Rheumatology High Blood Pressure Protocol Reduces Disparities, But Delays Remain for External Primary Care.

BACKGROUND/OBJECTIVE: To address high blood pressure (BP) in rheumatology patients, we previously implemented BP Connect, a brief staff-driven protocol to address high BP. Although timely follow-up and hypertension rates improved for patients with in-system primary care (PC), many receive PC and rheumatology care in separate health systems. In this cohort study, we compared rates of timely PC follow-up for high BP across-system health maintenance organizations (HMOs) before and after BP Connect implementation. METHODS: All adult patients with high rheumatology clinic BP and PC in that HMO were eligible. BP Connect's protocol engaged the staff in remeasuring high BP (≥140/90 mm Hg), advising cardiovascular disease risk, and connecting timely PC follow-up, which for patients with PC across system includes written follow-up instructions. After an eligible rheumatology visit, the next HMO PC visit with BP was used to determine rates and odds of timely follow-up before and after using multivariable logistic regression. RESULTS: Across 1327 rheumatology visits with high BP and across-system PC (2013-2019), 951 occurred after 2015 BP Connect implementation; 400 had confirmed high BP. Primary care follow-up rose from 20.5% to 23.5%. The odds of timely PC BP follow-up insignificantly changed (odds ratio, 1.19; confidence interval, 0.85-1.68). For visits with Black patients, the odds of timely follow-up did significantly increase (1.95; confidence interval, 1.02-3.79). CONCLUSIONS: Timely follow-up for Black patients did improve, highlighting protocol interventions for more equitable health care. In contrast to our prior in-system study, BP Connect did not significantly improve follow-up with an across-system PC, indicating a need for direct scheduling. Future directions include piloting direct across-system scheduling.

Mask Adherence and the Relationship Between Masking and Weather-Related Metrics.

Little is known about adherence to COVID-19 masking mandates on college campuses or the relationship between weather-related variables and masking. This study aimed to (1) observe students' adherence to on-campus mask mandates and (2) estimate the effect of weather on mask-wearing. Temple University partnered in the Centers for Disease Control and Prevention's observational Mask Adherence Surveillance at Colleges and Universities Project. February-April 2021, weekly observations were completed at 12 on-campus locations to capture whether individuals wore masks, wore them correctly, and the type of mask worn. Fashion and university masks also were recorded. Weekly average temperature, humidity, and precipitation were calculated. Descriptive statistics were calculated for masking adherence overall, over time, and by location. Statistical significance was assessed between correct mask use and mask type and the linear relationships between weekly weather metrics and mask use. Overall, 3508 individuals were observed with 89.6% wearing masks. Of those, 89.4% correctly wore masks. Cloth (58.7%) and surgical masks (35.3%) were most commonly observed and 21.3% wore fashion masks. N95/KN95 masks were correctly worn in 98.3% of observations and surgical and cloth masks were correctly worn ~ 90% of the time. Weekly adherence varied over time and by campus location. Significant inverse linear relationships existed between weekly temperature (r = - 0.72; p < 0.05) and humidity (r = - 0.63; p ≤ 0.05) and masking. Mask adherence and correct use was high. Temperature and humidity inversely affected adherence. Adherence varied by on-campus location, which suggests the locations (e.g., academic buildings, recreational center) and possibly the characteristics of individuals who frequent certain areas impacted adherence.

Effect of eliglustat on the pharmacokinetics of digoxin, metoprolol, and oral contraceptives and absorption of eliglustat when coadministered with acid-reducing agents.

Eliglustat is an oral substrate reduction therapy indicated for patients with Gaucher disease type 1. Based on in vitro data, clinical trials were conducted to assess the potential for drug-drug interactions between eliglustat and digoxin (P-glycoprotein substrate), metoprolol (sensitive CYP2D6 substrate), a combined oral contraceptive (CYP3A substrate), and acid-reducing agents. Healthy subjects were enrolled in four Phase 1 clinical studies to evaluate the effect of eliglustat on the pharmacokinetics, safety, and tolerability of digoxin (N = 28), metoprolol (N = 14), and a combined oral contraceptive (N = 30) and the effect of acid-reducing agents on eliglustat pharmacokinetics, safety, and tolerability (N = 24). Coadministration resulted in increased exposure to digoxin (1.49-fold) and metoprolol (2-fold) with eliglustat, negligible effects on oral contraceptive pharmacokinetics with eliglustat, and a negligible effect of acid-reducing agents on eliglustat pharmacokinetics. Across all studies, eliglustat was well-tolerated. One serious adverse event (spontaneous abortion) and one discontinuation due to an adverse event (urinary tract infection) were reported, both during the acid-reducing agents study. When eliglustat is coadministered with medications that are P-glycoprotein or CYP2D6 substrates, lower doses of these concomitant medications may be required. Eliglustat may be coadministered with oral contraceptives and acid-reducing agents without dose modifications for either drug.

Do Insurance-mandated Precertification Criteria and Insurance Plan Type Determine the Utilization of Bariatric Surgery Among Individuals With Private Insurance?

BACKGROUND: Access to bariatric surgery is restricted by insurers in numerous ways, including by precertification criteria such as 3-6 months preoperative supervised medical weight management and documented 2-year weight history. OBJECTIVES: To investigate if there is an association between the aforementioned precertification criteria, insurance plan type, and the likelihood of undergoing bariatric surgery, after controlling for potential sociodemographic confounders. RESEARCH DESIGN: The study was conducted using the Pennsylvania Health Care Cost Containment Council's data in 5 counties of Pennsylvania in 2016 and records of preoperative insurance requirements maintained by the Temple University Bariatric Surgery Program.Privately insured bariatric surgery patients and individuals who met the eligibility criteria but did not undergo surgery were identified and 1:1 matched by sex, race, age group, and zip code (n=1054). Univariate tests and logistic regression analysis were utilized for data analysis. RESULTS: The insurance requirement for 3-6 months preoperative supervised medical weight management was associated with smaller odds of undergoing surgery [odds ratio (OR)=0.459; 95% confidence interval (CI), 0.253-0.832; P=0.010], after controlling for insurance plan type and the requirement for documented weight history.Preferred provider organization (OR=1.422; 95% CI, 1.063-1.902; P=0.018) and fee-for-service (OR=1.447; 95% CI, 1.021-2.050; P=0.038) plans were associated with greater odds of undergoing surgery, compared with health maintenance organization plans, after controlling for the studied precertification requirements. The documented weight history requirement was not a significant predictor of the odds of undergoing surgery (P=0.132). CONCLUSIONS: There is a need for consideration of insurance benefits design as a determinant of access to bariatric surgery.

A pooled analysis of adverse events in 393 adults with Gaucher disease type 1 from four clinical trials of oral eliglustat: Evaluation of frequency, timing, and duration.

Eliglustat, an oral substrate reduction therapy, is a first-line therapy for adults with Gaucher disease type 1 and a compatible CYP2D6 metabolizer phenotype. Clinicians have requested more information about frequency, timing, and duration of adverse events associated with eliglustat. Adverse event data as of January 31, 2013 for all patients who received at least one dose of eliglustat were pooled from four eliglustat clinical trials (393 patients representing 535 patient-years of exposure). The following 10 adverse events noted in the eliglustat US Prescribing Information (USPI) and EU Summary of Product Characteristics (SmPC) were evaluated with regard to frequency, drug-relatedness, severity, seriousness, duration, and timing of onset: headache, arthralgia, diarrhea, nausea, fatigue, flatulence, abdominal pain, upper abdominal pain, back pain, and extremity pain. Of 393 patients, 334 experienced one or more adverse events. Most patients (92%) continued taking eliglustat; 3% withdrew from a trial due to an adverse event. Among the 10 adverse events evaluated, none was reported as serious and none resulted in discontinuing treatment; most were mild or moderate, reported only once, and not considered eliglustat-related. The majority of adverse events noted in the eliglustat USPI and SmPC were non-serious, occasional, non-severe, and did not lead to drug discontinuation.

Supporting a Culture of Evidence-Based Policy: Federal Funding for Public Health Law Evaluation Research, 1985-2014.

OBJECTIVE: Law powerfully influences health and can be a critical tool for promoting population well-being. Evaluation research is needed to measure the health effects of law and guide policy making and implementation. The purpose of this study was to assess trends in National Institutes of Health (NIH) funding for scientific public health law research (PHLR). METHODS: Using data from the UberResearch NIH grant repository, we collected and coded all grants with a focus on health law between FY'85 and FY'14 and then analyzed the grants by funding agency and topic areas. RESULTS: Between FY'85 and FY'14, NIH funded 510 research grants on health policy making, the health effects of laws or enforcement practices. On average, 4 PHLR grants were funded annually with a median total funding of $545 956 (range: $2535-$44 052 300) and a median annual funding of $205 223 (range: $2535-$7 019 517). CONCLUSIONS: National Institutes of Health has supported important PHLR but not nearly to the extent necessary to ensure that public health laws affecting the population are evaluated in a rigorous and timely manner. In addition to greater funding evaluation research, NIH can increase its support for creating legal datasets, fund training in PHLR, and work with the National Library of Medicine to create Medical Subject Headings (MeSH) terms related to PHLR.

Policy Surveillance: A Vital Public Health Practice Comes of Age.

Governments use statutes, regulations, and policies, often in innovative ways, to promote health and safety. Organizations outside government, from private schools to major corporations, create rules on matters as diverse as tobacco use and paid sick leave. Very little of this activity is systematically tracked. Even as the rest of the health system is working to build, share, and use a wide range of health and social data, legal information largely remains trapped in text files and pdfs, excluded from the universe of usable data. This article makes the case for the practice of policy surveillance to help end the anomalous treatment of law in public health research and practice. Policy surveillance is the systematic, scientific collection and analysis of laws of public health significance. It meets several important needs. Scientific collection and coding of important laws and policies creates data suitable for use in rigorous evaluation studies. Policy surveillance addresses the chronic lack of readily accessible, nonpartisan information about status and trends in health legislation and policy. It provides the opportunity to build policy capacity in the public health workforce. We trace its emergence over the past fifty years, show its value, and identify major challenges ahead.

High Incidence of Noonan Syndrome Features Including Short Stature and Pulmonic Stenosis in Patients carrying NF1 Missense Mutations Affecting p.Arg1809: Genotype-Phenotype Correlation.

Neurofibromatosis type 1 (NF1) is one of the most frequent genetic disorders, affecting 1:3,000 worldwide. Identification of genotype-phenotype correlations is challenging because of the wide range clinical variability, the progressive nature of the disorder, and extreme diversity of the mutational spectrum. We report 136 individuals with a distinct phenotype carrying one of five different NF1 missense mutations affecting p.Arg1809. Patients presented with multiple café-au-lait macules (CALM) with or without freckling and Lisch nodules, but no externally visible plexiform neurofibromas or clear cutaneous neurofibromas were found. About 25% of the individuals had Noonan-like features. Pulmonic stenosis and short stature were significantly more prevalent compared with classic cohorts (P < 0.0001). Developmental delays and/or learning disabilities were reported in over 50% of patients. Melanocytes cultured from a CALM in a segmental NF1-patient showed two different somatic NF1 mutations, p.Arg1809Cys and a multi-exon deletion, providing genetic evidence that p.Arg1809Cys is a loss-of-function mutation in the melanocytes and causes a pigmentary phenotype. Constitutional missense mutations at p.Arg1809 affect 1.23% of unrelated NF1 probands in the UAB cohort, therefore this specific NF1 genotype-phenotype correlation will affect counseling and management of a significant number of patients.

The recurrent distal 22q11.2 microdeletions are often de novo and do not represent a single clinical entity: a proposed categorization system.

PURPOSE: The five segmental duplications (LCR22-D to -H) at the distal region of chromosome 22 band q11.2 in the region immediately distal to the DiGeorge/velocardiofacial syndrome deleted region have been implicated in the recurrent distal 22q11.2 microdeletions. To date, the distal 22q11.2 microdeletions have been grouped together as a single clinical entity despite the fact that these deletions are variable in size and position depending on the mediating LCR22s. METHODS: Here, we report 13 new unrelated patients with variable size deletions in the distal 22q11.2 region as shown by cytogenomic array analyses. We compare our patients' clinical features with those of previously reported cases to better dissect the phenotypic correlations based on the deletion size and position. RESULTS: Six patients had the 1.1-Mb deletion flanked by LCR22-D and -E, and presented clinically with a phenotype consistent with previously reported cases with distal 22q11.2 microdeletions. Three patients had the 1.8-Mb deletion flanked by LCR22-D and -F, and presented with a similar phenotype. Four patients had the 700-kb deletion flanked by LCR22-E and -F, and presented with a milder phenotype that lacked growth restriction and cardiovascular defects. CONCLUSION: We suggest that the recurrent distal 22q11.2 microdeletions do not represent a single clinical entity, and propose categorizing these deletions into three types according to their genomic position. All three deletion types are thought to be pathogenic and are most often de novo. They all share some presenting features but also have their unique features and risks.

Critical opportunities for public health law: a call for action.

Although legal interventions are responsible for many sentinel public health achievements, law is underutilized as a tool for advancing population health. Our purpose was to identify critical opportunities for public health lawmaking. We articulated key criteria and illustrated their use with 5 examples. These opportunities involve significant health problems that are potentially amenable to change through law and for which an effective legal intervention is available: optimizing graduated driver licensing laws, increasing tax rates on alcoholic beverages, regulating sodium in foods, enacting laws to facilitate reversal of opioid overdoses, and improving mental health interventions in the college setting. We call for a national conversation about critical opportunities for public health law to advance evidence-based policymaking.

Disarming Intimate Partner Violence Offenders: An In-Depth Descriptive Analysis of Federal and State Firearm Prohibitor Laws in the United States, 1991-2016.

Intimate partner violence is a preventable public health problem affecting more than 12 million people in the United States annually. The immense burden of victimization is most often borne by women. Nearly one in two female homicide victims are killed by current or former partners (more than 50% of which involve firearms). Firearm-related morbidity and mortality are concentrated where firearm ownership is most prevalent and firearm laws are least restrictive, indicating the potential for law to serve as an intervention. Understanding intricacies within laws and how they vary is critical to studying their influence on health. This study is the first to use the scientific legal mapping technique of policy surveillance to create legal data by systematically collecting and coding laws that authorize or require courts to prohibit offenders subject to domestic violence restraining orders (DVROs) and temporary restraining orders (TROs) from purchasing and possessing firearms ("firearm prohibitor" laws). These data measure key provisions of federal and state laws from 1991 to 2016, including whether the law includes a firearm prohibition, who qualifies as an intimate partner, notice and hearing requirements, whether the prohibition occurs automatically or through judicial discretion, and if the law permits or requires the relinquishment or removal of firearms. The federal law, enacted in 1994 (and reauthorized in 2022), only protects qualifying victims that obtain final DVROs. States can mirror or go beyond federal measures. From 1991 to 2016, 38 states enacted a firearm prohibitor law through DVROs (37 states), TROs (20 states), or both (19 states). Today, survivors suffer from a sluggish and fragmented legal system leading to the unequal protection of victims based on where they happen to live. This research provides an in-depth descriptive analysis of this complex and nuanced legal system, recommendations to spur policy reform, and longitudinal data for future research.

Supporting student learning and development through trauma-informed campuses.

Many students come to higher education with a history of trauma. College life may also expose students to traumatizing events. While the past decade has witnessed greater discussion of trauma-informed frameworks, it has not regularly been applied to the college environment. We advance the concept of a trauma-informed campus, where administrators, faculty, staff, and students from diverse disciplines create an environment that recognizes the widespread nature of trauma, integrates knowledge about trauma into practices and procedures, and minimizes further re-traumatization for all community members. A trauma-informed campus is prepared for students' past or future traumatic experiences, while also recognizing and responding to structural and historical harms. In addition, it recognizes the role of the surrounding community challenges, particularly how violence, substance use, hunger, poverty, and housing insecurity may contribute to further trauma or negatively impact healing. We use an ecological model to frame and shape the construct of trauma-informed campuses.

"Unprecedented Times:" Experiences of Social Work and Public Health Professionals during Times of Public Crises.

Social workers and public health professionals in the U.S. were profoundly impacted by COVID-19, systemic racism, and the 2020 U.S. presidential election. This study examined their external job support, burnout, and job satisfaction in the context of these circumstances. The findings suggest respondents, who had graduate degrees in social work or public health, overemphasized their job satisfaction and underemphasized their burnout. While social work and public health professionals felt satisfied with their labor, not acknowledging burnout limits the amount of support they may access to effectively continue the work. Interestingly, participants who had more administrative functions reported higher job satisfaction scores and lower burnout scores. Traditionally, those in administrative positions have more control over their schedule and work responsibilities. Findings suggest that more training, opportunities for self-care, and discussions about safety and systemic racism are needed in the workplace for social workers and public health professionals.

Moving from intersection to integration: public health law research and public health systems and services research.

CONTEXT: For three decades, experts have been stressing the importance of law to the effective operation of public health systems. Most recently, in a 2011 report, the Institute of Medicine recommended a review of state and local public health laws to ensure appropriate authority for public health agencies; adequate access to legal counsel for public health agencies; evaluations of the health effects and costs associated with legislation, regulations, and policies; and enhancement of research methods to assess the strength of evidence regarding the health effects of public policies. These recommendations, and the continued interest in law as a determinant of health system performance, speak to the need for integrating the emerging fields of Public Health Law Research (PHLR) and Public Health Systems and Services Research (PHSSR). METHODS: Expert commentary. FINDINGS: This article sets out a unified framework for the two fields and a shared research agenda built around three broad inquiries: (1) the structural role of law in shaping the organization, powers, prerogatives, duties, and limitations of public health agencies and thereby their functioning and ultimately their impact on public health ("infrastructure"); (2) the mechanisms through which public health system characteristics influence the implementation of interventional public health laws ("implementation"); and (3) the individual and system characteristics that influence the ability of public health systems and their community partners to develop and secure enactment of legal initiatives to advance public health ("innovation"). Research to date has laid a foundation of evidence, but progress requires better and more accessible data, a new generation of researchers comfortable in both law and health research, and more rigorous methods. CONCLUSIONS: The routine integration of law as a salient factor in broader PHSSR studies of public health system functioning and health outcomes will enhance the usefulness of research in supporting practice and the long-term improvement of system performance.

Public health law research: exploring law in public health systems.

The importance of law in the organization and operation of public health systems has long been a matter of interest to public health lawyers and practitioners, but empirical research on law as a factor in health system performance has been limited in quantity and sophistication. The emergence of Public Health Law Research and Public Health Systems and Services Research within a coordinated effort to strengthen public health research and practice has dramatically changed matters. This article introduces Public Health Law Research as an integral part of Public Health Systems and Services Research, discusses the challenges of integrating the 2 fields, and highlights 2 examples of current research that demonstrate the benefits of an integrated approach to improve the use of law in public health practice.

A summary of health outcomes: multistate foodborne disease outbreaks in the U.S., 1998-2007.

Multistate foodborne disease outbreaks (FBDOs) pose a particular threat to public health. The study described in this article sought to describe the incidence and health outcomes of multistate FBDOs in the U.S. from 1998 to 2007. The Centers for Disease Control and Prevention's (CDC's) OutbreakNet Foodborne Outbreak online database was used to analyze FBDOs reported to and confirmed by CDC between 1998 and 2007. Univariate analysis and ANOVA were used to examine outcomes of illnesses, hospitalizations, and deaths. Over 100 multistate FBDOs occurred between 1998 and 2007, with a slight increase over time. Average illnesses, hospitalizations, and deaths were 74.075 (SD = 106.24), 14.11 (SD = 23.23), and 0.826 (SD = 2.88), respectively. Vectors most often identified as the cause of the FBDOs were Salmonella (n = 57) and E. coli (n = 30), making up 81% of all multistate outbreaks. Policy makers and health officials need to reconsider the means by which industry and government coordinate response to outbreaks--particularly across jurisdictions--to ensure an efficient and seamless system of response, particularly in the case of multistate outbreaks.

Youth susceptibility to tobacco use in the Gulf Cooperation Council Countries, 2001-2018.

The Gulf Cooperation Council (GCC) countries - Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (UAE) - ratified the Framework Convention on Tobacco Control (FCTC) in 2006. Yet, GCC countries predict a slight reduction in tobacco use compared to the Eastern Mediterranean region's significant downward trend. The purpose of this study was to examine changes in self-reported intention to initiating tobacco use (susceptibility) among youth over time in five GCC countries and the relationship between susceptibility and key FCTC provisions. Complex sample logistic regression analyses were conducted using data from the 2001 to 2018 Global Youth Tobacco Survey (n = 349,878 adolescents). Since the ratification of FCTC in GCC countries, susceptibility to initiate tobacco use significantly decreased in Bahrain and Qatar while it increased in UAE (P < 0.001). Exposure to smoking in public places increased the odds of susceptibility to tobacco use in Bahrain (AOR = 1.6, 95% CI = [1.2-2.2), Kuwait (AOR = 1.6, 95% CI = [1.2-2.0]), Qatar (AOR = 1.9, 95% CI = [1.4-2.6]), and UAE (AOR = 2.1, 95% CI = [1.6-2.7]). Susceptibility to tobacco use was significantly associated with exposure to tobacco imagery in media in the UAE (AOR = 1.7, 95% CI = [1.2-2.3]) and with tobacco industry activities like promotion in Bahrain (AOR = 2.8, 95% CI = [1.9-4.2]) and Kuwait (AOR = 2.2, 95% CI = [1.5-3.1]). In conclusion, the impact of FCTC provisions on tobacco use differs across countries. Findings suggested that the implementation of tobacco control policies may independently influence the initiation of tobacco use.

Tobacco advertisement, promotion and sponsorship in Arabic media between 2017 and 2019.

Nineteen out of 22 countries in the Eastern Mediterranean region, including the Gulf Cooperation Council countries, have ratified the World Health Organization Framework Convention on Tobacco Control (FCTC) treaty. One of FCTC's provisions prohibits tobacco advertisement, promotion and sponsorship (TAPS). The TAPS provision requires nations to ban direct and indirect tobacco ads in media, as exposure to tobacco use in the media encourages smoking initiation. A limited number of studies have examined TAPS in Arabic media. This study examined the occurrence of tobacco use across Arabic television (TV) series released between January 2017 and December 2019 to assess compliance with the FCTC provision banning TAPS. The content analysis examined incidents of tobacco use in Arabic TV series, types of tobacco products used and the portrayal of second-hand smoking exposure. Out of 92 Arabic TV series (2952 episodes), there were 32 044 incidents of tobacco use. Incidents of tobacco use per episode fluctuated over time. During Ramadan, the median number of tobacco incidents declined from 6 in 2017 to 3 in 2019; however, it increased to 8 in 2018. Regular cigarettes and water pipes were the most common tobacco products used in TV series. While 27% of tobacco use showed characters who smoked tobacco products alone, 13% of the incidents portrayed characters who were smoking in the presence of children. This study concludes that tobacco imagery is not completely banned in Arabic media and its continued representation weakens tobacco control measures.

Health Correlates of Intimate Partner Violence and Help-seeking Among Unauthorized Immigrant Women.

Intimate partner violence (IPV) research on immigrant women who are unauthorized is particularly scarce, despite unique vulnerabilities associated with their documentation status that may impact help-seeking and health outcomes. The purpose of this study was to document the frequency of lifetime IPV and related help-seeking behaviors, and examine the relationship between IPV, major depressive disorder (MDD), post-traumatic stress disorder (PTSD), and health-related quality of life (HRQL) among a community health center-based sample of unauthorized, Spanish-speaking immigrant women in Philadelphia. A clinic-based sample of unauthorized Spanish-speaking women (N = 200, ages 18-65) completed an anonymous, cross-sectional survey on IPV experiences, help-seeking behaviors, and self-reported health in 2013-2014. Chi-square tests assessed associations between sociodemographic variables and IPV. Multivariable logistic regression investigated whether IPV predicted mental health outcomes. Approximately one in three (34.5%) women reported lifetime IPV experiences. Of these, half (56.6%) sought help (formal n = 22; informal n = 25) because of the violence. Women identified not knowing where to go, believing that help was not necessary, and embarrassment as barriers to help-seeking. Symptoms consistent with MDD and PTSD were reported by 40.5% and 16% of the sample, respectively. In unadjusted logistic regression models, IPV survivors were more likely to endorse MDD and PTSD, and report low mental health HRQL scores than counterparts without IPV. In fully adjusted models, only the association between IPV and PTSD remained significant (OR: 3.80, p =.01). Study findings document high frequencies of IPV, MDD, and PTSD among this clinic-based sample of unauthorized immigrant women. Women who reported IPV also had a greater likelihood of reporting symptoms consistent with PTSD. Findings highlight the need for clinic-based mental health and trauma-informed services tailored to unauthorized immigrant women as well as interventions to decrease IPV.