Diseases Linked to Increased Risk of Knee Osteoarthritis, Study Finds

South Korea: A recent nationwide cohort study published in Scientific Reports has highlighted a significant link between atopic diseases and an increased risk of knee osteoarthritis (OA), with individuals suffering from multiple atopic conditions being at a particularly higher risk.

The researchers revealed that atopic diseases like asthma, allergic rhinitis, and atopic dermatitis were linked to a 36% higher risk of knee osteoarthritis, with the risk rising further with multiple conditions. Strongest associations were seen in those aged 50–59, males, and non-obese individuals, highlighting atopic diseases as a notable risk factor for knee OA.

Knee osteoarthritis and atopic diseases, such as asthma, allergic rhinitis, and atopic dermatitis, share the common underlying mechanisms of chronic inflammation. However, the potential link between these conditions has remained unclear. For this purpose, Dojoon Park, The Catholic University of Korea, Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, Republic of Korea, and colleagues conducted a large nationwide cohort study to investigate whether individuals with atopic diseases face a higher risk of developing knee OA.

For this purpose, the researchers conducted a nationwide cohort study using data from the Korean National Health Insurance Service (NHIS), encompassing 880,300 individuals aged 50 and older. Atopic diseases were defined based on three or more outpatient visits for asthma, allergic rhinitis, or atopic dermatitis. The incidence of knee osteoarthritis was identified using ICD-10 diagnostic codes, and hazard ratios (HRs) were calculated using Cox proportional hazards models to assess the association between atopic conditions and knee OA risk.

The key findings of the study were as follows:

  • Individuals with atopic diseases had a 36% higher risk of developing knee osteoarthritis compared to those without (HR = 1.36).
  • A dose-response relationship was observed, with the risk rising as the number of atopic conditions increased (HR = 1.44 for two conditions; HR = 1.51 for all three).
  • The strongest associations were among individuals aged 50–59 years and among males.

The nationwide cohort study highlights a significant link between atopic diseases and an elevated risk of knee osteoarthritis, particularly in younger individuals. These findings suggest that atopic conditions may serve as a potential risk factor for knee OA, underscoring the need for further research to clarify the role of atopic-specific inflammation and explore possible avenues for targeted prevention and treatment strategies.

“Future research should prioritize longitudinal studies to monitor the progression of osteoarthritis in individuals with atopic diseases, along with experimental investigations into shared inflammatory pathways,” the authors noted. They further emphasized that identifying common biomarkers could facilitate early diagnosis and targeted therapies, while clinical trials assessing the impact of managing atopic inflammation on osteoarthritis outcomes would be essential for translating these findings into clinical practice.

Reference:

Park, D., Choi, Y., Han, K., Koh, H., & Koh, H. S. (2025). Risk of knee osteoarthritis in patients with multiple atopic conditions: A nationwide study. Scientific Reports, 15(1), 1-10. https://doi.org/10.1038/s41598-025-92247-7

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Obesity Linked to Higher OSA Odds, but Many with OSA Are Not Obese: Meta-analysis

USA: A meta-analysis of 12,860 adults revealed that obesity significantly increased the odds of obstructive sleep apnea (OSA), with a nearly fivefold higher risk (OR 4.84). However, only 31.5% of individuals with OSA were obese, while 44.4% were overweight. Overweight individuals had twice the odds of developing OSA (OR 2.18).

The study, published in eClinicalMedicine, also found that obesity was more common in women and younger adults under 65. These findings highlight that OSA can occur in individuals beyond those who are obese, emphasizing the need for broader clinical awareness and vigilance.

Obesity is a well-established risk factor for obstructive sleep apnea, a condition marked by repetitive interruptions in breathing during sleep. Neda Esmaeili, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA, and colleagues examined the mutual prevalence of obesity and OSA, exploring how it varies across different age groups and sexes.

For this purpose, the researchers conducted a systematic review up to March 27, 2025, which included data from four community-based cohort studies in the US and Switzerland. The severity of OSA was measured using the apnea-hypopnea index (AHI), which calculates the total number of apneas and hypopneas with ≥4% oxygen desaturation per hour. Using random effects individual participant data (IPD) meta-analyses, the researchers estimated the prevalences, while logistic regression was employed to compare the odds of OSA across different weight groups.

The key findings were as follows:

  • The study included 12,860 adults with a mean age of 66.6 years (± 7.3 years).
  • Of the participants, 7,222 (56.2%) had obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of ≥5 events per hour.
  • 3,309 (25.7%) participants were classified as obese, with a BMI of ≥30 kg/m².
  • Among individuals with OSA, 31.5% had obesity, and 44.4% had an overweight status (BMI between 25 and 30).
  • Among those with obesity, 74.3% had some form of OSA, while 59.8% of individuals with an overweight status had OSA.
  • Obesity was more prevalent in females than males with OSA and in younger adults (<65 years) compared to older individuals.
  • The odds of having OSA were 2.18 times higher in individuals with an overweight status and 4.84 times higher in those with obesity, compared to individuals with a BMI of less than 25 kg/m².

“Our analysis reveals that the majority of adults with OSA do not have obesity, with 44.4% being overweight and 23.5% having a normal weight or being underweight,” the authors noted. They further emphasized, “Obesity was more prevalent in females and younger individuals (<65 years) with OSA. These findings highlight that OSA is not exclusive to obesity, reinforcing the need for personalized treatment plans.”

Reference:

Esmaeili, N., Gell, L., Imler, T., Hajipour, M., Taranto-Montemurro, L., Messineo, L., Stone, K. L., Sands, S. A., Ayas, N., Yee, J., Cronin, J., Heinzer, R., Wellman, A., Redline, S., & Azarbarzin, A. (2025). The relationship between obesity and obstructive sleep apnea in four community-based cohorts: An individual participant data meta-analysis of 12,860 adults. EClinicalMedicine, 83, 103221. https://doi.org/10.1016/j.eclinm.2025.103221

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Copeptin levels may predict physiological changes associated with cardiac surgery with CPB: Study

Recently published research assessed copeptin levels during the entire perioperative period of open adult cardiac surgeries involving cardiopulmonary bypass (CPB) in a prospective cohort study at a tertiary care hospital. The study included 61 patients, but ultimately analyzed data from 57 after exclusions for specific surgical conditions. Patients were sorted into subgroups based on their preoperative copeptin levels—either above or below 10 pmol/L, the established reference threshold.

Importance of Copeptin

Copeptin, a precursor of arginine vasopressin (AVP), has been recognized as a prognostic marker for various cardiovascular conditions, including heart failure and myocardial infarction. Several earlier studies indicated that copeptin levels could increase significantly during CPB and potentially correlate with adverse surgical outcomes. This investigation aimed to fill the gap in knowledge surrounding the dynamic changes in copeptin levels throughout the perioperative course. Preoperative levels of copeptin were measured a day before surgery, with subsequent samples collected at several critical time points: after sternotomy, at the commencement of CPB, during the procedure every 30 minutes, post cross-clamping, following CPB cessation, and at several intervals up to four days post-surgery. Copeptin was quantified in a laboratory using a well-validated method, ensuring accuracy in data.

Results Analysis

In analyzing the results, a significant rise in copeptin levels was observed following sternotomy and continuation during CPB, peaking around 60 minutes into bypass. Beyond this, levels plateaued rather than further increasing, indicating a maximum hormone production phase during CPB. Following the termination of CPB, copeptin levels began to decline, reaching near baseline values by the first postoperative day but remaining elevated up to day four. Subgroup analysis indicated individuals with higher preoperative copeptin had significantly elevated levels postoperatively, suggesting that initial copeptin levels may relate to responses during and after surgery.

Statistical Findings

The assessments confirmed substantial statistical differences across multiple perioperative time points concerning copeptin release, with a notable peak corresponding to critical perioperative events. However, while copeptin acts as a reliable marker for hemodynamic stress during CPB, exact physiological mechanisms for its release in this context remain unclear.

Study Limitations

Study limitations noted the underrepresentation of women and the relatively small sample size, potentially affecting the generalizability of findings. The variations in patient numbers over time during CPB also posed challenges for precise subgroup analyses.

Conclusion and Future Directions

In conclusion, copeptin levels were distinctly characterized through various perioperative phases of cardiac surgery. The results emphasize the role of copeptin as an active biomarker that reflects physiological changes occurring during cardiac surgery with CPB. The study advocates for continued research to explore copeptin’s prognostic potential further and enhance risk assessment models in cardiac surgical procedures.

Key Points

– A prospective cohort study was conducted involving 61 patients undergoing open adult cardiac surgeries with cardiopulmonary bypass (CPB), with final analysis based on 57 patients after excluding specific cases; patients were categorized based on preoperative copeptin levels (above or below 10 pmol/L).

– Copeptin, a precursor to arginine vasopressin (AVP), serves as a prognostic marker for cardiovascular conditions such as heart failure and myocardial infarction, with prior studies indicating a significant rise during CPB linked to adverse surgical outcomes.

– Preoperative copeptin levels were measured one day before surgery, followed by multiple sampling points during the perioperative period, including after sternotomy, at the commencement of CPB, and several intervals up to four days post-surgery, with accurate quantification using validated laboratory methods.

– The results revealed a significant increase in copeptin levels after sternotomy, with a peak around 60 minutes into CPB, which plateaued during the procedure and began to decline after CPB cessation, though remained elevated up to four days post-surgery; higher preoperative copeptin levels correlated with elevated levels postoperatively.

– Statistical analysis demonstrated significant differences in copeptin release across various perioperative time points, peaking during critical events, yet the exact physiological mechanisms for copeptin release during CPB remain poorly understood.

– Limitations included a small sample size and underrepresentation of women, which may impact the generalizability of the findings; variability in patient numbers during CPB also complicated subgroup analyses, underscoring the need for further research into copeptin’s prognostic capabilities in cardiac surgery risk assessments.

Reference –

Selma Samuelsson et al. (2025). Copeptin Levels During Cardiac Surgery.. *Journal Of Cardiothoracic And Vascular Anesthesia*. https://doi.org/10.1053/j.jvca.2025.02.014.

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Tension-Free Vaginal Tape More Effective Than Polyacrylamide Hydrogel for Stress Urinary Incontinence: NEJM

Finland: In a recent long-term study evaluating treatment approaches for stress urinary incontinence (SUI), researchers have found that the tension-free vaginal tape (TVT) procedure continues to deliver more favorable patient satisfaction outcomes than polyacrylamide hydrogel (PAHG) injections. The 5-year follow-up findings shed light on the durability and efficacy of both treatment options, commonly offered to women suffering from SUI.

The findings were published online in the New England Journal of Medicine on April 22, 2025.

Stress urinary incontinence, characterized by involuntary urine leakage during physical activity or exertion, affects the daily lives of many women. Tension-free vaginal tape has traditionally been the standard treatment, offering effective symptom relief. However, concerns regarding the safety of synthetic mesh used in the procedure have increased interest in alternative therapies. Among these, the transurethral injection of polyacrylamide hydrogel has emerged as a minimally invasive option. While both methods have been widely used, their long-term comparative effectiveness has remained unclear until now.

Against the above background, Anna-Maija Itkonen Freitas, Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland, and colleagues conducted a randomized, controlled, noninferiority trial (with a margin of 20%) at Helsinki University Hospital, Finland, to compare the effectiveness of tension-free vaginal tape and PAHG treatment.

The study’s primary outcome was patient satisfaction, with secondary outcomes focusing on treatment effectiveness and complications. While the results at 1 and 3 years have been previously published, this report presents the findings from the 5-year follow-up.

The key findings of the study were as follows:

  • Of the 223 women initially randomized to a treatment group, 212 women received the assigned treatment, and 195 (92.0%) attended the 5-year follow-up.
  • The median satisfaction score on the visual analog scale was 98 for the tension-free vaginal tape group and 90 for the PAHG group.
  • A satisfaction score of 80 or higher was achieved by 92.7% of participants in the tension-free vaginal tape group, compared to 74.7% in the PAHG group, with a difference of 18.0 percentage points.
  • PAHG did not meet the noninferiority criteria set in the trial.
  • In the 5-year follow-up, peri- or postoperative complications occurred in 43.8% of women in the tension-free vaginal tape group and 22.2% of women in the PAHG group, with a difference of 21.5 percentage points.

“In the long-term follow-up, treatment for stress urinary incontinence with polyacrylamide hydrogel was found to be less effective than tension-free vaginal tape in terms of patient satisfaction scores,” the researchers wrote. “Additionally, complications occurred twice as often in the TVT group compared to the PAHG group.”

Reference: https://evidence.nejm.org/doi/full/10.1056/EVIDoa2400216

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MASLD and MetALD may increase risks of Alzheimer’s and vascular dementia: BMC

A new study published in the journal of BMC Gastroenterology showed that dementia risk was higher in patients with metabolic alcohol-associated liver disease (MetALD) and metabolic dysfunction-associated steatotic liver disease (MASLD).

The following mechanisms may contribute to the development of dementia: increased insulin resistance in the brain, which causes oxidative stress, excessive free fatty acids, and mitochondrial dysfunction; and inflammation caused by liver fat, which activates microglial cells and increases the expression of inflammatory cytokines in the brain. There is mounting evidence linking MASLD to structural brain changes. Thus, this study sought to examine the relationship between MASLD and MetALD and the onset of dementia, including Alzheimer’s disease (AD) and vascular dementia (VaD), in this sizable group of elderly Koreans, in comparison to those without steatosis liver disease (SLD).

A total of 2,96,001 people over 60 who had health exams between 2009 and 2010 were included in this retrospective cohort research. The participants were tracked until dementia onset, death, or December 31, 2019, and were divided into three groups: non-SLD (reference), MASLD, and MetALD.

A fatty liver index of 30 or above was considered SLD, whereas (i) MASLD was determined by cardiometabolic risk factors, and (ii) MetALD was defined as MASLD with moderate alcohol use. The results included VaD, Alzheimer’s disease (AD), and general dementia. The Fine-Gray model was used to compute subdistribution hazard ratios (SHRs), which treated mortality as a competing risk.

There were 11,345 instances of dementia during 74,30,253 person-years of follow-up (10,863 AD and 2,159 VaD). For MASLD, the adjusted SHRs were 1.20 (1.13–1.27) for VaD and 1.10 (1.07–1.13) for AD.

SHRs for MetALD were 1.53 (1.40–1.66) for VaD and 0.90 (0.87–0.94) for AD. Both MASLD and MetALD had higher dementia risk over longer time periods; initially, MetALD was associated with higher VaD risk and lower AD risk, but this relationship flipped after three years.

Overall, in relation to the study’s findings, diagnosing SLD patients according to their metabolic complexity, hepatic steatosis, and alcohol intake may help to clarify how these factors relate to the risk of incident dementia and its subtypes, possibly providing different approaches to preventing dementia in both the MASLD and MetALD groups.

Reference:

Shin, W.-Y., Kang, E. S., Oh, Y. H., Sha, M., Xia, Q., Jeong, S., & Cho, Y. (2025). Metabolic dysfunction-associated steatotic liver disease, metabolic alcohol-related liver disease, and incident dementia: a nationwide cohort study : MASLD, MetALD, and dementia risk: MASLD, MetALD, and dementia risk. BMC Gastroenterology, 25(1), 308. https://doi.org/10.1186/s12876-025-03814-1

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INI CET July 2025: AIIMS issues addendum to submission of protocol and thesis guidelines

New Delhi- The All India Institute of Medical Sciences (AIIMS), New Delhi, has released an important notice concerning the upcoming Institute of National Importance Combined Entrance Test (INI-CET) for the July 2025 session. The notice addresses the submission guidelines for protocols and theses for postgraduate medical students appearing for the exam.

In reference to the AIIMS Prospectus Part-B for the INI-CET July 2025 session, the notice directs candidates to refer to the Office Memorandum No. F. 11-Misc/2025(6)-Acad.II, dated 4th February 2025, which states:

1 For 6-year DM/MCh courses will continue to require 02 Thesis as presently is being done.

2 Protocol submission deadlines will continue as are presently being done (1st Protocol within 4 months of joining the course in the 1st year of Junior Residency from the date of registration. 2nd Protocol in the 4th year of the course, within 4 months of Senior Residency. For each protocol, the Dean (Acad) could grant an extension of 2 months based on the merits of the case.

3 Both thesis submission deadlines would be 31st August or 31st January in the year that the exam is held (both thesis could be submitted together).

4 The final exam will be held at the end of 6 years for all 6-year DM/MCh courses.

As pe the recent AIIMS notice , this memorandum should be considered as part of the submission requirements under Point F (ii) – Submission of Protocol and Thesis, which is detailed on page 6 of the prospectus, which states:

F. (i) SUBMISSION OF PROTOCOL AND THESIS
The Junior Residents registered for MD/MS/MDS courses shall be required to get his/her plan of
thesis protocol approved by his/her departmental faculty and submit it to Academic Section within
4 months of joining. If a candidate fails to submit the thesis protocol within the prescribed
period, his/her registration will stand cancelled. The last date for submission of thesis for the
students registered for MD/MS/MDS degree will be 30th June for those appearing at the
December examination and 30th November for those appearing at the May examination.
(ii) For 6 years DM/M.Ch. course two Thesis are to be submitted by candidates and two protocols to be
submitted as under:
1. 1st Protocol within 4 months of 1st year in Junior Residency from the date of registration/joining.
2. 2nd Protocol in 4th year in Senior Residency within 4 months.
The last date for submission of thesis for the DM/M.Ch. will be 31st August for those appearing
in the December Examination and 31st January for those appearing in the May Examination.
Note: –
The Final examination will be held at a date fixed by the Examination Section. In order to appear for
the final exam candidates must: –
1. Submit their thesis as mentioned above (i & ii)

2. Complete the prescribed posting trainings, work schedules and assessments during the tenure.
3. Not have availed EOL more than 30 days during the entire tenure. Maternity leave period will
be assessed in a manner similar to EOL for the purpose of calculation of extension of tenure
and postponement of exams.

Also Read: AIIMS INI CET 2025 July Session Admit Card OUT, Download Now

To view the notice, click the link below

https://medicaldialogues.in/pdf_upload/aiims-new-delhi-286525.pdf

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Meagre Rs 12000 a month! JnK MBBS Interns Demand Stipend Hike

Srinagar: MBBS interns from medical
colleges across Jammu and Kashmir have made an appeal to the state Government and the Health and Medical Education Department, seeking an increase
in their monthly stipend to Rs 26,350 following the recommendations of a
committee under the Director Finance of the department.

The medicos referred to the recommendations of a government-appointed committee, which had advocated for a substantial hike. A delegation of interns recalled that the government had constituted a committee under the Director Finance of the H&ME Department through order number 538 JK-HME dated 27-06-2023. The committee submitted its report in August 2023, recommending an increase in the stipend to Rs 26,350, aligning it with half the basic pay of a Medical Officer in J&K, as per National Medical Commission norms, reports the Rising Kashmir.

Also Read:BHISHM portable hospitals set for deployment in Jammu for emergency response

Currently drawing a
monthly stipend of Rs 12,000, a delegation of interns expressed concern that
their remuneration is far below what their counterparts in other medical and
dental colleges across the country receive. “Surprisingly, the stipends of
interns in the rest of the country were hiked twice to thrice in the last five
years leaving us to suffer,” the delegation members told Rising Kashmir.

However, the interns stated that the
proposal has been pending with the Finance Department since January 2024, with
no further movement for over a year. In October 2024, some interns had also met
Chief Minister Omar Abdullah at the Civil Secretariat in Srinagar, where he
assured them that there would be no inequality between J&K interns and
those in other states. Despite that assurance, the issue remains unresolved.

“We
work diligently, often putting in extra hours and performing every duty of a
resident doctor, yet our compensation is lower than that of daily laborers,”
said one of the interns at Government Medical College (GMC), Anantnag.

The interns pointed out
that their stipend was last revised in January 2019, during the Governor’s rule,
and has since remained unchanged, making it the lowest in the country. They had
hoped that the committee’s recommendations would finally bring parity, but the
prolonged inaction has left them discouraged.

“Since the Finance Department
falls under the domain of CM, we request his intervention to grant budgetary
approval for the stipend hike. It would bring immense relief and recognition to
interns who are at the frontline of patient care,” said another member of the
delegation.

Also Read:JnK MBBS interns demand fair stipend

Last week,
representatives from various Government Medical Colleges in J&K once again
met with the Deputy Chief Minister, Advisor to the Chief Minister, and the
Health Minister, urging them to address the long-standing issue. They submitted
a detailed memorandum outlining the urgency of implementing the revised stipend
structure and called on the Chief Minister to personally intervene, citing
growing financial burdens and widening disparities with other states.

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Study finds no increased risk of gynecological cancer with testosterone use after five years

Transmasculine and gender-diverse individuals who use testosterone are not at increased risk of gynecological cancer in the first years of hormone therapy. This is evident from large-scale research by Amsterdam UMC, which was published in eClinicalMedicine.

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To increase childhood vaccine uptake, researchers look to dental visits

In the early months of the COVID-19 pandemic, federal data showed declining rates of childhood vaccinations as more and more people were avoiding non-emergency contact with the health care system. So, to help reverse this trend, the Health Resources and Services Administration (HRSA) put out a call for solutions with the Promoting Pediatric Primary Prevention (P4) Challenge.

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