Publications by authors named "Lawrence Brown"

428 Publications

Research priorities for expanding access to methadone treatment for opioid use disorder in the United States: A National Institute on Drug Abuse Center for Clinical Trials Network Task Force report.

Subst Abus 2021 ;42(3):245-254

Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.

In the US, methadone treatment can only be provided to patients with opioid use disorder (OUD) through federal and state-regulated opioid treatment programs (OTPs). There is a shortage of OTPs, and racial and geographic inequities exist in access to methadone treatment. The National Institute on Drug Abuse Center for Clinical Trials Network convened the Methadone Access Research Task Force to develop a research agenda to expand and create more equitable access to methadone treatment for OUD. This research agenda included mechanisms that are available within and outside the current regulations. The task force identified 6 areas where research is needed: (1) access to methadone in general medical and other outpatient settings; (2) the impact of methadone treatment setting on patient outcomes; (3) impact of treatment structure on outcomes in patients receiving methadone; (4) comparative effectiveness of different medications to treat OUD; (5) optimal educational and support structure for provision of methadone by medical providers; and (6) benefits and harms of expanded methadone access. In addition to outlining these research priorities, the task force identified important cross-cutting issues, including the impact of patient characteristics, treatment, and treatment system characteristics such as methadone formulation and dose, concurrent behavioral treatment, frequency of dispensing, urine or oral fluid testing, and methods of measuring clinical outcomes. Together, the research priorities and cross-cutting issues represent a compelling research agenda to expand access to methadone in the US.
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http://dx.doi.org/10.1080/08897077.2021.1975344DOI Listing
January 2021

Investigation of gene-environment interactions in relation to tic severity.

J Neural Transm (Vienna) 2021 Aug 13. Epub 2021 Aug 13.

Department of Child and Adolescent Psychiatry, TU Dresden, Dresden, Germany.

Tourette syndrome (TS) is a neuropsychiatric disorder with involvement of genetic and environmental factors. We investigated genetic loci previously implicated in Tourette syndrome and associated disorders in interaction with pre- and perinatal adversity in relation to tic severity using a case-only (N = 518) design. We assessed 98 single-nucleotide polymorphisms (SNPs) selected from (I) top SNPs from genome-wide association studies (GWASs) of TS; (II) top SNPs from GWASs of obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorder (ASD); (III) SNPs previously implicated in candidate-gene studies of TS; (IV) SNPs previously implicated in OCD or ASD; and (V) tagging SNPs in neurotransmitter-related candidate genes. Linear regression models were used to examine the main effects of the SNPs on tic severity, and the interaction effect of these SNPs with a cumulative pre- and perinatal adversity score. Replication was sought for SNPs that met the threshold of significance (after correcting for multiple testing) in a replication sample (N = 678). One SNP (rs7123010), previously implicated in a TS meta-analysis, was significantly related to higher tic severity. We found a gene-environment interaction for rs6539267, another top TS GWAS SNP. These findings were not independently replicated. Our study highlights the future potential of TS GWAS top hits in gene-environment studies.
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http://dx.doi.org/10.1007/s00702-021-02396-yDOI Listing
August 2021

Stress distribution in the walls of major arteries: implications for atherogenesis.

Quant Imaging Med Surg 2021 Aug;11(8):3494-3505

School of Public Health, Faculty of Health Sciences, Curtin University, Nedlands, WA, Australia.

Background: There is a correlation between the sites of atheroma development and stress points in the arterial system. Generally, pulse pressure results in stresses acting on the vascular vessel, including longitudinal stress, radial or normal stress, tangential stress or hoop stress and shear stress. This paper explores the relationship between arterial wall shear stress and pulsatile blood pressure with the aim of furthering the understanding of atherogenesis and plaque progression.

Methods: We computed the magnitude of the shear stresses within the carotid bifurcation geometry of a patient and calculated the increase in shear stress levels that would occur when the blood pressure and pulse pressures rise during exertion. We also determined in which layer of the artery wall the maximum shear stress is located, and computed the shear stress at different levels within the media. We used the theory of laminate analysis, (Classical Laminate Plate Theory), to analyse the stress distribution on the carotid artery wall. Computational Fluid Dynamics (CFD) analysis was used on anatomy based on a CT angiogram of the carotid bifurcation of a patient with a 90% stenosis on the right side and 10% on the left. The pulsatile non-Newtonian blood flow with a resting blood pressure of 120/80 mmHg and an exertion pressure of 200/100 mmHg was simulated and the resultant forces were transferred to an ANSYS Composite PrepPost (ACP) model for wall shear stress analysis. A multilayer elastic, anisotropic, and inhomogeneous arterial wall (intima, internal elastic lamina, media, external elastic lamina, and adventitial layers) was modelled and the shear stress magnitudes and change over time between the layers was calculated.

Results: Shear stress in the individual composite layers is far greater than that acting on the endothelium (less than 5 Pa). At rest, the maximum variation of shear stress in the arterial wall occurs in the intima (138 Pa) and adventitia (135 Pa). The medial layer has the lowest variation of shear stress. Under severe exertion, the maximum shear stress magnitude in the intimal layer and the adjacent medial layer is near the ultimate stress level. The maximum/minimum shear stress ratios during the cardiac cycle vary most widely in the innermost part of the media, adjacent to the intima, with a four-fold ratio increase. This compares with a less than two-fold increase in all the other layers including the intima and adventitia, making the inner media the most vulnerable layer to mechanical injury.

Conclusions: This study showed that the magnitude of exertion-induced shear stress approaches the ultimate stress limit in the intima and the immediate adjacent medial layer. The variation in stress is maximal in the inner layer of the media. These findings correlate the site of atheroma development with the most vulnerable site for injury in the media and emphasise the impact of pulse pressure. Further biological studies are required to ascertain whether this leads to injury that initiates atheroma that then precipitates an injury/healing cycle.
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http://dx.doi.org/10.21037/qims-20-614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245957PMC
August 2021

Virtual Peer-to-Peer Learning to Enhance and Accelerate the Health System Response to COVID-19: The HHS ASPR Project ECHO COVID-19 Clinical Rounds Initiative.

Ann Emerg Med 2021 08 17;78(2):223-228. Epub 2021 Apr 17.

Dell Medical School at the University of Texas, Austin, TX; US Acute Care Solutions, Canton, OH.

Tasked with identifying digital health solutions to support dynamic learning health systems and their response to COVID-19, the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response partnered with the University of New Mexico's Project ECHO and more than 2 dozen other organizations and agencies to create a real-time virtual peer-to-peer clinical education opportunity: the COVID-19 Clinical Rounds Initiative. Focused on 3 "pressure points" in the COVID-19 continuum of care-(1) the out-of-hospital and/or emergency medical services setting, (2) emergency departments, and (3) inpatient critical care environments-the initiative has created a massive peer-to-peer learning network for real-time information sharing, engaging participants in all 50 US states and more than 100 countries. One hundred twenty-five learning sessions had been conducted between March 24, 2020 and February 25, 2021, delivering more than 58,000 total learner-hours of contact in the first 11 months of operation.
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http://dx.doi.org/10.1016/j.annemergmed.2021.03.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052469PMC
August 2021

Patient characteristics associated with the use of pharmacist-administered vaccination services and predictors of service utilization.

J Am Pharm Assoc (2003) 2021 May 29. Epub 2021 May 29.

Background: Data on the impact of pharmacists as vaccinators are available; however, research on understanding the characteristics of users of pharmacist-administered vaccinations is scarce.

Objectives: This study aimed to identify the characteristics of the users of pharmacist-administered vaccinations and recognize predictors of utilizing these services.

Methods: Data were obtained from a cross-sectional online survey, and the sample size was 26,173 respondents from all over the United States. The outcome measure was the previous use of pharmacist-administered vaccination. Independent variables were demographic factors, health-related factors, and previous utilization of pharmacy products and services. Chi-square test and multivariable logistic regression analyses were conducted to examine the factors associated with the use of this service. P values, odds ratios (ORs), and 95% CIs were computed and reported.

Results: About 31% of respondents reported previous use of pharmacist-administered vaccination. The gender of respondents was mainly female (71.2%), and the race was mainly white (80.7%). Chi-square analysis showed a statistically significant association of service use with age, education, geographic region, use of other pharmacy services and products, type of pharmacy, and the number of chronic diseases (P < 0.05). Logistic regression analysis showed a statistically significant association with the number of chronic diseases (OR 1.085 [95% CI 1.049-1.122]), level of education (1.352 [1.35-1.28]), race (0.901 [0.840-0.969]), and proximity to pharmacy (0.995 [0.992-0.997]). Age, type of pharmacy, and previous use of other pharmacist-provided services and products also showed statistically significant associations (P < 0.05).

Conclusion: The use of pharmacist-administered vaccination has been increasing over the past years. The service has many advantages compared with other vaccination service providers and associated with higher vaccination rates among people with older age, higher education, and a higher number of chronic diseases. With proper training and education, pharmacists are unique in improving vaccination services and public health in general.
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http://dx.doi.org/10.1016/j.japh.2021.05.014DOI Listing
May 2021

Use of National Consumer Survey Data to Explore Perceptions of Complementary and Alternative Medicine.

Innov Pharm 2020 30;11(2). Epub 2020 Apr 30.

Chapman University.

Background: Although Complementary and Alternative Medicine (CAM) has been the standard of therapy in Asia for centuries, it started receiving more attention in the U.S. in the last three decades.

Objectives: The primary study objective was to explore individuals' perspectives of CAM. A secondary objective was to describe individuals' perceptions of pharmacists' roles in facilitating their use of these services and products.

Methods: Data were obtained from the 2015 and 2016 National Consumer Surveys on the Medication Experience and Pharmacist Roles. Data were collected from adults residing in the United States via on-line, self-administered surveys coordinated by Qualtrics Panels between April 28 and June 22, 2015 (n = 26,173) and between March 14 and 30, 2016 (n = 10,500). This study focused on written comments made in the surveys with Content Conventional Analysis applied to the text. Four researchers were trained to conduct coding to assess inter-judge reliability. The four judges had a high level of agreement which was greater than 0.95 for category type.

Results: Out of a total of 36,673 respondents, 80% (29,426) submitted written comments at the end of the survey. Of these, 2,178 comments were about medications or health and 170 (8%) comments specifically about CAM, of which 136 (6%) were usable for analysis. Conventional Content Analysis revealed five themes:1)The role of pharmaceutical and insurance companies in CAM; 2) Overuse of medications; 3)Physicians can play a role in creating a balance between prescription use and CAM; 4) Individuals believe that CAM is more effective than Western medicines and prefer it; 5) Individuals want pharmacists to have a better understanding of CAM. Theresults of this study reveal individuals' opinions regarding how they want CAM to be considered in their interactions with their healthcare team.

Conclusion: Emergent themes suggest that individuals are interested in receiving more professionals' healthcare to become more knowledgeable about CAM.
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http://dx.doi.org/10.24926/iip.v11i2.2263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051915PMC
April 2020

Surveillance of Depleted Uranium-exposed Gulf War Veterans: More Evidence for Bone Effects.

Health Phys 2021 06;120(6):671-682

Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.

Abstract: Gulf War I veterans who were victims of depleted uranium (DU) "friendly-fire" incidents have undergone longitudinal health surveillance since 1994. During the spring of 2019, 36 members of the cohort were evaluated with a monitoring protocol including exposure assessment for total and isotopic uranium concentrations in urine and a comprehensive review of health outcomes, including measures of bone metabolism and bone mineral density (BMD) determination. Elevated urine U concentrations were observed in cohort members with retained depleted uranium (DU) shrapnel fragments. In addition, a measure of bone resorption, N-telopeptide, showed a statistically significant increase in those in the high DU subgroup, a finding consistent with a statistically significant decrease in bone mass also observed in this high DU subgroup compared to the low DU subgroup. After more than 25 y since first exposure to DU, an aging cohort of military veterans continues to show few U-related health effects in known target organs of U toxicity. The new finding of impaired BMD in the high DU subgroup has now been detected in two consecutive surveillance visits. While this is a biologically plausible uranium effect, it is not reflected in other measures of bone metabolism in the full cohort, which have largely been within normal limits. However, ongoing accrual of the U burden from fragment absorption over time and the effect of aging further impairing BMD suggest the need for future surveillance assessments of this cohort.
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http://dx.doi.org/10.1097/HP.0000000000001395DOI Listing
June 2021

A national trauma data bank analysis of large animal-related injuries.

Injury 2021 Sep 12;52(9):2677-2681. Epub 2021 Mar 12.

Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Trauma Services, 1500 Red River St, TX 78701, Austin. Electronic address:

Introduction: Large animal-related injuries (LARI) are relatively uncommon, but, nevertheless, a public hazard. The objective of this study was to better understand LARI injury patterns and outcomes.

Materials And Methods: We performed a retrospective review of the 2016 National Trauma Data Bank and used ICD-10 codes to identify patients injured by a large animal. The primary outcome was severe injury pattern, while secondary outcomes included mortality, hospital length of stay, ICU admission, and mechanical ventilation usage.

Results: There were 6,662 LARI included in our analysis. Most LARI (66%) occurred while riding the animal, and the most common type of LARI was fall from horse (63%). The median ISS was 9 and the most severe injuries (AIS ≥ 3) were to the chest (19%), head (10%), and lower extremities (10%). The overall mortality was low at 0.8%. Compared to non-riders, riders sustained more severe injuries to the chest (21% vs. 16%, p<0.001) and spine (4% vs. 2%, p<0.001). Compared to motor vehicle collisions (MVC), riders sustained fewer severe injuries to the head (10% vs. 12%, p<0.001) and lower extremity (10% vs. 12%, p=0.01). Compared to auto-pedestrian accidents, non-riders sustained fewer severe injuries to the head (11% vs. 19%, p<0.001) and lower extremity (10% vs. 20%, p<0.001).

Conclusion: Patients involved in a LARI are moderately injured with more complex injuries occurring in the chest, head, and lower extremities. Fall from horse was the most common LARI mechanism. Overall mortality was low. Compared to non-riders, riders were more likely to sustain severe injuries to the chest and spine. Severe injury patterns were similar when comparing riders to MVC and, given that most LARI are riding injuries, we recommend trauma teams approach LARI as they would an MVC.
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http://dx.doi.org/10.1016/j.injury.2021.03.020DOI Listing
September 2021

Predisposing, Enabling, and Need Factors Associated with the Choice of Pharmacy Type in the US: Findings from the 2015/2016 National Consumer Survey on the Medication Experience and Pharmacists' Roles.

Pharmacy (Basel) 2021 Mar 28;9(2). Epub 2021 Mar 28.

Department of Biomedical and Pharmaceutical Sciences, School of Pharmacy, Chapman University, Irvine, CA 92866, USA.

Background: Knowing the type of pharmacy used by the patient is meaningful to the pharmacist. Previous studies have assessed different factors predicting the kind of pharmacy selection and reached inconsistent findings.

Objectives: To identify patient and health-related factors associated with pharmacy type selection.

Methods: The Andersen Behavioral Model of Health Service Use was used to organize the selection of patient characteristics and categorize them as predisposing, enabling, and need factors. The dependent variable was the type of pharmacy used. Logistic regression was used to predict the association between patient-related characteristics and the type of pharmacy used.

Results: Older age respondents were less likely to use independent pharmacies (OR = 0.992) and more likely to use mail pharmacy services (OR = 1.026). Highly educated people showed higher use of chain and mail pharmacies (OR = 1.272, 1.185, respectively) and less tendency to use the independent, supermarket, and prescription-only pharmacy types. Men were less likely to use chain pharmacies (OR = 0.932) and more likely to use supermarket pharmacies than women. Patients who use Medication Therapy Management (MTM) services had higher odds of using independent and supermarket pharmacies (OR = 2.808, 1.689, respectively). Patients with a higher number of chronic diseases and experienced side effects of medications were more likely to use independent pharmacies (OR for number of disease = 1.097 and for side effects = 1.095).

Conclusions: This study's findings identify characteristics associated with selecting certain pharmacy settings and direct future research to include other predictors encompassing beliefs, attitudes, and other social factors.
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http://dx.doi.org/10.3390/pharmacy9020072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103259PMC
March 2021

The EMS Modified Early Warning Score (EMEWS): A Simple Count of Vital Signs as a Predictor of Out-of-Hospital Cardiac Arrests.

Prehosp Emerg Care 2021 Apr 13:1-22. Epub 2021 Apr 13.

For patients at risk for out-of-hospital cardiac arrest (OHCA) after Emergency Medical Services (EMS) arrival, outcomes may be mitigated by identifying impending arrests and intervening before they occur. Tools such as the Modified Early Warning Score (MEWS) have been developed to determine the risk of arrest, but involve relatively complicated algorithms that can be impractical to compute in the prehospital environment. A simple count of abnormal vital signs, the "EMS Modified Early Warning Score" (EMEWS), may represent a more practical alternative. We sought to compare to the ability of MEWS and EMEWS to identify patients at risk for EMS-witnessed OHCA. We conducted a retrospect analysis of the 2018 ESO Data Collaborative database of EMS encounters. Patients without cardiac arrest before EMS arrival were categorized into those who did or did not have an EMS-witnessed arrest. MEWS was evaluated without its temperature component (MEWS-T). The performance of MEWS-T and EMEWS in predicting EMS witnessed arrest was evaluated by comparing receiver-operating characteristic curves. Of 369,064 included encounters, 4,651 were EMS witnessed arrests. MEWS-T demonstrated an area under the curve (AUC) of 0.79 (95% CI: 0.79 - 0.80), with 86.8% sensitivity and 51.0% specificity for MEWS-T ≥ 3. EMEWS demonstrated an AUC of 0.74 (95% CI: 0.73 - 0.75), with 81.3% sensitivity and 53.9% specificity for EMEWS ≥ 2. EMEWS showed a similar ability to predict EMS-witnessed cardiac arrest compared to MEWS-T, despite being significantly simpler to compute. Further study is needed to evaluate whether the implementation of EMEWS can aid EMS clinicians in anticipating and preventing OHCA.
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http://dx.doi.org/10.1080/10903127.2021.1908464DOI Listing
April 2021

Chest and Pelvis X-Rays as a Screening Tool for Abdominal Injury in Geriatric Blunt Trauma Patients.

Am Surg 2021 Mar 11:3134821998665. Epub 2021 Mar 11.

Dell Medical School at the University of Texas, Austin, TX, USA.

Background: This study evaluates the utility of chest (CXR) and pelvis (PXR) X-ray, as adjuncts to the primary survey, in screening geriatric blunt trauma (GBT) patients for abdominal injury or need for laparotomy.

Methods: We performed a retrospective analysis of patients 65-89 years in the 2014 National Trauma Data Bank. X-ray injuries were identified by ICD9 codes and defined as any injury felt to be readily detectable by a non-radiologist. X-ray findings were dichotomized as "both negative" (no injury presumptively apparent on CXR or PXR) or "either positive" (any injury presumptively apparent on CXR or PXR). Rates of abdominal injuries and laparotomy were compared and used to calculate sensitivity and specificity. The primary outcomes were abdominal injury and laparotomy. The secondary outcomes included mortality, ventilator days, and hospital days.

Results: A total of 202 553 patients met criteria. Overall, 9% of patients with either positive X-rays had abdominal injury and 2% laparotomy vs. 1.1% and .3% with both negative ( < .001). The specificity for any positive X-ray was 79% for abdominal injury and 78% for laparotomy. The sensitivity was 69% for abdominal injury and laparotomy. The either positive group had fewer ventilator days (.3 vs. .8, < .0001), longer length of stay (7 vs. 5, < .0001), and higher mortality (6% vs. 4%, < .0001) vs both negative.

Conclusion: CXR and PXR can be used to assess for intra-abdominal injury and need for laparotomy. GBT patients with either positive X-rays should continue workup regardless of mechanism due to the high specificity of this tool for abdominal injury and need for laparotomy.
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http://dx.doi.org/10.1177/0003134821998665DOI Listing
March 2021

Risk scoring models fail to predict pulmonary embolism in trauma patients.

Am J Surg 2021 Oct 11;222(4):855-860. Epub 2021 Feb 11.

Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas, 1500 Red River St, Austin, TX, 78701, USA. Electronic address:

Background: We aimed to identify risk factors and risk scoring models to help identify post-traumatic pulmonary embolisms (PE).

Methods: We performed a retrospective review (2014-2019) of all adult trauma patients admitted to our Level I trauma center that received a CT pulmonary angiogram (CTPA) for a suspected PE. A systematic literature search found eleven risk scoring models, all of which were applied to these patients. Scores of patients with and without PE were compared.

Results: Of the 235 trauma patients that received CTPA, 31 (13%) showed a PE. No risk scoring model had both a sensitivity and specificity above 90%. The Wells Score had the highest area under the curve (0.65). After logistic regression, no risk scoring model variables were independently associated with PE.

Conclusions: In trauma patients with clinically suspected PE, clinical variables and current risk scoring models do not adequately differentiate patients with and without PE.
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http://dx.doi.org/10.1016/j.amjsurg.2021.02.007DOI Listing
October 2021

Synaptic processes and immune-related pathways implicated in Tourette syndrome.

Transl Psychiatry 2021 01 18;11(1):56. Epub 2021 Jan 18.

Sorbonne Universités, UPMC Université Paris 06, UMR S 1127, CNRS UMR 7225, ICM, Paris, France.

Tourette syndrome (TS) is a neuropsychiatric disorder of complex genetic architecture involving multiple interacting genes. Here, we sought to elucidate the pathways that underlie the neurobiology of the disorder through genome-wide analysis. We analyzed genome-wide genotypic data of 3581 individuals with TS and 7682 ancestry-matched controls and investigated associations of TS with sets of genes that are expressed in particular cell types and operate in specific neuronal and glial functions. We employed a self-contained, set-based association method (SBA) as well as a competitive gene set method (MAGMA) using individual-level genotype data to perform a comprehensive investigation of the biological background of TS. Our SBA analysis identified three significant gene sets after Bonferroni correction, implicating ligand-gated ion channel signaling, lymphocytic, and cell adhesion and transsynaptic signaling processes. MAGMA analysis further supported the involvement of the cell adhesion and trans-synaptic signaling gene set. The lymphocytic gene set was driven by variants in FLT3, raising an intriguing hypothesis for the involvement of a neuroinflammatory element in TS pathogenesis. The indications of involvement of ligand-gated ion channel signaling reinforce the role of GABA in TS, while the association of cell adhesion and trans-synaptic signaling gene set provides additional support for the role of adhesion molecules in neuropsychiatric disorders. This study reinforces previous findings but also provides new insights into the neurobiology of TS.
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http://dx.doi.org/10.1038/s41398-020-01082-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814139PMC
January 2021

Surgical staging and resection of malignant pleural mesothelioma.

J Thorac Dis 2020 Dec;12(12):7467-7480

Mayo Clinic, Division of General Thoracic Surgery, Department of Surgery, Rochester, MN, USA.

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http://dx.doi.org/10.21037/jtd-19-2267DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797813PMC
December 2020

Repairing the World One Patient at a Time.

Authors:
Lawrence W Brown

Pediatr Neurol 2021 03 27;116:27-30. Epub 2020 Nov 27.

Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.pediatrneurol.2020.11.013DOI Listing
March 2021

Corrigendum to "Fatal crashes in the 5 years after recreational marijuana legalization in Colorado and Washington" [Accid. Anal. Prev. 132 (2019) 105284].

Accid Anal Prev 2021 Mar 24;151:105757. Epub 2020 Dec 24.

Division of Emergency Medicine, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas Austin, 1400 N IH35, Suite 2.230, Austin, TX, 78701, USA. Electronic address:

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http://dx.doi.org/10.1016/j.aap.2020.105757DOI Listing
March 2021

Practical Tools to Monitor and Evaluate Transition.

Authors:
Lawrence W Brown

Semin Pediatr Neurol 2020 Dec 26;36:100852. Epub 2020 Oct 26.

Perelman School of Medicine of the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA. Electronic address:

The success of transition for children and youth with neurological disorders depends on leadership from the pediatric neurology team to encourage and support the patient's firm knowledge base of the medical condition, gradual acceptance of self-management skills and confident self-advocacy. While the foundations of effective medical transition have been effectively outlined, the challenge remains to translate from principles to practice. The Child Neurology Foundation has published open source, practical guides which are designed to facilitate the ability to structure and monitor the process through adolescence as well as to insure an effective transfer of care to adult providers. In addition, this article provides one hospital;'s efforts to integrate the transition process into the electronic medical record.
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http://dx.doi.org/10.1016/j.spen.2020.100852DOI Listing
December 2020

Introduction.

Semin Pediatr Neurol 2020 Dec 26;36:100851. Epub 2020 Oct 26.

Division of Pediatric Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA. Electronic address:

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http://dx.doi.org/10.1016/j.spen.2020.100851DOI Listing
December 2020

Injury rates per mile of travel for electric scooters versus motor vehicles.

Am J Emerg Med 2021 02 27;40:166-168. Epub 2020 Oct 27.

Division of Emergency Medicine, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, TX, USA; U.S. Acute Care Solutions, Canton, OH, USA. Electronic address:

Objective: This study determined the vehicle-miles-traveled (VMT)-based injury rate for stand-up, dockless electric rental scooters (e-scooters), and compare it with the VMT-based injury rate for motor vehicle travel.

Methods: In this secondary analysis of existing data, the e-scooter injury rate was calculated based on e-scooter injuries presenting to an emergency department or the emergency medical services system in Austin, TX between September and November 2018. Injuries were identified by Austin Public Health through a targeted e-scooter epidemiological injury investigation; e-scooter VMT data were reported by e-scooter vendors as a condition of their city licensing. Comparative injury rates for motor vehicle travel in Texas, and specifically in Travis County were calculated using annual motor vehicle crash (MVC) injury and VMT data reported by the Texas Department of Transportation.

Results: There were 160 confirmed e-scooter injuries identified by the e-scooter injury investigation, with 891,121 reported miles of e-scooter travel during the study period. This produces an injury rate estimate of 180 injuries/million VMT (MVMT). The injury rates for motor vehicle travel for Texas and for Travis County were 0.9 injuries/MVMT and 1.0 injuries/MVMT, respectively.

Conclusion: The observed VMT-based e-scooter injury rate was approximately 175 to 200 times higher than statewide or county specific injury rates for motor vehicle travel. These findings raise concerns about the potential higher injury rate associated with e-scooters, and highlight the need for further injury surveillance, research and prevention activities addressing this emerging transportation technology.
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http://dx.doi.org/10.1016/j.ajem.2020.10.048DOI Listing
February 2021

Trump v. The ACA.

Health Econ Policy Law 2021 07 3;16(3):251-255. Epub 2020 Nov 3.

Mailman School of Public Health, Columbia University, New York, USA.

Before his incoherent response to the COVID-19 pandemic, the focus of President Trump's health policy agenda was the elimination of the Patient Protection and Affordable Care Act (ACA), which he has called a 'disaster'. The attacks on the ACA included proposals to repeal the law through the legislative process, to erode it through a series of executive actions, and to ask the courts to declare it unconstitutional. Despite these ongoing challenges, the ACA remains largely intact as the U.S. heads into the 2020 election. The longer term fate of the law, however, is uncertain and the outcome of the 2020 election is likely to have a dramatic effect on the direction of health policy in the U.S.
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http://dx.doi.org/10.1017/S1744133120000389DOI Listing
July 2021

Getting The Price Right: How Some Countries Control Spending In A Fee-For-Service System.

Health Aff (Millwood) 2020 11;39(11):1867-1874

Lawrence D. Brown is a professor in the Department of Health Policy and Management in the Mailman School of Public Health, Columbia University.

Although the US has the highest health care prices in the world, the specific mechanisms commonly used by other countries to set and update prices are often overlooked, with a tendency to favor strategies such as reducing the use of fee-for-service reimbursement. Comparing policies in three high-income countries (France, Germany, and Japan), we describe how payers and physicians engage in structured fee negotiations and standardize prices in systems where fee-for-service is the main model of outpatient physician reimbursement. The parties involved, the frequency of fee schedule updates, and the scope of the negotiations vary, but all three countries attempt to balance the interests of payers with those of physician associations. Instead of looking for policy importation, this analysis demonstrates the benefits of structuring negotiations and standardizing fee-for-service payments independent of any specific reform proposal, such as single-payer reform and public insurance buy-ins.
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http://dx.doi.org/10.1377/hlthaff.2019.01804DOI Listing
November 2020

Major gaps in human evidence for structure and function of the vasa vasora limit our understanding of the link with atherosclerosis.

J Anat 2021 03 20;238(3):785-793. Epub 2020 Oct 20.

School of Public Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia.

Atherosclerosis is the major pathology causing death in the developed world and, although risk factor modification has improved outcomes over the last decade, there is no cure. The role of the vasa vasora (VV) in the pathogenesis of atherosclerotic plaque is unclear but must relate to the predictability of diseased sites in the arterial tree. VV are small vessels found on major arteries and veins which supply nutrients and oxygen to the vessel wall itself while removing waste. Numerous studies have been carried out to investigate the anatomy and function of the VV as well as their significance in vascular disease. There is convincing evidence that VV are related to atherosclerotic plaque progression and vessel thrombosis, however, their link to the pathology of plaque initiation remains an interesting but neglected topic. We aim to present the evidence on the anatomy and functional behaviour of VV as well as their relationship to the initiation of atherosclerosis. At the same time, we wish to highlight inconsistencies in, and limitations of, the evidence available.
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http://dx.doi.org/10.1111/joa.13324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855071PMC
March 2021

Does preoperative magnetic resonance imaging alter the surgical plan in patients with acute traumatic cervical spinal cord injury?

J Trauma Acute Care Surg 2021 01;90(1):157-162

From the Department of Surgery and Perioperative Care (F.R.B., V.Y.W., J.P.A., J.R.O.-B., L.H.B., P.G.T., J.D.A., E.L., S.A.), Dell Medical School, and Trauma Services, Dell Seton Medical Center (C.V.R.B.), University of Texas at Austin, Austin, Texas.

Background: Whether magnetic resonance imaging (MRI) adds value to surgical planning for patients with acute traumatic cervical spinal cord injury (ATCSCI) remains controversial. In this study, we compared surgeons' operative planning decisions with and without preoperative MRI. We had two hypotheses: (1) the surgical plan for ATCSCI would not change substantially after the MRI and (2) intersurgeon agreement on the surgical plan would also not change substantially after the MRI.

Methods: We performed a vignette-based survey study that included a retrospective review of all adult trauma patients who presented to our American College of Surgeons-verified level 1 trauma center from 2010 to 2019 with signs of acute quadriplegia and underwent computed tomography (CT), MRI, and subsequent cervical spine surgery within 48 hours of admission. We abstracted patient demographics, admission physiology, and injury details. Patient clinical scenarios were presented to three spine surgeons, first with only the CT and then, a minimum of 2 weeks later, with both the CT and MRI. At each presentation, the surgeons identified their surgical plan, which included timing (none, <8, <24, >24 hours), approach (anterior, posterior, circumferential), and targeted vertebral levels. The outcomes were change in surgical plan and intersurgeon agreement. We used Fleiss' kappa (κ) to measure intersurgeon agreement.

Results: Twenty-nine patients met the criteria and were included. Ninety-three percent of the surgical plans were changed after the MRI. Intersurgeon agreement was "slight" to "fair" both before the MRI (timing, κ = 0.22; approach, κ = 0.35; levels, κ = 0.13) and after the MRI (timing, κ = 0.06; approach, κ = 0.27; levels, κ = 0.10).

Conclusion: Surgical plans for ATCSCI changed substantially when the MRI was presented in addition to the CT; however, intersurgeon agreement regarding the surgical plan was low and not improved by the addition of the MRI.

Level Of Evidence: Diagnostic, level II.
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http://dx.doi.org/10.1097/TA.0000000000002962DOI Listing
January 2021

Ketamine for Prehospital Pain Management Does Not Prolong Emergency Department Length of Stay.

Prehosp Emerg Care 2020 Oct 12:1-8. Epub 2020 Oct 12.

Background: Ketamine is gaining acceptance as an agent for prehospital pain control, but the associated risks of agitation, hallucinations and sedation have raised concern about its potential to prolong emergency department (ED) length of stay (LOS). This study compared ED LOS among EMS patients who received prehospital ketamine, fentanyl or morphine specifically for pain control. We hypothesized ED LOS would not differ between patients receiving the three medications.

Methods: This retrospective observational study utilized the 2018 ESO Research Database, which includes more than 7.5 million EMS events attended by more than 1,200 agencies. Inclusion criteria were a 9-1-1 scene response; age ≥ 18 years; a recorded pain score greater than 4; an initial complaint or use of a treatment protocol indicating a painful condition; prehospital administration of ketamine, fentanyl or morphine; and ED LOS data available. Patients were excluded if they received a combination of the medications, or if there were indications that medication administration could have been for airway management (i.e., altered mental status, head injury, respiratory distress/depression) or agitation control (e.g., behavioral complaints). Kruskal-Wallis test was used to compare ED LOS among patients receiving each of the three medications. evaluations of between-group differences were conducted using Wilcoxon Rank Sum test and a Bonferroni-corrected alpha value of 0.017.

Results: Of 9,548 patients who met the inclusion criteria, 119 received ketamine, 1,359 received morphine, and 8,070 received fentanyl. Patient and event characteristics did not significantly differ between the three groups. Median (IQR) ED LOS was 3.5 (2.5-6.1) hours for patients who received ketamine, 4.0 (2.7-6.1) hours for patients who received morphine, and 3.7 (2.6-5.4) hours for patients who received fentanyl (p = 0.002). In pairwise comparisons, patients who received morphine had significantly longer ED LOS than patients who received fentanyl (p < 0.001); there was no significant difference in ED LOS for patients who received ketamine vs. morphine (p = 0.161) or for patients who received ketamine vs. fentanyl (p = 0.809).

Conclusion: ED LOS is not longer for patients who receive prehospital ketamine, versus morphine or fentanyl, for management of isolated painful non-cardiorespiratory conditions.
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http://dx.doi.org/10.1080/10903127.2020.1819493DOI Listing
October 2020

Use of the Jung/Myers Model of Personality Types to Identify and Engage with Individuals at Greatest Risk of Experiencing Depression and Anxiety.

J Behav Health Serv Res 2021 07;48(3):446-467

Chapman University, One University Drive, Orange, CA, 92866, USA.

Depression is the leading cause of ill health and disability worldwide. Objectives were (1) to determine the strength of the association between personality type with depression and anxiety using the Preferred Communication Style Questionnaire (PCSQ©) and the Four-Item Patient Health Questionnaire for Depression and Anxiety (PHQ-4) and (2) evaluate the extent to which severity of depression and anxiety is associated with personality type. Data were collected via a self-administered online survey of 10,500. Chi-square analysis compared personality types and depression and anxiety. Practical significance was determined by calculating the percentage-from-expected score based on established statistics reflecting each personality type's percentage in the US population. Personality type was strongly associated with both depression and anxiety with certain types at significantly greater risk than others. Findings can improve the research and clinical community's understanding of the specific risk factors and triggers for depression and anxiety, and result in more efficacious, tailored treatment options.
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http://dx.doi.org/10.1007/s11414-020-09724-2DOI Listing
July 2021

Integrating quality improvement into the ECHO model to improve care for children and youth with epilepsy.

Epilepsia 2020 09 29;61(9):1999-2009. Epub 2020 Aug 29.

Maryland Coalition of Families, Columbia, Maryland.

Objective: Project ECHO (Extension for Community Healthcare Outcomes), a telementoring program, utilizes lectures, case-based learning, and an "all teach-all learn" approach to increase primary care provider (PCP) knowledge/confidence in managing chronic health conditions. The American Academy of Pediatrics (AAP) Epilepsy and Comorbidities ECHO incorporated quality improvement (QI) methodology to create meaningful practice change, while increasing PCP knowledge/self-efficacy in epilepsy management using the ECHO model.

Methods: Monthly ECHO sessions (May 2018 to December 2018) included lectures, case presentations/discussion, and QI review. Pediatric practices were recruited through the AAP. Practices engaged in ECHO sessions and improvement activities including monthly Plan-Do-Study-Act cycles, team huddles, chart reviews, and QI coaching calls to facilitate practice change. They were provided resource toolkits with documentation templates, safety handouts, and medication side effects sheets. QI measures were selected from the American Academy of Neurology Measurement Set for Epilepsy. The AAP Quality Improvement Data Aggregator was used for data entry, run chart development, and tracking outcomes. Participants completed retrospective surveys to assess changes in knowledge and self-efficacy.

Results: Seven practices participated across five states. Average session attendance was 14 health professionals (range = 13-17). A total of 479 chart reviews demonstrated improvement in six of seven measures: health care transition (45.3%, P = .005), safety education (41.6%, P = .036), mental/behavioral health screening (32.2% P = .027), tertiary center referral (26.7%, not significant [n.s.]), antiseizure therapy side effects (23%, n.s.), and documenting seizure frequency (7.1%, n.s.); counseling for women of childbearing age decreased by 7.8%.

Significance: This project demonstrated that integrating QI into an ECHO model results in practice change and increases PCP knowledge/confidence/self-efficacy in managing epilepsy.
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http://dx.doi.org/10.1111/epi.16625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7693351PMC
September 2020

The characteristics of dockless electric rental scooter-related injuries in a large U.S. city.

Traffic Inj Prev 2020 12;21(7):476-481. Epub 2020 Aug 12.

Division of Emergency Medicine, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas, Austin, Texas.

Objective: To describe the characteristics of dockless electric rental scooter ("e-scooter")-related injuries presenting to two emergency departments in one large U.S. city.

Methods: This observational cohort study utilized the city's public health syndromic surveillance system to prospectively identify patients with e-scooter-related injuries presenting between September and November 2018. The medical records for all adult patients treated at the two participating emergency departments were manually reviewed to extract demographic and clinical data. Cases involving mobility scooters or non-electric scooters were excluded.

Results: For the 124 included adult patients with e-scooter-related injuries, the median age was 30 years (IQR: 22-43), they were predominantly male (59.7%), and approximately half (51.6%) arrived by ambulance. Falling from the scooter (84.7%) was the most common mechanism; twelve patients (9.7%) had collided with a motor vehicle. Head and face injuries (45.5%) were common; only 2 patients (1.6%) were documented as wearing a helmet at the time of injury. Most patients (n = 112, 90.3%) required imaging, more than half (n = 78, 62.9%) required an emergency department procedure, and 26 (21.0%) required surgical intervention. Most patients were discharged home, but 35 (28.2%) were admitted to hospital. Two patients (1.6%) were admitted to the intensive care unit.

Conclusions: E-scooters are an emerging transportation technology associated with a wide range of potentially serious injuries that consume substantial emergency department and hospital resources. Head injuries are a particular concern, as few e-scooter riders are wearing helmets at the time of injury.
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http://dx.doi.org/10.1080/15389588.2020.1804059DOI Listing
April 2021
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