Effectiveness of Substance Use Navigation for Emergency Department Patients With Substance Use Disorders: An Implementation Study.

STUDY OBJECTIVE: We implemented a whole person care-informed intervention delivered by substance use navigators (SUN) for emergency department (ED) patients with substance use disorders. METHODS: This was an implementation study of adult patients discharged from 3 public hospital EDs between September 1, 2021 through January 31, 2022 with cocaine, methamphetamine, alcohol, and opioid use-related diagnoses. The primary effectiveness outcome was treatment engagement within 30 days of ED discharge among patients with and without the SUN intervention. We used logistic regression and nearest neighbor propensity score matching without replacement to control for confounding effects. RESULTS: There were 1,328 patients in the cohort, and 119 (9.0%) received the SUN intervention; 50.4% of patients in the SUN intervention group and 15.9% of patients without the SUN intervention were engaged in outpatient treatment within 30 days of ED discharge (difference in proportions: 34.5%, 95% confidence interval [CI] 25.3% to 43.8%). In the unadjusted analysis, the SUN intervention was associated with higher rates of treatment engagement after ED discharge for patients with alcohol, opioid, and cocaine-related diagnoses; patients with methamphetamine-related diagnoses had low engagement rates with or without the SUN intervention. In addition, the SUN intervention was associated with higher odds of treatment engagement in the multivariable model (aOR 3.7, 95% CI 2.4 to 5.8) and in the propensity score-matched analysis (OR 2.1, 95% CI 1.2 to 3.5). CONCLUSION: A whole person care-informed intervention delivered by SUNs for ED patients with substance use disorders was strongly associated with higher engagement rates in addiction treatment after discharge.

Utilizing a combined hospital and criminal justice database to identify risk factors for repeat firearm injury or violent-crime arrest among firearm victims.

Introduction: Identifying firearm victims with the greatest risk of repeat-firearm exposure and offering interventions has the potential to disrupt recurrent violence. This study explored risk factors associated with repeat violence among survivors of intentional firearm injury in a unique clinical and criminal justice (CJ) dataset. Methods: This study analyzed a retrospective cohort (n = 4058) of persons injured by nonfatal intentional firearm violence from 2013 to 2016 in one metropolitan area. Data were collected from a single level I trauma center, city police records, and state CJ databases from 1948 to 2019. The primary outcome of interest was another firearm injury or violent-crime arrest (defined as a violent or firearm felony offense). Results: Among 4058 nonfatal intentional firearm victims, 1202 (29.6%) individuals had a repeat-firearm injury or violent-crime arrest. In a bivariate analysis, history of mental, physical, and/or emotional abuse (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.40-1.86), mental health diagnosis (OR, 1.88; 95% CI, 1.51-2.35), or illegal substance use (OR, 2.87; 95% CI, 2.48-3.32) was associated with increased risk of repeat-firearm injury or violent-crime arrest. Prior felony arrest (OR, 3.68; 95% CI, 3.19-4.24), prior incarceration (OR, 3.72; 95% CI, 3.04-4.56), prior firearm charge (OR, 4.06; 95% CI, 3.33-4.96), and suspected gang membership (OR, 8.69; 95% CI, 6.14-12.32) demonstrated the greatest association with significant repeat violence. Conclusions: Thirty percent of those who experienced an intentional firearm injury were found to have a repeat-firearm injury or violent-crime arrest multi-disciplinary interventions that address the complex needs of a CJ-involved population are needed to mitigate significant repeat violence.

Patient Characteristics and Perspectives of Firearm Safety Discussions in the Emergency Department.

INTRODUCTION: Firearm injury prevention discussions with emergency department (ED) patients provide a unique opportunity to prevent death and injury in high-risk patient groups. Building mutual understanding of safe firearm practices between patients and providers will aid the development of effective interventions. Examining ED patient baseline characteristics, perspectives on healthcare-based safety discussions, and experience with and access to firearms, will allow practitioners to craft more effective messaging and interventions. METHODS: Using an institutional review board-approved cross-sectional survey modified from a validated national instrument, we recruited 625 patients from three large, urban, academically affiliated EDs in the South to assess patient baseline characteristics, perspectives regarding firearms and firearm safety discussions, and prior violence history, as well as firearm access and safety habits. We compared the degree to which patients were open to discussions regarding firearms across a variety of provider types and clinical scenarios between those with and without gun access. RESULTS: Of the 625 patients consented and eligible for the study, 306 had access to firearms. The patients with firearm access were predominantly male, were more likely to have military experience, live in an urban or suburban region, and have experienced prior violence when compared to those without firearm access. Patients with and without gun access view firearm safety discussions with their healthcare provider as acceptable and analogous to other behavioral health interventions (i.e., helmet/seat belt use, alcohol/cigarette use). Patients were also accepting of these firearm safety discussions in many clinical contexts and led by multiple provider types. Of the patients with gun access, storage of each type of firearm was reviewed and the primary reason for ownership was for personal protection across all firearm types. CONCLUSION: Patients in the ED indicate openness to firearm safety discussions delivered by a variety of providers and in diverse clinical scenarios. Healthcare providers engaging firearm owners in appropriate risk-benefit discussions using a trauma-informed approach is a critical next step in research and intervention.

A Content Analysis of Hospitals' Community Health Needs Assessments in the Most Violent U.S. Cities.

The emergence of evidence-supported interventions allows hospitals the opportunity to reduce future reinjury among patients who are violently injured. However, hospital knowledge of these interventions and their perceived role in violence prevention is unknown. The Patient Protection and Affordable Care Act created new legal requirements for non-profit hospitals to conduct community health needs assessments (CHNA) every three years to maintain not-for-profit status. In turn, this allows an empiric evaluation of hospital recognition and response to community violence. To do so, this study performed a content analysis of hospital CHNAs from the 20 U.S. cities with the highest violent crime rates. A total of 77 CHNAs were examined for specific violence-related keywords as well as whether violence prevention was listed as a priority community need. Overall, 74% of CHNAs mentioned violence-related terms and only 32% designated violence prevention as a priority need. When discussed, 88% of CHNAs referenced community violence, 42% intimate partner or sexual violence, and 22% child abuse. This study suggests that hospitals may lack awareness of violence as an actionable, preventable public health issue. Further, evidence-based program models are available to hospitals that can reduce the recurrence of assaultive injuries.

Subjective cognitive decline and ß-amyloid burden predict cognitive change in healthy elderly.

OBJECTIVE: To assess in a longitudinal study whether subjective cognitive decline (SCD) and brain ß-amyloid (Aß) contribute unique information to cognitive decline. METHODS: One hundred thirty-six healthy elderly from the Berkeley Aging Cohort Study were followed up for a mean of 4 years. SCD and affective measures were generated from the Geriatric Depression Scale (GDS) with factor analysis on data from a larger set of 347 healthy, nondepressed (GDS <11) elderly individuals. Cognition was summarized with previously validated factor scores. Pittsburgh compound B (PiB)-PET scans were acquired to determine the presence (PiB+) or absence (PiB-) of Aß pathology. Mixed models were used to assess the independent and interactive effects of SCD, affective features, PiB status, and time on cognition, with adjustment for demographic variables. RESULTS: SCD score demonstrated good construct validity compared to an existing measure of subjective memory and was partially explained by several lower-order measurements. Mixed models revealed that SCD interacted with PiB status to predict change in episodic memory and global cognition over time, with adjustment for affective features. PiB+ individuals with more severe SCD demonstrated the steepest cognitive decline. Worse SCD predicted faster decline in working memory independently of PiB status. No such effects were seen for affective scores when adjusted for SCD. CONCLUSIONS: PiB+ individuals with SCD are at greatest risk of cognitive decline. Evidence for amyloid alone is not sufficient to indicate risk of rapid cognitive decline in healthy elderly. Effects of GDS on cognitive decline in nondepressed cohorts may be driven by SCD rather than subsyndromal depression.

Aging Affects Dopaminergic Neural Mechanisms of Cognitive Flexibility.

Aging is accompanied by profound changes in the brain's dopamine system that affect cognitive function. Evidence of powerful individual differences in cognitive aging has sharpened focus on identifying biological factors underlying relative preservation versus vulnerability to decline. Dopamine represents a key target in these efforts. Alterations of dopamine receptors and dopamine synthesis are seen in aging, with receptors generally showing reduction and synthesis demonstrating increases. Using the PET tracer 6-[18F]fluoro-l-m-tyrosine, we found strong support for upregulated striatal dopamine synthesis capacity in healthy older adult humans free of amyloid pathology, relative to young people. We next used fMRI to define the functional impact of elevated synthesis capacity on cognitive flexibility, a core component of executive function. We found clear evidence in young adults that low levels of synthesis capacity were suboptimal, associated with diminished cognitive flexibility and altered frontoparietal activation relative to young adults with highest synthesis values. Critically, these relationships between dopamine, performance, and activation were transformed in older adults with higher synthesis capacity. Variability in synthesis capacity was related to intrinsic frontoparietal functional connectivity across groups, suggesting that striatal dopamine synthesis influences the tuning of networks underlying cognitive flexibility. Together, these findings define striatal dopamine's association with cognitive flexibility and its neural underpinnings in young adults, and reveal the alteration in dopamine-related neural processes in aging. SIGNIFICANCE STATEMENT: Few studies have combined measurement of brain dopamine with examination of the neural basis of cognition in youth and aging to delineate the underlying mechanisms of these associations. Combining in vivo PET imaging of dopamine synthesis capacity, fMRI, and a sensitive measure of cognitive flexibility, we reveal three core findings. First, we find evidence supporting older adults' capacity to upregulate dopamine synthesis. Second, we define relationships between dopamine, cognition, and frontoparietal activity in young adults indicating high levels of synthesis capacity are optimal. Third, we demonstrate alteration of these relationships in older adults, suggesting neurochemical modulation of cognitive flexibility changes with age.

PET Imaging of Tau Deposition in the Aging Human Brain.

Tau pathology is a hallmark of Alzheimer's disease (AD) but also occurs in normal cognitive aging. Using the tau PET agent (18)F-AV-1451, we examined retention patterns in cognitively normal older people in relation to young controls and AD patients. Age and ß-amyloid (measured using PiB PET) were differentially associated with tau tracer retention in healthy aging. Older age was related to increased tracer retention in regions of the medial temporal lobe, which predicted worse episodic memory performance. PET detection of tau in other isocortical regions required the presence of cortical ß-amyloid and was associated with decline in global cognition. Furthermore, patterns of tracer retention corresponded well with Braak staging of neurofibrillary tau pathology. The present study defined patterns of tau tracer retention in normal aging in relation to age, cognition, and ß-amyloid deposition.

Impact of lifestyle dimensions on brain pathology and cognition.

Single lifestyle factors affect brain biomarkers and cognition. Here, we addressed the covariance of various lifestyle elements and investigated their impact on positron emission tomography-based ß-amyloid (Aß), hippocampal volume, and cognitive function in aged controls. Lower Aß burden was associated with a lifestyle comprising high cognitive engagement and low vascular risk, particularly in apolipoprotein E ε4 carriers. Although cognitive function was related to high lifetime cognitive engagement and low vascular risk, Aß load had no relation to current cognitive function. The covariance between high adult socioeconomic status, high education, and low smoking prevalence predicted better cognitive function and this was mediated by larger hippocampal volume. Our data show that lifestyle is a complex construct composed of associated variables, some of which reflect factors operating over the life span and others which may be developmental. These factors affect brain health via different pathways, which may reinforce one another. Our findings moreover support the importance of an intellectually enriched lifestyle accompanied by vascular health on both cognition and presumed cerebral mediators of cognitive function.