Early Results of an Initiative to Assess Exposure to Firearm Violence in Ambulatory Care: Descriptive Analysis of Electronic Health Record Data

BACKGROUND

 Current research on firearm violence is largely limited to patients who received care in emergency departments or inpatient acute care settings or who died. This is because standardized disease classification codes for firearm injury only represent bodily trauma. As a result, research on pathways and health impacts of firearm violence is largely limited to people who experienced acute bodily trauma and does not include the estimated millions of individuals who were exposed to firearm violence but did not sustain acute injury. Assessing and collecting data on exposure to firearm violence in ambulatory care settings can expand research and more fully frame the public health issue.

OBJECTIVE

The aim of the study is to evaluate the demographic and clinical characteristics of patients who self-reported exposure to firearm violence during a behavioral health visit.

METHODS

This study assessed early data from an initiative implemented in 2022 across a national network of ambulatory behavioral health centers to support trauma-informed care by integrating structured data fields on trauma exposure into an electronic health record behavioral health patient assessment form (SmartForm), as such variables are generally not included in standard outpatient medical records. We calculated descriptive statistics on clinic characteristics, patient demographics, and select clinical conditions among clinics that chose to implement the SmartForm and among patients who reported an exposure to firearm violence. Data on patient counts are limited to positive reports of exposure to firearm violence, and the representativeness of firearm exposure among all patients could not be calculated due to unknown variability in the implementation of the SmartForm.

RESULTS

There were 323 of 629 (51%) clinics that implemented the SmartForm and reported at least 1 patient exposed to firearm violence. In the first 11 months of implementation, 3165 patients reported a recent or past exposure to firearm violence across the 323 clinics. Among patients reporting exposure, 52.7% (n=1669) were male, 38.8% (n=1229) were Black, 45.7% (n=1445) had posttraumatic stress disorder, 37.5% (n=1186) had a substance abuse disorder (other than nicotine), and 11.7% (n=371) had hypertension.

CONCLUSIONS

Current research on firearm violence using standardized data is limited to acute care settings and death data. Early results from an initiative across a large network of behavioral health clinics demonstrate that a high number of clinics chose to implement the SmartForm, resulting in thousands of patients reporting exposure to firearm violence. This study demonstrates that collecting standardized data on firearm violence exposure in ambulatory care settings is feasible. This study further demonstrates that resultant data from ambulatory settings can be used for meaningful analysis in describing populations affected by firearm violence. The results of this study hold promise for further collection of structured data on exposure to firearm violence in ambulatory settings.

Use of F-Specific RNA Bacteriophage to Estimate Infectious Norovirus Levels in Oysters

Contamination of bivalve shellfish, particularly oysters, with norovirus is recognised as a significant food safety risk. Methods for quantification of norovirus in oysters using the quantitative real-time reverse transcription polymerase chain reaction (RT-qPCR) are well established, and various studies using RT-qPCR have detected norovirus in a considerable proportion of oyster samples, both in the UK and elsewhere. However, RT-qPCR detects viral genome, and by its nature is unable to discriminate between positive results caused by infectious viruses and those caused by non-infectious remnants including damaged virus particles and naked RNA. As a result, a number of alternative or complementary approaches to RT-qPCR testing have been proposed, including the use of infectious viral indicator organisms, most frequently F-specific RNA bacteriophage (F-RNA phage). In this study, we investigated the relationships between F-RNA phage and norovirus in digestive tissues from two sets of oyster samples, one randomly collected at retail (630 samples), and one linked to suspected norovirus illness outbreaks (nine samples). A positive association and correlation between PCR-detectable levels of genogroup II F-RNA bacteriophage (associated with human faecal contamination) and norovirus was found in both sets of samples, with more samples positive for genogroup II phage, at generally higher levels than norovirus. Levels of both viruses were higher in outbreak-related than retail samples. Infectious F-RNA phage was detected in 47.8% of all retail samples, and for a subset of 224 samples where characterisation of phage was carried out, infectious GII phage was detected in 30.4%. Infectious GII phage was detected in all outbreak-related samples. Determination of infectivity ratios by comparing levels of PCR-detectable (copies/g) and infectious GII phage (pfu/g) revealed that in the majority of cases less than 10% of virus detected by RT-qPCR was infectious. Application of these ratios to estimate infectious norovirus levels indicated that while 77.8% of outbreak-related samples contained > 5 estimated infectious norovirus/g, only 13.7% of retail samples did. Use of a combination of levels of PCR-detectable norovirus and infectious F-RNA phage showed that while only 7.0% of retail samples contained both > 100 copies/g norovirus and > 10 pfu/g F-RNA phage, these combined levels were present in 77.8% of outbreak-related samples, and 75.9% of retail samples with > 5 estimated infectious norovirus/g. We therefore suggest that combining RT-qPCR testing with a test for infectious F-RNA phage has the potential to better estimate health risks, and to better predict the presence of infectious norovirus than RT-qPCR testing alone.

Applying a Commercialization-Readiness Framework to Optimize Value for Achieving Sustainability of an Electronic Health Data Research Network and Its Data Capabilities: The SAFTINet Experience

CONTEXT

Sustaining electronic health data networks and maximizing return on federal investment in their development is essential for achieving national data insight goals for transforming health care. However, crossing the business model chasm from grant funding to self-sustaining viability is challenging.

CASE DESCRIPTION

This paper presents lessons learned in seeking the sustainability of the Scalable Architecture for Federated Translational Inquiries Network (SAFTINet), and electronic health data network involving over 50 primary care practices in three states. SAFTINet was developed with funding from the Agency for Healthcare Research and Quality to create a multi-state network for comparative effectiveness research (CER) involving safety-net patients.

METHODS

Three analyses were performed: (1) a product gap analysis of alternative data sources; (2) a Strengths-Weaknesses-Opportunities-Threat (SWOT) analysis of SAFTINet in the context of competing alternatives; and (3) a customer discovery process involving approximately 150 SAFTINet stakeholders to identify SAFTINet's sustaining value proposition for health services researchers, clinical data partners, and policy makers.

FINDINGS

The results of this business model analysis informed SAFTINet's sustainability strategy. The fundamental high-level product needs were similar between the three primary customer segments: credible data, efficient and easy to use, and relevance to their daily work or 'jobs to be done'. However, how these benefits needed to be minimally demonstrated varied by customer such that different supporting evidence was required.

MAJOR THEMES

The SAFTINet experience illustrates that commercialization-readiness and business model methods can be used to identify multi-sided value propositions for sustaining electronic health data networks and their data capabilities as drivers of health care transformation.

Sports-related injuries in the United States: who gets care and who does not

OBJECTIVE

To describe the pattern of sports-related injuries (SRIs), healthcare obtained for these injuries, and factors associated with obtaining healthcare.

DESIGN AND SETTING

Retrospective analysis of the adult subgroup within the Medical Expenditures Panel Survey dataset from 1996 to 2001, which is weighted to represent all noninstitutionalized US residents.

PARTICIPANTS

Survey participants (2996) aged 0 to 64 years reporting an SRI.

MAIN OUTCOME MEASUREMENT

Whether healthcare was obtained for an SRI.

RESULTS

A weighted estimate of 6.7 million individuals reported an SRI annually. Two million individuals (30%) did not obtain healthcare for an SRI. Twenty-four percent of those with "serious" injuries did not obtain healthcare. Predictors of obtaining healthcare include the following: an upper extremity injury [adjusted odds ratio (OR) 1.57, 95% confidence intervals (CI): 1.17, 2.10]; a "very or somewhat serious" injury (adjusted OR 1.64, 95% CI 1.24, 2.17); and one SRI versus >1 SRI (adjusted OR 1.37, 95% CI: 1.06, 1.78). Predictors of not obtaining healthcare for an SRI include the following: Black race (adjusted OR 0.59, 95%CI: 0.44, 0.79); no health insurance (adjusted OR 0.45, 95%CI: 0.33, 0.63); and no usual source of care (adjusted OR 0.71, 95% CI: 0.56, 0.91).

CONCLUSIONS

SRIs are common and often patients do not obtain healthcare for these injuries. Among Americans with an SRI, those who are Black, and those who lack insurance or a usual source of care, are at risk for not obtaining care for an SRI. Not obtaining healthcare and lacking knowledge about the consequences of sports injury may lead to unnecessary, additional morbidity and cost. Education targeted at these groups, at their physicians, and at policymakers may help reduce untreated SRIs.

Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals

BACKGROUND/PURPOSE

To improve clinical results and resource utilization in the care of appendicitis in children, the authors examined the current practice and outcomes of 30 pediatric hospitals.

METHODS

The Pediatric Health Information System (PHIS) database consists of comparative data from 30 free-standing Children's hospitals. The study population of 3,393 children was derived from the database by selecting the "Diagnosis Related Group Code" for appendicitis (APRDRGv12 164), ages 0 to 17 years, using discharges between October 1, 1999 and September 30, 2000. Data are expressed as the range and median for individual hospital outcomes.

RESULTS

The nonpositive appendectomy rate ranged from 0 to 17% at the 30 hospitals (median, 2.6%). Ruptured appendicitis varied from 20% to 76% (median, 36.5%). The median length of stay (LOS) for nonruptured appendicitis was 2 days (range, 1.4 to 3.1 days), ruptured appendicitis varied from 4.4 to 11 days (median, 6 days). The median readmission rate within 14 days was 4.3% (0 to 10%). Laparoscopic appendectomy varied from 0 to 95% in the 30 hospitals (mean, 31%) The LOS did not vary significantly in laparoscopic versus open for nonruptured (2.3 v 2.0 days) or ruptured appendicitis (5.5 v 6.2 days). Days on antibiotics for ruptured appendicitis ranged from 4.6 to 7.9 days (median, 5.9 days) Children receiving any study varied from 18% to 89% (median, 69%). Ultrasound scan and computed tomography (CT) were comparable in both nonruptured (13% ultrasound scan v 14%) and ruptured appendicitis (14% ultrasound scan v 21% CT).

CONCLUSIONS

Significant variability in practice patterns and resource utilization exists in the management of acute appendicitis in pediatric hospitals. Clinical outcomes could be improved by collaborative initiatives to adopt evidence-based best practices.

New anilinophthalazines as potent and orally well absorbed inhibitors of the VEGF receptor tyrosine kinases useful as antagonists of tumor-driven angiogenesis

The sprouting of new blood vessels, or angiogenesis, is necessary for any solid tumor to grow large enough to cause life-threatening disease. Vascular endothelial growth factor (VEGF) is one of the key promoters of tumor induced angiogenesis. VEGF receptors, the tyrosine kinases Flt-1 and KDR, are expressed on vascular endothelial cells and initiate angiogenesis upon activation by VEGF. 1-Anilino-(4-pyridylmethyl)-phthalazines, such as CGP 79787D (or PTK787 / ZK222584), reversibly inhibit Flt-1 and KDR with IC(50) values < 0.1 microM. CGP 79787D also blocks the VEGF-induced receptor autophosphorylation in CHO cells ectopically expressing the KDR receptor (ED(50) = 34 nM). Modification of the 1-anilino moiety afforded derivatives with higher selectivity for the VEGF receptor tyrosine kinases Flt-1 and KDR compared to the related receptor tyrosine kinases PDGF-R and c-Kit. Since these 1-anilino-(4-pyridylmethyl)phthalazines are orally well absorbed, these compounds qualify for further profiling and as candidates for clinical evaluation.

Partnerships in healthcare: a Commonwealth perspective

This article briefly outlines the nature and characteristics of partnership, and points to the need to build partnerships through deliberate efforts, since they do not occur by simply bringing people and/or resources together. It identifies some of the reasons why partnerships in health are invaluable in meeting the priority health needs of populations, and the importance which the Commonwealth places on partnerships given the unique characteristics which are common to its member countries. The article then uses practical examples to illustrate the value of partnerships in health at the national, regional and international level. For the benefit of front-line healthcare providers, some suggestions are given of how partnerships could be used to enhance the services which they give to the communities they serve.

Novel C5a receptor antagonists regulate neutrophil functions in vitro and in vivo

Novel recombinant human C5a receptor antagonists were discovered through modification of the C terminus of C5a. The C5a1-71T1M,C27S,Q71C monomer, (C5aRAM; CGS 27913), was a pure and potent functional antagonist. The importance of a C-terminal cysteine at position 71 to antagonist properties of C5aRAM was confirmed by studying C5a1-71 derivatives with replacements of Q71, C5a derivatives of various lengths (70-74) with C-terminal cysteines, and C5a derivatives of various lengths (71-74) with Q71C replacements. The majority of C5a1-71Q71 derivatives were agonists (C5a-like) in the human neutrophil C5a-induced intracellular calcium mobilization assay. The C5a1-71Q71C derivative was an antagonist. C5a derivatives of lengths 73 and 74 with C-terminal cysteines were agonists, while lengths 70 to 72 were antagonists. C5a derivatives of lengths 72, 73, and 74 with Q71C replacements were agonists, while, again, C5a1-71Q71C was an antagonist. C5aRAM and its adducts, including its dimer, C5aRAD (CGS 32359), were pure antagonists. Additionally, CSaRAM and CSaRAD inhibited binding of 125I-labeled recombinant human C5a to neutrophil membranes (Ki = 79 and 2 pM, respectively), C5a-stimulated neutrophil intracellular calcium mobilization (8 and 13 nM), CD11b integrin up-regulation (10 and 1 nM), superoxide generation (182 and 282 nM), lysozyme release (1 and 2 microM), and chemotaxis (11 and 7 microM). In vivo, intradermal injection of C5aRAM inhibited C5a-induced dermal edema in rabbits. Furthermore, a 5-mg/kg i.v. bolus of C5aRAD significantly inhibited C5a-induced neutropenia in micropigs when challenged with C5a 30 min after C5aRAD administration. C5aRAM and C5aRAD are novel, potent C5a receptor antagonists devoid of agonist or proinflammatory activity with demonstrated efficacy in vitro and in vivo.

Novel spirodihydrobenzofuranlactams as antagonists of endothelin and as inhibitors of HIV-1 protease produced by Stachybotrys Sp. I. Fermentation, isolation and biological activity

Six novel spirodihydrobenzofuranlactams I - VI (1 - 6) and a related spirodihydrobenzofuranalcohol, the previously described natural compound L-671,776 (7), were isolated from cultures of two different Stachybotrys species. These secondary metabolites showed antagonistic effects in the endothelin receptor binding assay and inhibited HIV-1 protease. Both biological activities are novel for L-671,776 (7). The pseudosymmetric spirodihydrobenzofuranlactam VI (6) is the most potent representative of this class of compounds exhibiting IC50 values of 1.5 microM in the ET-A receptor binding assay and 11 microM in the HIV-1 protease inhibition assay.

Pizotifen (Sanomigran) in childhood migraine. A double-blind controlled trial

Forty-seven children with migraine have been included in a double-blind cross-over study with pizotifen and placebo. The children received either pizotifen for 3 months followed by placebo or vice versa. Thirty-nine children completed the trial and there was no significant difference between active and placebo treatment as regards reduction of number of attacks, total and mean duration of attacks and duration of longest attacks. Pizotifen was well tolerated by the children.

Trephine drill biopsy in the diagnosis of malignant pleural mesothelioma

Trephine drill biopsy of the pleura was utilized to establish the diagnosis of malignant pleural mesothelioma in a patient with a thickened pleura without pleural effusion.

Interaction between thyroxine and tricyclic antidepressant drugs on cardiac neurotransmitter receptors

The effect of chronic administration of desmethylimipramine (DMI) and iprindole on cardiac neurotransmitter receptors was studied. In addition, the influence of these drugs on the action of thyroxine (T4) on myocardial receptors was investigated. Administration of iprindole (10 mg/kg i.p., twice daily for 11 days) markedly increased the number of beta- adrenergic receptors in the heart and significantly reduced the affinity of these receptors for (-)[3H]dihydroalprenolol ([3H]DHA). Injection of T4 (500 mg/rat i.m., for 5 days) concomitantly with iprindole resulted in a lower beta-adrenergic receptor density that with iprindole treatment alone, but significantly higher than that measured in control rats. Affinity of the receptors for (-)[3H]quinuclidinyl benzilate ([3H]QNB) in heart membrane preparations of animals pretreated with T4 alone or with T4 plus iprindole was not different from control. Neither pretreatment with DMI nor with iprindole affected the density of cholinergic muscarinic receptors in the heart or their affinity for [3H]QNB. The decrease in cardiac cholinergic receptors induced by administration of T4 was not prevented by simultaneous injections of DMI. Combined administration of iprindole and T4 caused a reduction in the affinity of myocardial cholinergic muscarinic receptors, but restored the number of these receptors to normal. The results demonstrate distinct differences between DMI and iprindole in their effects on cardiac neurotransmitter receptors and in the influence of these drugs on the actions of T4 on receptors in the heart.

Monitoring octanoic and decanoic acids in plasma from children with intractable epilepsy treated with medium-chain triglyceride diet

We describe a procedure for gas-chromatographic determination of n-octanoic and n-decanoic acids in 100 microL of plasma from children with intractable epilepsy treated with medium-chain triglyceride (MCT) diet. With n-nonanoic acid as the internal standard, the extraction efficiencies for octanoic and decanoic acids were 98 and 105%, respectively. Within-run CVs for octanoic acid at 0.5, 1.0, 2.5, 5.0, 7.5, and 10.0 micrograms/0.1 mL were 8.8, 7.9, 8.5, 6.5, 4.3, and 5.7%, respectively. For decanoic acid at identical concentrations, the CVs were 10.0, 7.4, 4.9, 4.0, 2.6, and 3.5%, respectively. For 10 children on MCT diet (45.9% of calories supplied as MCT) the mean concentrations of octanoic and decanoic acids were 44.2 and 27.0 mg/L, respectively. Presence of relatively "high" quantities of these acids in plasma may contribute to seizure control when MCT diet is prescribed for intractable childhood epilepsy.

Monitoring octanoic and decanoic acids in plasma from children with intractable epilepsy treated with medium-chain triglyceride diet

We describe a procedure for gas-chromatographic determination of n-octanoic and n-decanoic acids in 100 microL of plasma from children with intractable epilepsy treated with medium-chain triglyceride (MCT) diet. With n-nonanoic acid as the internal standard, the extraction efficiencies for octanoic and decanoic acids were 98 and 105%, respectively. Within-run CVs for octanoic acid at 0.5, 1.0, 2.5, 5.0, 7.5, and 10.0 micrograms/0.1 mL were 8.8, 7.9, 8.5, 6.5, 4.3, and 5.7%, respectively. For decanoic acid at identical concentrations, the CVs were 10.0, 7.4, 4.9, 4.0, 2.6, and 3.5%, respectively. For 10 children on MCT diet (45.9% of calories supplied as MCT) the mean concentrations of octanoic and decanoic acids were 44.2 and 27.0 mg/L, respectively. Presence of relatively "high" quantities of these acids in plasma may contribute to seizure control when MCT diet is prescribed for intractable childhood epilepsy.

Bilateral hilar enlargement as a presenting sign of multiple primary bronchogenic carcinoma

An asymptomatic patient presented with a chest roentgenogram showing bilateral hilar enlargement compatible with stage II sarcoidosis. However, evaluation revealed double primary bronchogenic carcinoma. A possible pitfall in the non-pathologic diagnosis of sarcoidosis and the implications of double primary bronchogenic carcinoma are discussed.

Massachusetts: The transfer of state hospital resources to community programs

Gardner (Mass). State Hospital began transferring its resources to two community programs two years ago. During the transfer administrative problems increased and become more difficult to resolve, hospital staff and community members became fearful that the hospital would be phased out, and the possibility of a budget cut was a constant threat. When the hospital census was reduced to 225 patients who could not enter community programs, the commissioner of mental health appointed a commission to make recommendations about the hospital's future role. Five options open to the commission, and its recommendations, are discussed.