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Richards JA, Kuo E, Stewart C, Shulman L, Parrish R, Whiteside U, Boggs JM, Simon GE, Rowhani-Rahbar A, Betz ME. Reducing Firearm Access for Suicide Prevention: Implementation Evaluation of the Web-Based "Lock to Live" Decision Aid in Routine Health Care Encounters. JMIR Med Inform 2024; 12:e48007. [PMID: 38647319 PMCID: PMC11063417 DOI: 10.2196/48007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/12/2023] [Accepted: 02/27/2024] [Indexed: 04/25/2024] Open
Abstract
Background "Lock to Live" (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians. Objective The goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters. Methods The L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)-a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model-Reach, Adoption, and Implementation-were selected to inform and evaluate the implementation of L2L at KPWA (January 1, 2020, to December 31, 2021). Electronic health record (EHR) data were used to purposefully recruit adult patients, including firearm owners and patients reporting suicidality, to participate in semistructured interviews. Interview themes were used to facilitate L2L implementation and inform subsequent semistructured interviews with clinicians responsible for suicide risk mitigation. Audio-recorded interviews were conducted via the web, transcribed, and coded, using a rapid qualitative inquiry approach. A descriptive analysis of EHR data was performed to summarize L2L reach and adoption among patients identified at high risk of suicide. Results The initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) "have an open conversation," (2) "validate their situation," (3) "share what to expect," (4) "make it accessible and memorable," and (5) "walk through the tool." Clinicians' interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from <1% to 48% among mental health clinicians. Conclusions Understanding the value of L2L from users' perspectives was essential for facilitating implementation and increasing patient reach and clinician adoption. Incorporating L2L into the existing system-level, EHR-based safety plan template reduced the effort to use L2L and was likely the most impactful implementation strategy. As rising suicide rates galvanize the urgency of prevention, the findings from this project, including L2L implementation tools and strategies, will support efforts to promote safety for suicide prevention in health care nationwide.
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Affiliation(s)
- Julie Angerhofer Richards
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States
| | - Elena Kuo
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Christine Stewart
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Lisa Shulman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Rebecca Parrish
- Department of Mental Health & Wellness, Kaiser Permanente Washington, Seattle, WA, United States
| | - Ursula Whiteside
- NowMattersNow.org, Seattle, WA, United States
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Jennifer M Boggs
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, United States
| | - Gregory E Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
- Department of Mental Health & Wellness, Kaiser Permanente Washington, Seattle, WA, United States
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Ali Rowhani-Rahbar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, United States
- Firearm Injury and Policy Research Program, University of Washington, Seattle, WA, United States
| | - Marian E Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States
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Lee AK, Bobb JF, Richards JE, Achtmeyer CE, Ludman E, Oliver M, Caldeiro RM, Parrish R, Lozano PM, Lapham GT, Williams EC, Glass JE, Bradley KA. Integrating Alcohol-Related Prevention and Treatment Into Primary Care: A Cluster Randomized Implementation Trial. JAMA Intern Med 2023; 183:319-328. [PMID: 36848119 PMCID: PMC9972247 DOI: 10.1001/jamainternmed.2022.7083] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/24/2022] [Indexed: 03/01/2023]
Abstract
Importance Unhealthy alcohol use is common and affects morbidity and mortality but is often neglected in medical settings, despite guidelines for both prevention and treatment. Objective To test an implementation intervention to increase (1) population-based alcohol-related prevention with brief interventions and (2) treatment of alcohol use disorder (AUD) in primary care implemented with a broader program of behavioral health integration. Design, Setting, and Participants The Sustained Patient-Centered Alcohol-Related Care (SPARC) trial was a stepped-wedge cluster randomized implementation trial, including 22 primary care practices in an integrated health system in Washington state. Participants consisted of all adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018. Data were analyzed from August 2018 to March 2021. Interventions The implementation intervention included 3 strategies: practice facilitation; electronic health record decision support; and performance feedback. Practices were randomly assigned launch dates, which placed them in 1 of 7 waves and defined the start of the practice's intervention period. Main Outcomes and Measures Coprimary outcomes for prevention and AUD treatment were (1) the proportion of patients who had unhealthy alcohol use and brief intervention documented in the electronic health record (brief intervention) for prevention and (2) the proportion of patients who had newly diagnosed AUD and engaged in AUD treatment (AUD treatment engagement). Analyses compared monthly rates of primary and intermediate outcomes (eg, screening, diagnosis, treatment initiation) among all patients who visited primary care during usual care and intervention periods using mixed-effects regression. Results A total of 333 596 patients visited primary care (mean [SD] age, 48 [18] years; 193 583 [58%] female; 234 764 [70%] White individuals). The proportion with brief intervention was higher during SPARC intervention than usual care periods (57 vs 11 per 10 000 patients per month; P < .001). The proportion with AUD treatment engagement did not differ during intervention and usual care (1.4 vs 1.8 per 10 000 patients; P = .30). The intervention increased intermediate outcomes: screening (83.2% vs 20.8%; P < .001), new AUD diagnosis (33.8 vs 28.8 per 10 000; P = .003), and treatment initiation (7.8 vs 6.2 per 10 000; P = .04). Conclusions and Relevance In this stepped-wedge cluster randomized implementation trial, the SPARC intervention resulted in modest increases in prevention (brief intervention) but not AUD treatment engagement in primary care, despite important increases in screening, new diagnoses, and treatment initiation. Trial Registration ClinicalTrials.gov Identifier: NCT02675777.
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Affiliation(s)
- Amy K. Lee
- Kaiser Permanente Washington Health Research Institute, Seattle
- Mental Health and Wellness Department, Kaiser Permanente Washington, Seattle
| | | | - Julie E. Richards
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle
| | - Carol E. Achtmeyer
- Veterans Affairs Puget Sound Health Care System, Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Evette Ludman
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Malia Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Ryan M. Caldeiro
- Mental Health and Wellness Department, Kaiser Permanente Washington, Seattle
| | - Rebecca Parrish
- Mental Health and Wellness Department, Kaiser Permanente Washington, Seattle
| | - Paula M. Lozano
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Gwen T. Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle
| | - Emily C. Williams
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle
- Veterans Affairs Puget Sound Health Care System, Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Joseph E. Glass
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Katharine A. Bradley
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle
- Department of Medicine, School of Medicine, University of Washington, Seattle
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Richards JE, Kuo ES, Whiteside U, Shulman L, Betz ME, Parrish R, Boggs JM, Rowhani-Rahbar A, Simon GE. Patient and Clinician Perspectives of a Standardized Question About Firearm Access to Support Suicide Prevention: A Qualitative Study. JAMA Health Forum 2022; 3:e224252. [PMID: 36416815 PMCID: PMC9685488 DOI: 10.1001/jamahealthforum.2022.4252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Importance US residents report broad access to firearms, which are the most common means of suicide death in the US. Standardized firearm access questions during routine health care encounters are uncommon despite potential benefits for suicide prevention. Objective To explore patient and clinician experiences with a standard question about firearm access on a self-administered mental health questionnaire routinely used prior to primary care and mental health specialty encounters. Design, Setting, and Participants Qualitative semistructured interviews were conducted from November 18, 2019, to October 8, 2020, at Kaiser Permanente Washington, a large integrated care delivery system and insurance provider. Electronic health record data identified adult patients with a documented mental health diagnosis who had received a standard question about firearm access ("Do you have access to guns? yes/no") within the prior 2 weeks. A stratified sampling distribution selected 30% who answered "yes," 30% who answered "no," and 40% who left the question blank. Two groups of clinicians responsible for safety planning with patients at risk of suicide were also sampled: (1) licensed clinical social workers (LICSWs) in primary and urgent care settings and (2) consulting nurses (RNs). Main Outcomes and Measures Participants completed semistructured telephone interviews, which were recorded and transcribed. Directive (deductive) and conventional (inductive) content analyses were used to apply knowledge from prior research and describe new information. Thematic analysis was used to organize key content, and triangulation was used to describe the intersections between patient and clinician perspectives. Results Thirty-six patients were interviewed (of 76 sampled; mean [SD] age, 47.3 [17.9] years; 19 [53%] were male; 27 [75%] were White; 3 [8%] were Black; and 1 [3%] was Latinx or Hispanic. Sixteen participants had reported firearm access and 15 had reported thoughts of self-harm on the questionnaire used for sampling. Thirty clinicians were interviewed (of 51 sampled) (mean [SD] age, 44.3 [12.1] years; 24 [80%] were female; 18 [60%] were White; 5 [17%] were Asian or Pacific Islander; and 4 [13%] were Latinx or Hispanic) including 25 LICSWs and 5 RNs. Key organizing themes included perceived value of standardized questions about firearm access, challenges of asking and answering, and considerations for practice improvement. Clinician interview themes largely converged and/or complemented patient interviews. Conclusions and Relevance In this qualitative study using semistructured interviews with patients and clinicians, a standardized question about firearm access was found to encourage dialogue about firearm access. Respondents underscored the importance of nonjudgmental acknowledgment of patients' reasons for firearm access as key to patient-centered practice improvement.
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Affiliation(s)
- Julie E. Richards
- Kaiser Permanente Washington Health Research Institute, Seattle,Department of Health Systems & Population Health, School of Public Health, University of Washington, Seattle
| | - Elena S. Kuo
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Ursula Whiteside
- Psychiatry and Behavioral Sciences, University of Washington, Seattle,NowMattersNow.org, Seattle, Washington
| | - Lisa Shulman
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Marian E. Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Rebecca Parrish
- Kaiser Permanente Washington Department of Mental Health & Wellness, Seattle
| | | | - Ali Rowhani-Rahbar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle,Harborview Injury Prevention & Research Center, Seattle, Washington
| | - Gregory E. Simon
- Kaiser Permanente Washington Health Research Institute, Seattle,Psychiatry and Behavioral Sciences, University of Washington, Seattle,Kaiser Permanente Washington Department of Mental Health & Wellness, Seattle
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Butler AJ, Greenbank H, Parrish R, Nielsen MK, Stoughton WB. Prevalence of anthelmintic resistant cyathostomins in Prince Edward Island, Canada. Vet Parasitol Reg Stud Reports 2021; 26:100629. [PMID: 34879940 DOI: 10.1016/j.vprsr.2021.100629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/06/2021] [Accepted: 08/28/2021] [Indexed: 11/17/2022]
Abstract
Cyathostomins are the most common parasites of adult horses worldwide. Currently, the three classes of anthelmintics used to treat cyathostomin infections includes benzimidazoles, pyrimidines and macrocyclic lactones. However, due to widespread overuse, cyathostomins have developed varying degrees of resistance to all classes of anthelmintics. Fecal egg count reduction tests (FECRT) are currently used to determine the presence of anthelmintic resistance (AR), while egg reappearance periods (ERP) are used to investigate early macrocyclic lactone resistance. The objective of this study was to investigate the prevalence of cyathostomin pyrantel pamoate and ivermectin resistance, and to determine ERP at Prince Edward Island (PEI), Canada horse farms. In addition, fecal cultures and larval identification were performed to evaluate the prevalence of small and large strongyle egg shedding in PEI. Fecal egg counts (FEC) were performed on 270 horses on 14 horse farms across PEI. Horses with≥ 200 eggs per gram (EPG) met the inclusion criteria and were enrolled in the study (n = 101). The median (range) horses per farm was 7.5 (4-11) and 6.0 (4-8) for pyrantel pamoate and ivermectin groups, respectively. Horses were initially treated with 6.6 mg/kg of pyrantel pamoate orally (n = 101). Fecal egg counts were conducted every two weeks for 8 weeks post treatment. Once individual FEC were ≥ 200 EPG, horses were dewormed with 0.2 mg/kg of ivermectin orally (n = 80), and FEC were performed every 2-3 weeks for seven weeks. In this study the ERP was defined as the week the mean FECR were 10% below the initial mean two-week post treatment FECR. Fecal egg count reduction tests and ERP were used to evaluate the efficacy of each anthelmintic. Fecal culture was performed to confirm the shedding of cyathostomin eggs. Fecal egg count reduction tests detected pyrantel pamoate resistance on 5/14 farms. No signs of ivermectin AR were detected, while reappearance of eggs occurred at 4-6 weeks and 7-9 weeks for pyrantel pamoate and ivermectin, respectively. Fecal culture detected large strongyles on 5/14 farms, which accounted for 0.3% of strongyle type eggs cultured. The prevalence of Strongylus vulgaris among individual horses in this study was 2.8% and was detected on 2/14 farms. These findings will allow us to educate owners and veterinarians on appropriate anthelmintic protocols in PEI and can be used as a baseline for continued monitoring of ERP and anthelmintic resistance in this region.
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Affiliation(s)
- Amanda Jaimie Butler
- Department of Health Management, Atlantic Veterinary College, University of Prince Edward Island, 550 University Ave, Charlottetown, PE C1A 4P3, Canada
| | - Haley Greenbank
- Department of Health Management, Atlantic Veterinary College, University of Prince Edward Island, 550 University Ave, Charlottetown, PE C1A 4P3, Canada
| | - Rebecca Parrish
- Department of Health Management, Atlantic Veterinary College, University of Prince Edward Island, 550 University Ave, Charlottetown, PE C1A 4P3, Canada
| | - Martin K Nielsen
- M.H. Gluck Equine Research Center, Department of Veterinary Science, University of Kentucky. Lexington, KY 40546, USA
| | - William B Stoughton
- Department of Health Management, Atlantic Veterinary College, University of Prince Edward Island, 550 University Ave, Charlottetown, PE C1A 4P3, Canada.
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Franklinos LHV, Parrish R, Burns R, Caflisch A, Mallick B, Rahman T, Routsis V, López AS, Tatem AJ, Trigwell R. Key opportunities and challenges for the use of big data in migration research and policy. UCL Open Environ 2021; 3:e027. [PMID: 37228797 PMCID: PMC10171412 DOI: 10.14324/111.444/ucloe.000027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/23/2021] [Indexed: 05/27/2023]
Abstract
Migration is one of the defining issues of the 21st century. Better data is required to improve understanding about how and why people are moving, target interventions and support evidence-based migration policy. Big data, defined as large, complex data from diverse sources, is regularly proposed as a solution to help address current gaps in knowledge. The authors participated in a workshop held in London, UK, in July 2019, that brought together experts from the United Nations (UN), humanitarian non-governmental organisations (NGOs), policy and academia to develop a better understanding of how big data could be used for migration research and policy. We identified six key areas regarding the application of big data in migration research and policy: accessing and utilising data; integrating data sources and knowledge; understanding environmental drivers of migration; improving healthcare access for migrant populations; ethical and security concerns around the use of big data; and addressing political narratives. We advocate the need for careful consideration of the challenges faced by the use of big data, as well as increased cross-disciplinary collaborations to advance the use of big data in migration research whilst safeguarding vulnerable migrant communities.
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Affiliation(s)
- Lydia H. V. Franklinos
- Institute for Global Health, University College London, London, UK
- Centre for Biodiversity and Environment Research, Department of Genetics, Evolution and Environment, University College London, London, UK
| | - Rebecca Parrish
- Institute for Global Health, University College London, London, UK
- Institute of Environment, Health and Societies, Brunel University, London, UK
| | - Rachel Burns
- Centre of Public Health Data Science, Institute of Health Informatics, University College London, London, UK
| | - Andrea Caflisch
- United Nations’ Displacement Tracking Matrix, International Organization for Migration, International Organization for Migration, Juba, South Sudan
| | - Bishawjit Mallick
- CU Population Center, Institute of Behavioral Science, University of Colorado Boulder Campus, Boulder, CO, USA
- Faculty of Environmental Sciences, Technische Universität Dresden, Dresden, Germany
| | - Taifur Rahman
- Health Management BD Foundation, Sector 6, Uttara, Dhaka, Bangladesh
- Adjunct Faculty, Department of Public Health, North South University, Dhaka, Bangladesh
| | - Vasileios Routsis
- Department of Information Studies, University College London, London, UK
| | - Ana Sebastián López
- GMV Innovating Solutions Ltd, HQ Building, Thomson Avenue, Harwell Campus, Didcot, UK
| | - Andrew J. Tatem
- WorldPop, School of Geography and Environmental Science, University of Southampton, Southampton, UK
| | - Robert Trigwell
- United Nations’ Displacement Tracking Matrix, International Organization for Migration, United Nations, London, UK
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Richards JE, Kuo E, Stewart C, Bobb JF, Mettert KD, Rowhani-Rahbar A, Betz ME, Parrish R, Whiteside U, Boggs JM, Simon GE. Self-reported Access to Firearms Among Patients Receiving Care for Mental Health and Substance Use. JAMA Health Forum 2021; 2:e211973. [PMID: 35977197 PMCID: PMC8796974 DOI: 10.1001/jamahealthforum.2021.1973] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/14/2021] [Indexed: 12/03/2022] Open
Abstract
Question Did patients respond to a standard question about firearm access on a mental health questionnaire, and, if so, how did they respond? Findings In this cross-sectional study of 128 802 patients receiving care for mental health and substance use, 83% of primary care patients answered a standard question about firearm access and 21% reported access. In mental health clinics, 92% of patients answered the question and 15% reported access. Meaning In this study, most patients reported firearm access on standard questionnaires; this screening practice may improve efforts to identify and engage patients at risk of suicide in discussions about securing firearms. Importance Firearms are the most common method of suicide, one of the “diseases of despair” driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown. Objective To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access. Design, Setting, and Participants Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system. Main Outcomes and Measures Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021. Results Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access. Conclusions and Relevance In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.
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Affiliation(s)
- Julie E. Richards
- Health Research Institute, Kaiser Permanente Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Elena Kuo
- Health Research Institute, Kaiser Permanente Washington, Seattle
| | | | - Jennifer F. Bobb
- Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Kayne D. Mettert
- Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Ali Rowhani-Rahbar
- Department of Epidemiology, University of Washington School of Public Health, Seattle
- Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Marian E. Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Rebecca Parrish
- Department of Mental Health & Wellness, Kaiser Permanente Washington, Seattle
| | - Ursula Whiteside
- NowMattersNow.org, Seattle, Washington
- Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | | | - Gregory E. Simon
- Health Research Institute, Kaiser Permanente Washington, Seattle
- Department of Mental Health & Wellness, Kaiser Permanente Washington, Seattle
- Psychiatry and Behavioral Sciences, University of Washington, Seattle
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Glass JE, Matson TE, Lim C, Hartzler AL, Kimbel K, Lee AK, Beatty T, Parrish R, Caldeiro RM, Garza McWethy A, Curran GM, Bradley KA. Approaches for Implementing App-Based Digital Treatments for Drug Use Disorders Into Primary Care: A Qualitative, User-Centered Design Study of Patient Perspectives. J Med Internet Res 2021; 23:e25866. [PMID: 34255666 PMCID: PMC8293157 DOI: 10.2196/25866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/11/2021] [Accepted: 05/04/2021] [Indexed: 01/23/2023] Open
Abstract
Background Digital interventions, such as websites and smartphone apps, can be effective in treating drug use disorders (DUDs). However, their implementation in primary care is hindered, in part, by a lack of knowledge on how patients might like these treatments delivered to them. Objective This study aims to increase the understanding of how patients with DUDs prefer to receive app-based treatments to inform the implementation of these treatments in primary care. Methods The methods of user-centered design were combined with qualitative research methods to inform the design of workflows for offering app-based treatments in primary care. Adult patients (n=14) with past-year cannabis, stimulant, or opioid use disorder from 5 primary care clinics of Kaiser Permanente Washington in the Seattle area participated in this study. Semistructured interviews were recorded, transcribed, and analyzed using qualitative template analysis. The coding scheme included deductive codes based on interview topics, which primarily focused on workflow design. Inductive codes emerged from the data. Results Participants wanted to learn about apps during visits where drug use was discussed and felt that app-related conversations should be incorporated into the existing care whenever possible, as opposed to creating new health care visits to facilitate the use of the app. Nearly all participants preferred receiving clinician support for using apps over using them without support. They desired a trusting, supportive relationship with a clinician who could guide them as they used the app. Participants wanted follow-up support via phone calls or secure messaging because these modes of communication were perceived as a convenient and low burden (eg, no copays or appointment travel). Conclusions A user-centered implementation of treatment apps for DUDs in primary care will require health systems to design workflows that account for patients’ needs for structure, support in and outside of visits, and desire for convenience.
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Affiliation(s)
- Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Theresa E Matson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Catherine Lim
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Andrea L Hartzler
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle, WA, United States
| | - Kilian Kimbel
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Tara Beatty
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Rebecca Parrish
- Kaiser Permanente Washington Mental Health & Wellness Services, Renton, WA, United States
| | - Ryan M Caldeiro
- Kaiser Permanente Washington Mental Health & Wellness Services, Renton, WA, United States
| | - Angela Garza McWethy
- Kaiser Permanente Washington Mental Health & Wellness Services, Renton, WA, United States
| | - Geoffrey M Curran
- University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
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Yeung K, Richards J, Goemer E, Lozano P, Lapham G, Williams E, Glass J, Lee A, Achtmeyer C, Caldeiro R, Parrish R, Bradley K. Costs of using evidence-based implementation strategies for behavioral health integration in a large primary care system. Health Serv Res 2020; 55:913-923. [PMID: 33258127 PMCID: PMC7704468 DOI: 10.1111/1475-6773.13592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To describe the cost of using evidence-based implementation strategies for sustained behavioral health integration (BHI) involving population-based screening, assessment, and identification at 25 primary care sites of Kaiser Permanente Washington (2015-2018). DATA SOURCES/STUDY SETTING Project records, surveys, Bureau of Labor Statistics compensation data. STUDY DESIGN Labor and nonlabor costs incurred by three implementation strategies: practice coaching, electronic health records clinical decision support, and performance feedback. DATA COLLECTION/EXTRACTION METHODS Personnel time spent on these strategies was estimated for five broad roles: (a) project leaders and administrative support, (b) practice coaches, (c) clinical decision support programmers, (d) performance metric programmers, and (e) primary care local implementation team members. PRINCIPAL FINDING Implementation involved 286 persons, 18 131 person-hours, costing $1 587 139 or $5 per primary care visit with screening or $38 per primary care visit identifying depression, suicidal thoughts and/or alcohol or substance use disorders, in a single year. The majority of person-hours was devoted to project leadership (35%) and practice coaches (34%), and 36% of costs were for the first three sites. CONCLUSIONS When spread across patients screened in a single year, BHI implementation costs were well within the range for commonly used diagnostic assessments in primary care (eg, laboratory tests). This suggests that implementation costs alone should not be a substantial barrier to population-based BHI.
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Affiliation(s)
- Kai Yeung
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
- The Comparative Health OutcomesPolicy, and Economics (CHOICE) InstituteSeattleWashingtonUSA
- University of WashingtonSeattleWashingtonUSA
| | - Julie Richards
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
- Department of Health ServicesUniversity of WashingtonSeattleWashingtonUSA
| | - Eric Goemer
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Paula Lozano
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Gwen Lapham
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Emily Williams
- Department of Health ServicesUniversity of WashingtonSeattleWashingtonUSA
- VA Puget Sound Health Care SystemSeattleWashingtonUSA
| | - Joseph Glass
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
- Department of Psychiatry and Behavioral SciencesSchool of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Amy Lee
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Carol Achtmeyer
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
- VA Puget Sound Health Care SystemSeattleWashingtonUSA
| | - Ryan Caldeiro
- Behavioral Health Services DepartmentKaiser Permanente WashingtonSeattleWashingtonUSA
| | - Rebecca Parrish
- Behavioral Health Services DepartmentKaiser Permanente WashingtonSeattleWashingtonUSA
| | - Katharine Bradley
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
- Department of Health ServicesUniversity of WashingtonSeattleWashingtonUSA
- Department of Psychiatry and Behavioral SciencesSchool of MedicineUniversity of WashingtonSeattleWashingtonUSA
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Parrish R, Colbourn T, Lauriola P, Leonardi G, Hajat S, Zeka A. A Critical Analysis of the Drivers of Human Migration Patterns in the Presence of Climate Change: A New Conceptual Model. Int J Environ Res Public Health 2020; 17:ijerph17176036. [PMID: 32825094 PMCID: PMC7504370 DOI: 10.3390/ijerph17176036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 11/16/2022]
Abstract
Both climate change and migration present key concerns for global health progress. Despite this, a transparent method for identifying and understanding the relationship between climate change, migration and other contextual factors remains a knowledge gap. Existing conceptual models are useful in understanding the complexities of climate migration, but provide varying degrees of applicability to quantitative studies, resulting in non-homogenous transferability of knowledge in this important area. This paper attempts to provide a critical review of climate migration literature, as well as presenting a new conceptual model for the identification of the drivers of migration in the context of climate change. It focuses on the interactions and the dynamics of drivers over time, space and society. Through systematic, pan-disciplinary and homogenous application of theory to different geographical contexts, we aim to improve understanding of the impacts of climate change on migration. A brief case study of Malawi is provided to demonstrate how this global conceptual model can be applied into local contextual scenarios. In doing so, we hope to provide insights that help in the more homogenous applications of conceptual frameworks for this area and more generally.
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Affiliation(s)
- Rebecca Parrish
- Institute of Environment, Health and Societies, Brunel University London, Uxbridge UB8 3PH, UK
- Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UK;
- Correspondence: (R.P.); (A.Z.); Tel.: +44-(0)-7837-974-527 (R.P.); +44-(0)-1895-267359 (A.Z.)
| | - Tim Colbourn
- Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UK;
| | - Paolo Lauriola
- Institute of Clinical Physiology, Italian National Research Council, 56124 Pisa, Italy;
| | - Giovanni Leonardi
- Department of Public Health, Environments and Society; London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - Shakoor Hajat
- Centre on Climate Change and Planetary Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - Ariana Zeka
- Institute of Environment, Health and Societies, Brunel University London, Uxbridge UB8 3PH, UK
- Correspondence: (R.P.); (A.Z.); Tel.: +44-(0)-7837-974-527 (R.P.); +44-(0)-1895-267359 (A.Z.)
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Richards JE, Hohl SD, Whiteside U, Ludman EJ, Grossman DC, Simon GE, Shortreed SM, Lee AK, Parrish R, Shea M, Caldeiro RM, Penfold RB, Williams EC. If You Listen, I Will Talk: the Experience of Being Asked About Suicidality During Routine Primary Care. J Gen Intern Med 2019; 34:2075-2082. [PMID: 31346911 PMCID: PMC6816586 DOI: 10.1007/s11606-019-05136-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 02/21/2019] [Accepted: 05/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Routine population-based screening for depression is an essential part of evolving health care models integrating care for mental health in primary care. Depression instruments often include questions about suicidal thoughts, but how patients experience these questions in primary care is not known and may have implications for accurate identification of patients at risk. OBJECTIVES To explore the patient experience of routine population-based depression screening/assessment followed, for some, by suicide risk assessment and discussions with providers. DESIGN Qualitative, interview-based study. PARTICIPANTS Thirty-seven patients from Kaiser Permanente Washington who had recently screened positive for depression on the 2-item Patient Health Questionnaire [PHQ] and completed the full PHQ-9. APPROACH Criterion sampling identified patients who had recently completed the PHQ-9 ninth question which asks about the frequency of thoughts about self-harm. Patients completed semi-structured interviews by phone, which were recorded and transcribed. Directive and conventional content analyses were used to apply knowledge from prior research and elucidate new information from interviews; thematic analysis was used to organize key content overall and across groups based on endorsement of suicide ideation. KEY RESULTS Four main organizing themes emerged from analyses: (1) Participants believed being asked about suicidality was contextually appropriate and valuable, (2) some participants described a mismatch between their lived experience and the PHQ-9 ninth question, (3) suicidality disclosures involved weighing hope for help against fears of negative consequences, and (4) provider relationships and acts of listening and caring facilitated discussions about suicidality. CONCLUSIONS All participants believed being asked questions about suicidal thoughts was appropriate, though some who disclosed suicidal thoughts described experiencing stigma and sometimes distanced themselves from suicidality. Direct communication with trusted providers, who listened and expressed empathy, bolstered comfort with disclosure. Future research should consider strategies for reducing stigma and encouraging fearless disclosure among primary care patients experiencing suicidality.
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Affiliation(s)
- Julie E Richards
- Kaiser Permanente Washington Heath Research Institute, Seattle, WA, USA.
- Department of Health Services, University of Washington, Seattle, WA, USA.
| | - Sarah D Hohl
- Department of Health Services, University of Washington, Seattle, WA, USA
| | | | - Evette J Ludman
- Kaiser Permanente Washington Heath Research Institute, Seattle, WA, USA
| | - David C Grossman
- Kaiser Permanente Washington Heath Research Institute, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
- Department of Preventive Care, Kaiser Permanente Washington, Seattle, WA, USA
| | - Greg E Simon
- Kaiser Permanente Washington Heath Research Institute, Seattle, WA, USA
- Mental Heath & Wellness, Kaiser Permanente Washington, Seattle, WA, USA
| | - Susan M Shortreed
- Kaiser Permanente Washington Heath Research Institute, Seattle, WA, USA
| | - Amy K Lee
- Kaiser Permanente Washington Heath Research Institute, Seattle, WA, USA
| | - Rebecca Parrish
- Mental Heath & Wellness, Kaiser Permanente Washington, Seattle, WA, USA
| | - Mary Shea
- Kaiser Permanente Washington Heath Research Institute, Seattle, WA, USA
| | - Ryan M Caldeiro
- Mental Heath & Wellness, Kaiser Permanente Washington, Seattle, WA, USA
| | - Robert B Penfold
- Kaiser Permanente Washington Heath Research Institute, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Emily C Williams
- Kaiser Permanente Washington Heath Research Institute, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
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11
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McCarty CA, Zatzick D, Hoopes T, Payne K, Parrish R, Rivara FP. Collaborative care model for treatment of persistent symptoms after concussion among youth (CARE4PCS-II): Study protocol for a randomized, controlled trial. Trials 2019; 20:567. [PMID: 31533799 PMCID: PMC6749638 DOI: 10.1186/s13063-019-3662-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 08/19/2019] [Indexed: 11/26/2022] Open
Abstract
Background Currently, there is limited evidence to guide intervention and service delivery coordination for youth who suffer a concussion and subsequently experience persistent post-concussive symptoms (PCS) (Lumba-Brown et al. JAMA Pediatr 172(11):e182853, 2018; Lumba-Brown A et al. JAMA Pediatr 172(11):e182847, 2018). We have developed a collaborative care intervention with embedded cognitive-behavioral therapy, care management, and stepped-up psychotropic medication consultation to address persistent PCS and related psychological comorbidities. The CARE4PCS-II study was designed to assess whether adolescents with persistent symptoms after sports-related concussion will demonstrate better outcomes when receiving this collaborative care intervention compared to a usual care (control) condition. Methods/design This investigation is a randomized comparative effectiveness trial to receive intervention (collaborative care) or control (usual care). Two hundred sports-injured male and female adolescents aged 11–18 years with three or more post-concussive symptoms that persist for at least 1 month but less than 9 months after injury will be recruited and randomized into the study. The trial focuses on the effects of the intervention on post-concussive, depressive, and anxiety symptoms measured 3, 6, and 12 months after baseline. Discussion The CARE4PCS II study is a large comparative effectiveness trial targeting symptomatic improvements in sports injured adolescents after concussion. The study is unique in its adaptation of the collaborative care model to a broad spectrum of primary care, sports medicine, and school settings. The investigation incorporates novel elements such as the delivery of CBT through HIPAA complaint video conferenceing technology and has excellent widespread dissemination potential should effectiveness be demonstrated. Trial registration ClinicalTrials.gov, NCT03034720. Registered on January 27, 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3662-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carolyn A McCarty
- Seattle Children's Research Institute, P.O. Box 5371, M/S: CW8-5, Seattle, WA, 98145-5005, USA. .,Department of Pediatrics, University of Washington, Seattle, USA.
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington, Harborview Medical Center 325 9th Avenue, Box 359911, Seattle, WA, 98104-2499, USA
| | - Teah Hoopes
- Seattle Children's Research Institute, P.O. Box 5371, M/S: CW8-5, Seattle, WA, 98145-5005, USA
| | - Katelyn Payne
- Seattle Children's Research Institute, P.O. Box 5371, M/S: CW8-5, Seattle, WA, 98145-5005, USA
| | - Rebecca Parrish
- Seattle Children's Research Institute, P.O. Box 5371, M/S: CW8-5, Seattle, WA, 98145-5005, USA
| | - Frederick P Rivara
- Seattle Children's Research Institute, P.O. Box 5371, M/S: CW8-5, Seattle, WA, 98145-5005, USA.,Department of Pediatrics, University of Washington, Seattle, USA
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12
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Parrish R. Lessons from Implementation of Behavioral Health Integration in Kaiser Permanente Washington. Perm J 2019. [DOI: 10.7812/tpp/19-039-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Glass JE, Bobb JF, Lee AK, Richards JE, Lapham GT, Ludman E, Achtmeyer C, Caldeiro RM, Parrish R, Williams EC, Lozano P, Bradley KA. Study protocol: a cluster-randomized trial implementing Sustained Patient-centered Alcohol-related Care (SPARC trial). Implement Sci 2018; 13:108. [PMID: 30081930 PMCID: PMC6080376 DOI: 10.1186/s13012-018-0795-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/12/2018] [Indexed: 12/16/2022] Open
Abstract
Background Experts recommend that alcohol-related care be integrated into primary care (PC) to improve prevention and treatment of unhealthy alcohol use. However, few healthcare systems offer such integrated care. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington (KPWA) partnered to design a high-quality program of evidence-based care for unhealthy alcohol use: the Sustained Patient-centered Alcohol-related Care (SPARC) program. SPARC implements systems of clinical care designed to increase both prevention and treatment of unhealthy alcohol use. This clinical care for unhealthy alcohol use was implemented using three strategies: electronic health record (EHR) decision support, performance monitoring and feedback, and front-line support from external practice coaches with expertise in alcohol-related care (“SPARC implementation intervention” hereafter). The purpose of this report is to describe the protocol of the SPARC trial, a pragmatic, cluster-randomized, stepped-wedge implementation trial to evaluate whether the SPARC implementation intervention increased alcohol screening and brief alcohol counseling (so-called brief interventions), and diagnosis and treatment of alcohol use disorders (AUDs) in 22 KPWA PC clinics. Methods/Design The SPARC trial sample includes all adult patients who had a visit to any of the 22 primary care sites in the trial during the study period (January 1, 2015–July 31, 2018). The 22 sites were randomized to implement the SPARC program on different dates (in seven waves, approximately every 4 months). Primary outcomes are the proportion of patients with PC visits who (1) screen positive for unhealthy alcohol use and have documented brief interventions and (2) have a newly recognized AUD and subsequently initiate and engage in alcohol-related care. Main analyses compare the rates of these primary outcomes in the pre- and post-implementation periods, following recommended approaches for analyzing stepped-wedge trials. Qualitative analyses assess barriers and facilitators to implementation and required adaptations of implementation strategies. Discussion The SPARC trial is the first study to our knowledge to use an experimental design to test whether practice coaches with expertise in alcohol-related care, along with EHR clinical decision support and performance monitoring and feedback to sites, increase both preventive care—alcohol screening and brief intervention—as well as diagnosis and treatment of AUDs. Trial registration The trial is registered at ClinicalTrials.Gov: NCT02675777. Registered February 5, 2016, https://clinicaltrials.gov/ct2/show/NCT02675777. Electronic supplementary material The online version of this article (10.1186/s13012-018-0795-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA. .,Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
| | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
| | - Julie E Richards
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
| | - Evette Ludman
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
| | - Carol Achtmeyer
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA.,VA Puget Sound Health Care System, Center of Excellence in Substance Abuse Treatment and Education, Seattle, WA, USA
| | - Ryan M Caldeiro
- Behavioral Health Services Department, Kaiser Permanente Washington, Seattle, USA
| | - Rebecca Parrish
- Behavioral Health Services Department, Kaiser Permanente Washington, Seattle, USA
| | - Emily C Williams
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA.,Department of Health Services, University of Washington, Seattle, WA, USA.,VA Puget Sound, Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Paula Lozano
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, USA.,Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
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14
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Heilmeier U, Cheng K, Pasco C, Parrish R, Nirody J, Patsch JM, Zhang CA, Joseph GB, Burghardt AJ, Schwartz AV, Link TM, Kazakia G. Cortical bone laminar analysis reveals increased midcortical and periosteal porosity in type 2 diabetic postmenopausal women with history of fragility fractures compared to fracture-free diabetics. Osteoporos Int 2016; 27:2791-2802. [PMID: 27154435 PMCID: PMC6687459 DOI: 10.1007/s00198-016-3614-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 04/20/2016] [Indexed: 02/08/2023]
Abstract
UNLABELLED We investigated the characteristics and spatial distribution of cortical bone pores in postmenopausal women with type 2 diabetes (T2D). High porosity in the midcortical and periosteal layers in T2D subjects with fragility fractures suggests that these cortical zones might be particularly susceptible to T2D-induced toxicity and may reflect cortical microangiopathy. INTRODUCTION Elevated cortical porosity is regarded as one of the main contributors to the high skeletal fragility in T2D. However, to date, it remains unclear if diabetic cortical porosity results from vascular cortical changes or from an expansion in bone marrow space. Here, we used a novel cortical laminar analysis technique to investigate the characteristics and spatial radial distribution of cortical pores in a T2D group with prior history of fragility fractures (DMFx, assigned high-risk group) and a fracture-free T2D group (DM, assigned low-risk group) and to compare their results to non-diabetic controls with (Fx) and without fragility fractures (Co). METHODS Eighty postmenopausal women (n = 20/group) underwent high-resolution peripheral quantitative computed tomography (HR-pQCT) of the distal tibia and radius. Cortical bone was divided into three layers of equal width including an endosteal, midcortical, and periosteal layer. Within each layer, total pore area (TPA), total pore number (TPN), and average pore area (APA) were calculated. Statistical analysis employed Mann-Whitney tests and ANOVA with post hoc tests. RESULTS Compared to the DM group, DMFx subjects exhibited +90 to +365 % elevated global porosity (p = 0.001). Cortical laminar analysis revealed that this increased porosity was for both skeletal sites confined to the midcortical layer, followed by the periosteal layer (midcortical +1327 % TPA, p ≤ 0.001, periosteal +634 % TPA, p = 0.002), and was associated in both layers and skeletal sites with high TPN (+430 % TPN, p < 0.001) and high APA (+71.5 % APA, p < 0.001). CONCLUSION High porosity in the midcortical and periosteal layers in the high-risk T2D group suggests that these cortical zones might be particularly susceptible to T2D-induced toxicity and may reflect cortical microangiopathy.
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Affiliation(s)
- U Heilmeier
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry Street, San Francisco, CA, 94158, USA.
| | - K Cheng
- Department of Bioengineering, University of California Berkeley, 306 Stanley Hall, Berkeley, CA, 94720, USA
| | - C Pasco
- Department of Bioengineering, University of California Berkeley, 306 Stanley Hall, Berkeley, CA, 94720, USA
| | - R Parrish
- Department of Bioengineering, University of California Berkeley, 306 Stanley Hall, Berkeley, CA, 94720, USA
| | - J Nirody
- Biophysics Graduate Group, University of California Berkeley, 574 Stanley Hall, MC 3220, Berkeley, CA, 94720, USA
| | - J M Patsch
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry Street, San Francisco, CA, 94158, USA
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - C A Zhang
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - G B Joseph
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry Street, San Francisco, CA, 94158, USA
| | - A J Burghardt
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry Street, San Francisco, CA, 94158, USA
| | - A V Schwartz
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - T M Link
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry Street, San Francisco, CA, 94158, USA
| | - G Kazakia
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, 185 Berry Street, San Francisco, CA, 94158, USA
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Abstract
An important problem verb learners must solve is how to extend verbs. Children could use cross-situational information to guide their extensions, however comparing events is difficult. Two studies test whether children benefit from initially seeing a pair of similar events ('progressive alignment') while learning new verbs, and whether this influence changes with age. In Study 1, 2 ½- and 3 ½-year-old children participated in an interactive task. Children who saw a pair of similar events and then varied events were able to extend verbs at test, differing from a control group; children who saw two pairs of varied events did not differ from the control group. In Study 2, events were presented on a monitor. Following the initial pair of events that varied by condition, a Tobii x120 eye tracker recorded 2 ½-, 3 ½- and 4 ½-year-olds' fixations to specific elements of events (AOIs) during the second pair of events, which were the same across conditions. After seeing the pair of events that were highly similar, 2 ½-year-olds showed significantly longer fixation durations to agents and to affected objects as compared to the all varied condition. At test, 3 ½-year-olds were able to extend the verb, but only in the progressive alignment condition. These results are important because they show children's visual attention to relevant elements in dynamic events is influenced by their prior comparison experience, and they show that young children benefit from seeing similar events as they learn to compare events to each other.
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Affiliation(s)
| | | | | | - Clare Burch
- Department of Psychology, Trinity University
| | - Gavin Fung
- Department of Psychology, Trinity University
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16
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Ball K, Parrish R, Thornton A. P3-S3.10 An assessment of the effects of ancillary services on CD4 counts and viral loads of people living with HIV/AIDS. Br J Vener Dis 2011. [DOI: 10.1136/sextrans-2011-050108.459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Buckley TR, Stringer I, Gleeson D, Howitt R, Attanayake D, Parrish R, Sherley G, Rohan M. A revision of the New Zealand Placostylus land snails using mitochondrial DNA and shell morphometric analyses, with implications for conservation. New Zealand Journal of Zoology 2011. [DOI: 10.1080/03014223.2010.527997] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- TR Buckley
- a Landcare Research , Auckland, New Zealand
| | - I Stringer
- b Department of Conservation , Wellington, New Zealand
| | - D Gleeson
- a Landcare Research , Auckland, New Zealand
| | - R Howitt
- a Landcare Research , Auckland, New Zealand
| | | | - R Parrish
- c Karaka RD1 , Papakura, New Zealand
| | - G Sherley
- d United Nations Environmental Programme , Matautu Uta, Apia, Samoa
| | - M Rohan
- b Department of Conservation , Wellington, New Zealand
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18
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Parrish R. Ross Meuros Paxton. West J Med 2010. [DOI: 10.1136/bmj.c4522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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19
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Abstract
A 48-year-old Filipino female presented with unilateral acute onset painful red eye, blurred vision and yellow discharge. On examination she had a corrected visual acuity of 6/5 in the right eye and 6/18 in the left eye. There was a left-sided periorbital swelling, with chemosis involving the bulbar conjunctiva on the temporal aspect. Ocular motility showed limitation of left-sided abduction with mild limitation of laevoelevation and laevodepression. She was afebrile and systemic examination was unremarkable. Medical history included diagnosis of Crohn's disease since the age of 20. She was on oral mesalamine 1 g for mildly active colitis. Full blood count was normal but erythrocyte sedimentation rate and C reactive protein were raised. Blood culture and conjunctival swab were negative. Contrast-enhanced CT scan demonstrated enlargement of the lacrimal gland. She was managed conservatively with acetaminophen and codeine for pain and swelling. She recovered completely in 2 weeks with no sequelae.
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Affiliation(s)
- Vijay Wagh
- Royal Eye Infirmary, Plymouth Hospital NHS Trust, Plymouth, Devon, UK
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20
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Abstract
A case of occipital condylar fracture in a multiply injured and unconscious motorcyclist is reported. This injury was clinically unsuspected but found on the lowest cuts of head computed tomography. It is shown that this site is often inadequately imaged when scanning the head and neck in victims of trauma. The Anderson and Montesano classification of occipital condylar fracture is described. It is noted that types 1 and 2 are stable injuries but type 3 is potentially unstable. A retrospective analysis of 30 head computed tomography scans in trauma cases revealed that in only 16 were the occipital condyles adequately imaged. It is emphasised that vigilance is required to detect fractures of the occipital condyle and that it should be standard practice to include this area when performing computed tomography of the head in trauma victims.
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Affiliation(s)
- A Kelly
- Department of Accident and Emergency, Derriford Hospital, Plymouth.
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Richardson LA, Keller AM, Selby-Harrington ML, Parrish R. Identification and treatment of children's mental health problems by primary care providers: a critical review of research. Arch Psychiatr Nurs 1996; 10:293-303. [PMID: 8897712 DOI: 10.1016/s0883-9417(96)80038-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article critically reviews research studies on the identification and treatment of children's mental health problems by primary care providers. Using a valid and reliable instrument to guide the review, the investigators examined the methods and findings of all 13 studies published on the topic from 1979 to 1994. Overall, primary care providers appeared to underidentify mental health problems among children and adolescents, especially those whose emotional impairments were not overtly severe. Large proportions of youngsters identified as having mental health problems did not receive needed treatment.
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Affiliation(s)
- L A Richardson
- School of Nursing, University of North Carolina, Greensboro 27412-5001, USA
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Godder K, Pati A, Abhyankar S, Gee AP, Parrish R, Lee C, Henslee-Downey PJ. Partially mismatched related donor transplants as salvage therapy for patients with refractory leukemia who relapse post-BMT. Bone Marrow Transplant 1996; 17:49-53. [PMID: 8673054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Patients who relapse post-ABMT are usually resistant to conventional therapy, and a potentially curative therapy with allogeneic BMT is limited due to availability of a matched donor. To assess whether such patients can be salvaged using partially mismatched related donors (PMRD), eight patients age 6-50 years old underwent PMRD-BMT. All patients ALL (n = 3) and AML (n = 5) were in relapse 7-31 months after first BMT. Donors (1-3 Ag mismatch) were selected from family members. Conditioning included TBI, etoposide, Ara-C and cytoxan (n = 3), or busulfan, thiotepa, and etoposide (n = 5). GVHD prophylaxis consisted of partial T cell depletion followed by systemic immunosuppression. All evaluable patients established sustained engraftment by day 18. Severe regimen-related toxicity was evident in the gastrointestinal and hepatic systems (6/8 and 4/8, respectively), the latter associated with poor outcome (P < 0.014). Acute but not chronic GVHD, grade > or = II occurred in 3/7 patients. Four of eight patients are disease-free, maintaining longer remission than following their first BMT (14 vs 9 months). In conclusion, our data shows that PMRD-BMT is a feasible option for patients who relapse post-BMT and use of such alloreactive grafts may be appropriate earlier in the disease course of high risk patients.
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Affiliation(s)
- K Godder
- University of South Carolina, Richland Memorial Hospital, USA
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Parrish R. Who owns what I say? Oral presentations, scientific publications, and 'the times'. Arch Ophthalmol 1994; 112:1157-8. [PMID: 8085959 DOI: 10.1001/archopht.1994.01090210041014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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25
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Clymer EW, Parrish R. Productive administrative applications of computers in schools and programs for deaf students. Am Ann Deaf 1994; 139 Spec No:28-31. [PMID: 8178755 DOI: 10.1353/aad.2012.0990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Parrish R. Acute toxicity screening of water pollutants using a bacterial electrode. Comments. Environ Sci Technol 1985; 19:871. [PMID: 22196619 DOI: 10.1021/es00139a021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Abstract
The existence of hormone receptors on or within neoplastic tissue has potential diagnostic, therapeutic, and prognostic importance. It was the purpose of this study to measure estrogen and progesterone receptors in a large group of patients with head and neck cancer to determine their frequency. Sixty-five patients with head and neck tumors underwent a total of 75 estrogen and 50 progesterone receptor assays. In this group, 87.7% were squamous cell carcinoma. In the estrogen receptor assays, 89.3% (67/75) were negative, 8% (6/75) were borderline, and only 2.7% (2/75) were positive. In the progesterone receptor assays, 78% (39/50) were negative, 22% (11/50) were borderline, and there were no positive results. There were no changes in assays of tissue removed at biopsy v tissue removed during surgery. There was no impact with chemotherapy. In conclusion, head and neck cancers do not appear to possess estrogen or progesterone receptors and can be considered to be hormonally independent.
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Abstract
A therapeutic computed tomographic (CT) scanner uniquely dedicated to surgical usage allowed intraoperative CT imaging during precise resections of glial brain tumors in three patients. Intraoperative CT scanning provided accurate tumor localization, superior contrast and spatial resolution of the lesion, and cross sectional anatomy of the entire brain. Further development of intraoperative CT guidance will allow safer or even complete removal of some previously unresectable brain tumors.
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Parrish R, Herschler J. Eyes with end-stage neovascular glaucoma. Natural history following successful modified filtering operation. Arch Ophthalmol 1983; 101:745-6. [PMID: 6189472 DOI: 10.1001/archopht.1983.01040010745008] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
A modified filtering operation for neovascular glaucoma provided control of intraocular pressure after 12 to 23 months in ten of 13 eyes. After long-term follow-up, 23 to 54 months, seven of ten eyes still had controlled IOP. Two eyes were receiving no medication, two required miotics, and three required maximal medical therapy, including carbonic anhydrase inhibitors. One eye had undergone cyclocryotherapy four years after trabeculectomy. Four of seven eyes with diabetic neovascular glaucoma retained ambulatory vision. The eye with neovascular glaucoma from central retinal vein occlusion lost useful vision. The underlying disease process is an important determinant of surviving visual function.
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Parrish R. Planning for health: keeping an eye on the figures. Health Soc Serv J 1983; 93:202-4. [PMID: 10299141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
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Gass JD, Parrish R. Outer retinal ischemic infarction--a newly recognized complication of cataract extraction and closed vitrectomy. Part 1. A case report. Ophthalmology 1982; 89:1467-71. [PMID: 7162790 DOI: 10.1016/s0161-6420(82)34615-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
This report describes a peculiar syndrome occurring as a complication of cataract extraction. The syndrome is characterized initially by (1) acute loss of central and paracentral vision discovered usually on the first postoperative day; (2) diffuse and patchy whitening of the outer retinal layers in the posterior fundus; (3) normal angiographic retinal and choroidal appearance and circulation time; (4) a peculiar polygonal pattern of fluorescein staining of the pigment epithelium and outer retina in the area of retinal whitening, and followed later by (5) clearing of the retinal whitening and mottled changes in the pigment epithelium; (6) partial recovery of the central visual field; and (7) preservation of normal optic disc and retinal vessel caliber. Prolonged elevation of the intraocular pressure sufficient to obstruct choroidal blood flow occurring during the use of intraocular volume-reducing devices before surgery, during phakoemulsification or closed vitrectomy is postulated as the major cause of this complication.
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Parrish R, Gass JD, Anderson DR. Outer retina ischemic infarction--a newly recognized complication of cataract extraction and closed vitrectomy. Part 2. An animal model. Ophthalmology 1982; 89:1472-7. [PMID: 7162791 DOI: 10.1016/s0161-6420(82)34614-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Intraocular pressure was artificially elevated above systolic blood pressure in 40 owl monkey eyes. Diffuse retinal whitening of the posterior pole and subsequent retinal pigment epithelial disruption were produced in nine of ten eyes with high pressure for 90 minutes or longer, but also in a few eyes with high pressure for a shorter duration. Fluorescein angiography and histologic examination demonstrated damage of the photoreceptors and retinal pigment epithelium with sparing of the inner retinal layers. This animal model duplicates the acute visual loss due to outer retinal infarction that sometimes occurs after closed vitrectomy or after continuous external ocular compression in preparation for surgery.
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Abstract
Lupus erythematosus profundus (panniculitis) is a rare clinical variant of lupus erythematosus. It has not been implicated previously as a cause of lid edema or proptosis. In this report, three patients who had eyelid edema as the initial manifestation of lupus erythematosus profundus are presented. The ocular manifestations improved with antimalarial therapy.
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Abstract
The complete absorption of blood in patients with eight-ball hyphema and medically uncontrollable intraocular pressure occurred after iridectomy. No intra-operative complications were noted. Six of the seven patients maintained normal IOPs without medical therapy for at least six months postoperatively. Pupillary block by the clotted blood and the tamponade effect exerted by the total hyphema on the outflow pathway are possible mechanisms of the secondary glaucoma.
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Loysen GJ, Heffernan PK, Parrish R. The support services of library-media, curriculum, and reading at the Rochester School for the Deaf. Am Ann Deaf 1980; 125:662-673. [PMID: 7446330 DOI: 10.1353/aad.2012.1291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Abstract
Purple membrane was reacted with 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide at pH 4.5 and 8.0. At pH 4.5, the reaction yields cross-linked bacteriorhodopsin. The cross-linking is inhibited by pretreatment of the membrane with papain, or by the presence of carbohydrazide or glycine ethyl ester in the reaction mixture. The product of the pH 8.0 reaction is not cross-linked, but it displays altered properties. Two measures of photochemical activity (light-induced change in proton binding (delta h) and decay of photointermediate M) show changes indicative of slowed proton uptake. The delta h is increased by ethyl dimethylaminopropylcarbodiimide. This increase is unaffected by pretreatment of the membrane with papain, and it is not reversed by NH2OH. However, the reaction is inhibited by millimolar concentrations of CaCl2. The altered delta h is not apparent in detergent-solubilized membranes. Ethyl dimethylaminopropylcarbodiimide does not appear to cause a large alteration in the membrane surface charge, as measured by Ca2+ binding. We conclude that (1) at acid pH, ethyl dimethylaminopropylcarbodiimide can be used for cross-linking or for attachment of specific probes to the C-terminal region of bacteriorhodopsin, and hence to the cytoplasmic side of the purple membrane, and (2) at alkaline pH, ethyl dimethylaminopropylcarbodiimide reacts at a diffent type of site and appears to inhibit the proton pump.
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Kanto WP, Morales V, Parrish R. Antenatal intestinal perforation and meconium peritonitis associated with the neonatal small left colon syndrome. South Med J 1979; 72:894-5. [PMID: 572092 DOI: 10.1097/00007611-197907000-00043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Although NSLCS has been considered to have a benign course, we have described an infant who had intrauterine intestinal perforation and meconium peritonitis associated with the NSLCS. Infants of diabetic mothers who are stillborn or who develop abdominal distention shortly after delivery should be suspected of having this complication of NSLCS. This disorder must also be considered in the differential diagnosis of infants who present with meconium peritonitis.
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Parrish R. The cost benefit debate in evaluating health education. Health Soc Serv J 1979; 89:442-4. [PMID: 10308894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Health education programmes are often evaluated to determine their effectiveness and cost benefit to the NHS. Author argues that evaluation is not always as straightforward as it may appear initially and therefore it is essential to determine the degree of validity associated with such exercises.
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Parrish R, Hembree JH. Tarnish resistance of casting alloys: a laboratory study. J Tenn Dent Assoc 1978; 58:38-41. [PMID: 289875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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