Publications by authors named "Bram Wispelwey"

16 Publications

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Heart Failure Admission Service Triage (H-FAST) Study: Racialized Differences in Perceived Patient Self-Advocacy as a Driver of Admission Inequities.

Cureus 2021 Feb 16;13(2):e13381. Epub 2021 Feb 16.

Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.

Background Racial inequities in mortality and readmission for heart failure (HF) are well documented. Inequitable access to specialized cardiology care during admissions may contribute to inequity, and the drivers of this inequity are poorly understood. Methodology This prospective observational study explored proposed drivers of racial inequities in cardiology admissions among Black, Latinx, and white adults presenting to the emergency department (ED) with symptoms of HF. Surveys of ED providers examined perceptions of patient self-advocacy, outreach to other clinicians (e.g., outpatient cardiologist), diagnostic uncertainty, and other active co-morbid conditions. Service census, bed availability, prior admission service, and other structural factors were explored through the electronic medical record. Results Complete data were available for 61/135 patients admitted with HF during the study period, which halted early due to coronavirus disease 2019. No significant differences emerged in admission to cardiology versus medicine based on age, sex, insurance status, education level, or perceived race/ethnicity. White patients were perceived as advocating for admission to cardiology more frequently (18.9 vs. 5.6%) and more strenuously than Black patients (p = 0.097). ED clinicians more often reported having spoken with the patient's outpatient cardiologist for whites than for Black or Latinx patients (24.3 vs. 16.7%, p = 0.069). Conclusions Theorized drivers of racial inequities in admission service did not reach statistical significance, possibly due to underpowering, the Hawthorne effect, or clinician behavior change based on knowledge of previously identified inequities. The observed trend towards racial differences in coordination of care between ED and outpatient providers, as well as in either actual or perceived self-advocacy by patients, may be as-yet undemonstrated components of structural racism driving HF care inequities.
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http://dx.doi.org/10.7759/cureus.13381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7891794PMC
February 2021

A Longitudinal Case-Based Global Health Curriculum for the Medical Student Clerkship Year.

MedEdPORTAL 2020 12 8;16:11038. Epub 2020 Dec 8.

Instructor, Internal Medicine, Brigham and Women's Hospital and Harvard Medical School.

Introduction: Over 20% of U.S. medical students express interest in global health (GH) and are searching for opportunities within the field. In addition, domestic practice increasingly requires an understanding of the social factors affecting patients' health. Unfortunately, only 39% of medical schools offer formal GH education, and there is a need to incorporate more GH into medical school curricula.

Methods: We designed a longitudinal case-based curriculum for the core clerkships. We conducted an institution-wide survey to determine baseline GH interest and developed three case-based sessions to incorporate into medicine, surgery, and pediatrics clerkships. The cases included clinical learning while exploring fundamental GH concepts. Cases were developed with GH faculty, and the pilot was implemented from October to December 2019 with 55 students. We used pre- and postdidactic surveys to assess interest in GH and elicit qualitative feedback. A follow-up survey assessed students' identification of barriers faced by their patients domestically.

Results: Students felt that clinical management, physical exam skills, epidemiology, and social determinants of health were strengths of the sessions and that they were able to apply more critical thinking skills and cultural humility to their patients afterwards. Students felt that simulation would be a great addition to the curriculum and wanted both more time per session and more sessions overall.

Discussion: Integrating GH didactics into the core clerkships has potential to address gaps in GH education and to help students make connections between clinical learning and GH, enhancing their care of patients both domestically and in future GH work.
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http://dx.doi.org/10.15766/mep_2374-8265.11038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732136PMC
December 2020

Annual Primary Care 2030 Convening: Creating an Enabling Ecosystem for Person-Centered Primary Healthcare Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries.

Ann Glob Health 2020 08 20;86(1):106. Epub 2020 Aug 20.

Center for Primary Care, Harvard Medical School, Boston, MA, US.

Background: The 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana reaffirm the highest level of political commitment by United Nations Member States to achieve access to health services and primary healthcare for all. Both documents emphasize the importance of person-centered care in both healthcare services and systems design. However, there is limited consensus on how to build a strong primary healthcare system to achieve these goals.

Methods: We convened a diverse group of global stakeholders for a high-level dialogue on how to create a person-centered primary healthcare system, using the country examples of the Republic of Kenya and the Socialist Republic of Vietnam. We focused our discussion on four themes to enable the creation of person-centered primary healthcare systems in Kenya and Vietnam: (1) strengthened community, person and patient engagement in subnational and national decision making; (2) improved service delivery; (3) impactful use of innovation and technology; and (4) meaningful and timely use of measurement and data.

Findings: Here, we present a summary of our convening's proceedings, with specific insights on how to enable a person-centered primary healthcare system within each of these four domains.

Conclusions: Following the 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana, there is high-level commitment and global consensus that a person-centered approach is necessary to achieve high-quality primary healthcare and universal health coverage. We offer our recommendations to the global community to catalyze further discourse and inform policy-making and program development on the path to Universal Health Coverage by 2030.
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http://dx.doi.org/10.5334/aogh.2948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442168PMC
August 2020

The Great March of Return: Lessons from Gaza on Mass Resistance and Mental Health.

Health Hum Rights 2020 Jun;22(1):179-185

Psychiatrist and Executive Director of the Gaza Community Mental Health Programme, Palestine.

The Gaza Strip is under an Israeli land, sea, and air blockade that is exacerbated by Egyptian restrictions and imposes an enormous cost in terms of human suffering. The effects of blockade, poverty, and frequent attacks suffered by the population have taken a significant toll on people's mental health. The Great March of Return, a mass resistance movement begun in March 2018, initially provided a positive impact on community mental health via a sense of agency, hope, and unprecedented community mobilization. This improvement, however, has since been offset by the heavy burden of death, disability, and trauma suffered by protestors and family members, as well as by a failure of local and international governments to alleviate conditions for Palestinians in Gaza. Reflecting on the ephemerality of the material and political gains of this movement, this paper shows that Palestinian and international health practitioners have an opportunity to develop an understanding of the psychosocial consequences of community organizing and mass resistance while simultaneously providing holistic mental and physical health care to community members affected by the events of the Great March of Return and other efforts.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7348434PMC
June 2020

Structural violence in the era of a new pandemic: the case of the Gaza Strip.

Lancet 2020 Mar 27. Epub 2020 Mar 27.

University Hospital of North Norway, Tromsø, Norway; The Arctic University of Norway, Tromsø, Norway.

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http://dx.doi.org/10.1016/S0140-6736(20)30730-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7194595PMC
March 2020

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center.

Circ Heart Fail 2019 11 29;12(11):e006214. Epub 2019 Oct 29.

Division of Cardiovascular Medicine, and Department of Medicine (E.F..L.), Brigham and Women's Hospital, Boston, MA.

Background: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality.

Results: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race.

Conclusions: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183732PMC
November 2019

Gaza's Great March of Return: humanitarian emergency and the silence of international health professionals.

BMJ Glob Health 2019 22;4(3):e001673. Epub 2019 Jun 22.

Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1136/bmjgh-2019-001673DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6590976PMC
June 2019

Health equity in Israel.

Lancet 2018 02;391(10120):534

Brigham and Women's Hospital, Boston, MA 02116, USA.

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http://dx.doi.org/10.1016/S0140-6736(17)32171-2DOI Listing
February 2018

The transplantation of solid organs from HIV-positive donors to HIV-negative recipients: ethical implications.

J Med Ethics 2015 May 4;41(5):367-70. Epub 2014 Jun 4.

Department of Medicine, Soroka University Medical Center, Ben Gurion University of the Negev-The Medical School for International Health, Beer Sheva, Israel.

HIV-positive individuals have traditionally been barred from donating organs due to transmission concerns, but this barrier may soon be lifted in the USA in limited settings when recipients are also infected with HIV. Recipients of livers and kidneys with well-controlled HIV infection have been shown to have similar outcomes to those without HIV, erasing ethical concerns about poorly chosen beneficiaries of precious organs. But the question of whether HIV-negative patients should be disallowed from receiving an organ from an HIV-positive donor has not been adequately explored. In this essay, we will discuss the background to this scenario and the ethical implications of its adoption from the perspectives of autonomy, beneficence/non-maleficence and justice.
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http://dx.doi.org/10.1136/medethics-2014-102027DOI Listing
May 2015

Benchmarking outcomes in the critically injured burn patient.

Ann Surg 2014 May;259(5):833-41

*Department of Surgery, University of Washington School of Medicine and Harborview Medical Center, Seattle, WA †Department of Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA ‡Department of Medicine, Massachusetts General Hospital, Boston, MA §Department of Surgery, Massachusetts General Hospital, Boston, MA ¶Department of Surgery, Loyola University School of Medicine, Maywood, IL ‖Department of Surgery, University of Texas Medical Branch, Galveston, TX **Department of Surgery and Plastic Surgery, University of Toronto, Canada ††Department of Surgery, Parkland Memorial Hospital, University of Texas, Southwestern Medical Center, Dallas TX ‡‡Stanford Genome Technology Center, Palo Alto, CA §§Department of Surgery, Harborview Medical Center, Seattle, WA ¶¶Department of Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA.

Objective: To determine and compare outcomes with accepted benchmarks in burn care at 6 academic burn centers.

Background: Since the 1960s, US morbidity and mortality rates have declined tremendously for burn patients, likely related to improvements in surgical and critical care treatment. We describe the baseline patient characteristics and well-defined outcomes for major burn injuries.

Methods: We followed 300 adults and 241 children from 2003 to 2009 through hospitalization, using standard operating procedures developed at study onset. We created an extensive database on patient and injury characteristics, anatomic and physiological derangement, clinical treatment, and outcomes. These data were compared with existing benchmarks in burn care.

Results: Study patients were critically injured, as demonstrated by mean % total body surface area (TBSA) (41.2 ± 18.3 for adults and 57.8 ± 18.2 for children) and presence of inhalation injury in 38% of the adults and 54.8% of the children. Mortality in adults was 14.1% for those younger than 55 years and 38.5% for those aged 55 years and older. Mortality in patients younger than 17 years was 7.9%. Overall, the multiple organ failure rate was 27%. When controlling for age and % TBSA, presence of inhalation injury continues to be significant.

Conclusions: This study provides the current benchmark for major burn patients. Mortality rates, notwithstanding significant % TBSA and presence of inhalation injury, have significantly declined compared with previous benchmarks. Modern day surgical and medically intensive management has markedly improved to the point where we can expect patients younger than 55 years with severe burn injuries and inhalation injury to survive these devastating conditions.
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http://dx.doi.org/10.1097/SLA.0000000000000438DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4283803PMC
May 2014

To repent or to rationalize: three physicians exchange letters on the ethics of experimentation in postwar medicine.

Perspect Biol Med 2013 ;56(2):236-43

In the late 1990s, three prominent figures of 20th-century medicine-Paul Beeson, Howard Burchell, and Shimon Glick-exchanged private letters on the ethics of experimentation in the years following World War II. What began as a brief published back-and-forth blossomed into a long correspondence filled with humor and wisdom even in the face of continued disagreement. The history of postwar investigation unfolds memorably in their letters, starting with the whistleblowing of Beecher and Pappworth and moving into the 21st century. The heart of the discussion focuses on the ethics of consent and legitimate risk in clinical investigation, and on the prevalence of violations of patients' rights. Glick openly discusses his views about the widespread practice of their subjection to experiments without benefit or unrelated to their conditions. In opposition, Burchell claims that accusations of ethical misconduct during this period were exaggerated, and that most of these studies would pass review boards today. Just when things seem to reach an immutable impasse, Beeson weighs in with keen insight and personal experience. The debate provides not only an intimate perspective on some of the most influential physician investigators of the last half-century, but also a context for productively approaching ethical questions of today.
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http://dx.doi.org/10.1353/pbm.2013.0020DOI Listing
April 2014

Inflammatory bowel disease and preterm delivery.

Arch Gynecol Obstet 2013 Oct 10;288(4):725-30. Epub 2013 Aug 10.

Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, POB 151, Beersheba, 84101, Israel.

Background: The association between inflammatory bowel disease (IBD) and preterm delivery is controversial. Study size, quality, and design have been inconsistent, making it difficult to assess the relationship between IBD and preterm delivery.

Objective: Utilizing a systematic search of Pubmed for all relevant literature, this review seeks to clarify the correlation between IBD and preterm delivery and to assess the impact of disease activity and medication usage on this outcome.

Results: The available evidence is inadequate to make any robust claims about the association between IBD and preterm delivery. IBD in pregnant women may represent a risk for preterm delivery, and it is probable that IBD activity augments this risk. Many of the medications used to treat IBD also have a correlation with preterm delivery.

Conclusions: While an association between IBD and preterm delivery may exist, further well-designed prospective studies are necessary to determine how the course and management of disease may impact this outcome.
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http://dx.doi.org/10.1007/s00404-013-2989-3DOI Listing
October 2013

Cesarean delivery in obese women: a comprehensive review.

J Matern Fetal Neonatal Med 2013 Apr 28;26(6):547-51. Epub 2012 Nov 28.

Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Background: Obesity (BMI ≥30) is a significant independent risk factor for many gestational complications, including cesarean delivery (CD). While CD rates are increasing in women of every BMI, the trend is more pronounced as maternal weight increases.

Objective: This review seeks to describe the risk modulators that explain the high prevalence of CD in obese women, as well as to discuss the excess complications of the procedure in this group of parturients. In assessing the rationale for the procedure and weighing this against the excess risks involved, a clearer indication of when to perform CD in obese women might be developed.

Results: A thorough review of the literature indicates that a decreased cervical dilation rate, an increased induction rate, the presence of comorbid conditions, concern about shoulder dystocia, and weight gain in excess of recommendations during pregnancy all may contribute to the high rate of CD in obese women. Obese women are at increased risk of CD-related complications including anesthetic complications, wound complications, venous thromboembolism (VTE), and failure of vaginal birth after CD.

Conclusions: Given the excess risks associated with CD in obese women, and that some of the rationale for the procedure (e.g. slower labor, concern about shoulder dystocia) may not be justified based on current evidence, a reassessment of the threshold at which obese women are recommended for CD is necessary.
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http://dx.doi.org/10.3109/14767058.2012.745506DOI Listing
April 2013

Econutrition and utilization of food-based approaches for nutritional health.

Food Nutr Bull 2011 Mar;32(1 Suppl):S4-13

Institute of Human Nutrition, Columbia University College of Physicians and Surgeons, 630 West 168th Street, PH 1512, New York, NY 10032, USA.

Background: Macronutrient and micronutrient deficiencies continue to have a detrimental impact in lower-income countries, with significant costs in morbidity, mortality, and productivity. Food is the primary source of the nutrients needed to sustain life, and it is the essential component that links nutrition, agriculture, and ecology in the econutrition framework.

Objective: To present evidence and analysis of food-based approaches for improving nutritional and health outcomes in lower-income countries.

Methods: Review of existing literature.

Results And Conclusions: The benefits of food-based approaches may include nutritional improvement, food security, cost-effectiveness, sustainability, and human productivity. Food-based approaches require additional inputs, including nutrition education, gender considerations, and agricultural planning. Although some forms of malnutrition can be addressed via supplements, food-based approaches are optimal to achieve sustainable solutions to multiple nutrient deficiencies.
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http://dx.doi.org/10.1177/15648265110321S102DOI Listing
March 2011

Unusual but potential agents of terrorists.

Emerg Med Clin North Am 2007 May;25(2):549-66; abstract xi

Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, Charlottesville, VA 22908-0774, USA.

Emergency personnel are tasked with the daunting job of being the first to evaluate and manage victims of a terrorist attack. Numerous potential chemical agents could be used by terrorists. The challenge for first responders and local hospital emergency personnel is to prepare for a terrorist event that might use one or more of these agents. As part of that preparation, emergency physicians should have a basic understanding of potential chemical terrorist agents. It is beyond the scope of this article to review all potential terrorist agents. Rather, four potential agents have been chosen for review: sodium monofluoroacetate, trichothecene mycotoxins, vomiting agents, and saxitoxin.
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http://dx.doi.org/10.1016/j.emc.2007.02.006DOI Listing
May 2007