A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.

BACKGROUND: Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users. OBJECTIVES: We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. METHODS: We conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. RESULTS: The intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57-0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively. CONCLUSION: This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing.

The 24-month course of manic symptoms in children.

OBJECTIVES: The Longitudinal Assessment of Manic Symptoms (LAMS) study was designed to investigate phenomenology and establish predictors of functional outcomes in children with elevated manic symptoms. The purpose of this series of analyses was to determine whether the participants demonstrated different trajectories of parent-reported manic and biphasic symptoms over the first 24 months of follow-up and to describe the clinical characteristics of the trajectories. METHODS: The 707 participants were initially aged 6-12 years and ascertained from outpatient clinics associated with the four university-affiliated LAMS sites. There were 621 children whose parents/guardians' ratings scored ≥ 12 on the Parent General Behavior Inventory-10-item Mania Form (PGBI-10M) and a matched random sample of 86 children whose parents/guardians' ratings scored ≤ 11 on the PGBI-10M. Participants were seen every six months after the baseline and their parents completed the PGBI-10M at each visit. RESULTS: For the whole sample, manic symptoms decreased over 24 months (linear effect B = -1.15, standard error = 0.32, t = -3.66, p < 0.001). Growth mixture modeling revealed four unique trajectories of manic symptoms. Approximately 85% of the cohort belonged to two classes in which manic symptoms decreased. The remaining ~15% formed two classes (high and rising and unstable) characterized by the highest rates of diagnostic conversion to a bipolar disorder (all p-values < 0.001). CONCLUSIONS: Outcomes are not uniform among children with symptoms of mania or at high risk for mania. A substantial minority of clinically referred children shows unstable or steadily increasing manic symptoms, and these patterns have distinct clinical correlates.

ACPSEM position paper on ROMP scope of practice and staffing levels for magnetic resonance linear accelerators.

The purpose of this position paper is to outline the ACPSEM recommendations on Medical Physicist scope of practice and staffing levels, as they relate to the use of dedicated MRI-Linacs in the treatment of patients. A core function of Medical Physicists is to safely implement changes in medical practice via the introduction of new technology and to ensure high quality radiation oncology services are provided to patients. Determining the feasibility of MRI-Linacs in any existing setting, or in establishing a new site, mandates the knowledge and services of Radiation Oncology Medical Physicists (ROMPs) as the Qualified Experts within this setting. ROMPs are key members of the multi-disciplinary team which will be required to steer the successful establishment of MRI Linac infrastructure within departments. To support efficient implementation, ROMPs must be embedded in the process from the start, including any feasibility study, initiation of the project, and development of the business case. ROMPs must be retained throughout all stages of acquisition, service development, and ongoing clinical use and expansion. The number of MRI-Linacs in Australia and New Zealand is growing. This expansion is occurring in parallel with rapid technological evolution, expanding tumour stream applications, and increasing consumer uptake. Growth and applications of MRI-Linac therapy will continue to occur beyond current known horizons, via development on the MR-Linac platform itself and through the migration of learning from this platform to conventional Linacs (known horizons for example include the use of daily, online image guided adaptive radiotherapy and MRI data informing decision making for planning and treatment before and throughout treatment courses). Clinical use, research and development will be a significant component of expanding patient access to MRI-Linac treatment and there will be an ongoing need to attract and retain ROMPs to initially establish services and in particular to drive service development and delivery for the life of the Linacs. MRI and Linac technologies mean it is necessary to perform a specialized workforce assessment for these devices, distinct from those employed for conventional Linacs and associated services. MRI-Linacs are complex, have a heightened risk profile compared to standard Linacs, and are unique in their treatment of patients. Accordingly, the workforce needs for MRI-Linacs are greater than for standard Linacs. To ensure safe and high-quality Radiation Oncology patient services are provided, it is recommended that staffing levels should be based on the 2021 ACPSEM Australian Radiation Workforce model and calculator using the MRI-Linac specific ROMP workforce modelling guidelines outlined in this paper. The ACPSEM workforce model and calculator are closely aligned with other Australian/New Zealand and international benchmarks.

Performance evaluation of an LED flatbed scanner for triple channel film dosimetry with EBT3 and EBT-XD film.

We investigate the properties of a light emitting diode (LED) flatbed scanner for use with EBT3 and EBT-XD film types in a clinical radiochromic film (RCF) dosimetry program with modern treatment techniques. The flatbed scanner was characterised in terms of lateral and longitudinal response, X-Y scaling integrity, scanning reproducibility, scanner warm up dependence and film orientation dependence. The preferred lateral response artefact (LRA) corrections are investigated for the LED light source. Supporting evidence is provided regarding the dose independent nature of the corrections while also providing results suggesting a potential film type independence. Results from 2D gamma analysis of four patient treatments were compared between the new 12000XL and existing 10000XL model. Lastly, a dose uncertainty analysis was performed for the film-scanner system combination. It may be concluded that the lateral response variation requires correction while the longitudinal response variation is insignificant. The linear scaling in the lateral and longitudinal directions are within 0.5% and the scanner reproducibility is stable. Scanner warm up dependence no longer exists, and effort should be made to maintain all film orientation in a study set within 15°. The LRA corrections are as reported substantially dose independent and there is evidence to support film type independence. Comparative gamma analysis of patient specific dose maps between the EPSON 10000XL (xenon fluorescent lamp) and 12000XL (LED) scanners showed that results are indistinguishable for both film types across the two scanner models when the necessary corrections are applied. Dose uncertainty is in agreement with the literature and can be kept below 3% with necessary corrections applied.

Commissioning measurements on an Elekta Unity MR-Linac.

Magnetic resonance-guided radiotherapy technology is relatively new and commissioning publications, quality assurance (QA) protocols and commercial products are limited. This work provides guidance for implementation measurements that may be performed on the Elekta Unity MR-Linac (Elekta, Stockholm, Sweden). Adaptations of vendor supplied phantoms facilitated determination of gantry angle accuracy and linac isocentre, whereas in-house developed phantoms were used for end-to-end testing and anterior coil attenuation measurements. Third-party devices were used for measuring beam quality, reference dosimetry and during treatment plan commissioning; however, due to several challenges, variations on standard techniques were required. Gantry angle accuracy was within 0.1°, confirmed with pixel intensity profiles, and MV isocentre diameter was < 0.5 mm. Anterior coil attenuation was approximately 0.6%. Beam quality as determined by TPR20,10 was 0.705 ± 0.001, in agreement with treatment planning system (TPS) calculations, and gamma comparison against the TPS for a 22.0 × 22.0 cm2 field was above 95.0% (2.0%, 2.0 mm). Machine output was 1.000 ± 0.002 Gy per 100 MU, depth 5.0 cm. During treatment plan commissioning, sub-standard results indicated issues with machine behaviour. Once rectified, gamma comparisons were above 95.0% (2.0%, 2.0 mm). Centres which may not have access to specialized equipment can use in-house developed phantoms, or adapt those supplied by the vendor, to perform commissioning work and confirm operation of the MRL within published tolerances. The plan QA techniques used in this work can highlight issues with machine behaviour when appropriate gamma criteria are set.

Three-year latent class trajectories of attention-deficit/hyperactivity disorder (ADHD) symptoms in a clinical sample not selected for ADHD.

OBJECTIVE: This study aims to examine trajectories of attention-deficit/hyperactivity disorder (ADHD) symptoms in the Longitudinal Assessment of Manic Symptoms (LAMS) sample. METHOD: The LAMS study assessed 684 children aged 6 to 12 years with the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) and rating scales semi-annually for 3 years. Although they were selected for elevated manic symptoms, 526 children had baseline ADHD diagnoses. With growth mixture modeling (GMM), we separately analyzed inattentive and hyperactive/impulsive symptoms, covarying baseline age. Multiple standard methods determined optimal fit. The χ(2) and Kruskal-Wallis analysis of variance compared resulting latent classes/trajectories on clinical characteristics and medication. RESULTS: Three latent class trajectories best described inattentive symptoms, and 4 classes best described hyperactive/impulsive symptoms. Inattentive trajectories maintained their relative position over time. Hyperactive/impulsive symptoms had 2 consistent trajectories (least and most severe). A third trajectory (4.5%) started mild, then escalated; and a fourth (14%) started severe but improved dramatically. The improving trajectory was associated with the highest rate of ADHD and lowest rate of bipolar diagnoses. Three-fourths of the mildest inattention class were also in the mildest hyperactive/impulsive class; 72% of the severest inattentive class were in the severest hyperactive/impulsive class, but the severest inattention class also included 62% of the improving hyperactive-impulsive class. CONCLUSION: An ADHD rather than bipolar diagnosis prognosticates a better course of hyperactive/impulsive, but not inattentive, symptoms. High overlap of relative severity between inattention and hyperactivity/impulsivity confirms the link between these symptom clusters. Hyperactive/impulsive symptoms wane more over time. Group means are insufficient to understand individual ADHD prognosis. A small subgroup deteriorates over time in hyperactivity/impulsivity and needs better treatments than currently provided.

Characteristics of children with elevated symptoms of mania: the Longitudinal Assessment of Manic Symptoms (LAMS) study.

OBJECTIVE: The aim of the Longitudinal Assessment of Manic Symptoms (LAMS) study is to examine differences in psychiatric symptomatology, diagnoses, demographics, functioning, and psychotropic medication exposure in children with elevated symptoms of mania (ESM) compared to youth without ESM. This article describes the initial demographic information, diagnostic and symptom prevalence, and medication exposure for the LAMS cohort that will be followed longitudinally. METHOD: Guardians of consecutively ascertained new outpatients 6 to 12 years of age presenting for treatment at one of 10 university-affiliated mental health centers were asked to complete the Parent General Behavior Inventory-10-Item Mania Scale (PGBI-10M). Patients with scores ≥ 12 on the PGBI-10M (ESM+) and a matched sample of patients who screened negative (ESM-) were invited to participate. Patients were enrolled from December 13, 2005, to December 18, 2008. RESULTS: 707 children (621 ESM+, 86 ESM-; mean [SD] age = 9.4 [2.0] years) were evaluated. The ESM+ group, compared to the ESM- group, more frequently met DSM-IV criteria for a mood disorder (P < .001), bipolar spectrum disorders (BPSD; P < .001), and disruptive behavior disorders (P < .01). Furthermore, they showed poorer overall functioning and more severe manic, depressive, attention-deficit/hyperactivity, disruptive behavioral, and anxiety symptoms. Nevertheless, rates of BPSD were relatively low in the ESM+ group (25%), with almost half of these BPSD patients (12.1% of ESM+ patients) meeting DSM-IV criteria for bipolar disorder not otherwise specified. ESM+ children with BPSD had significantly more of the following: current prescriptions for antipsychotics, mood stabilizers, and anticonvulsants (P < .001 for each); psychiatric hospitalizations (P < .001); and biological parents with elevated mood (P = .001 for mothers, P < .013 for fathers). ESM+ children with BPSD were also lower functioning compared to ESM+ children without BPSD. CONCLUSIONS: Although ESM+ was associated with higher rates of BPSD than ESM-, 75% of ESM+ children did not meet criteria for BPSD. Results suggest that longitudinal assessment is needed to examine which factors are associated with diagnostic evolution to BPSD in children with elevated symptoms of mania.

Effectiveness of an intensive, school-based intervention for teen mothers.

PURPOSE: This study evaluated the effectiveness of a secondary teen pregnancy prevention intervention that includes school-based social work services coordinated with comprehensive health care for teen mothers and their children. METHODS: A prospective cohort study compared subsequent births to teen mothers followed for at least 24 months or until age 20 years (whichever was longer) compared with matched subjects from state data. Analyses were based on intent to treat and included chi(2), survival, and cost-benefit analysis. RESULTS: Subjects included 63 girls (97% eligible, 99% African-American, mean age 16 years). A propensity-matched comparison group (n = 252) did not differ from subjects. Participation in program components was good: (1) group meetings: 76%; (2) case management: 95%; (3) coordinated medical care: 63%. The majority of subjects used contraception (93%), with greater use of medroxyprogesterone associated with participation in coordinated medical care (80% vs. 50%, p = .0145). Subsequent births were more common in the comparison group (33%) than among subjects (17%) (p = .001), and survival curves were significantly different (p = .007) (hazard ratio = 2.5). There was a trend toward fewer births with increased participation in medical care (p = .08) and case management (p = .08) but not with group meetings. Cost savings were calculated as $19,097 per birth avoided or $5,055 per month. CONCLUSIONS: The intervention was effective in reducing subsequent births to teens; however selection bias of school enrollment cannot be excluded by this study. The cost savings of delayed births outweigh the expenses of this intensive model.

Missed opportunities for prevention: failure to identify smoking in the parents of adolescent patients.

Smoking is an addiction that often begins in childhood or adolescence. Factors associated with early smoking initiation include parental smoking and socialization about smoking with their children. Previous studies evaluating the history obtained during routine pediatric appointments have not focused on parental smoking history and counseling. In this study, seventy-three (73) adolescents (mean age: 15.2 years; 77% female; 64% African-American) seen for medical care in a primary care clinic and their accompanying parent(s) (mean age: 43.5 years; 91% female) were surveyed about smoking followed by a review of each chart measuring documentation of adolescent and parent smoking history and counseling. Although the majority of adolescents were questioned about smoking (92%), parents were rarely questioned (1%) (p < 0.05). Adolescents were counseled about smoking (7%) and other risk-taking behaviors (44%); however, no parents were counseled about smoking or smoking socialization. Physicians frequently overlook an important factor in the prevention of smoking initiation at a young age, parental smoking history and counseling.

Family-focused smoking cessation:enhanced efficacy by the addition of partner support and group therapy.

While partner support has been found to be an important factor in smoking cessation, programs with partner training have not demonstrated improved efficacy. The goal of this project was to evaluate the effectiveness of a smoking cessation treatment program that included partner support in an innovative education/therapy model similar to alcohol and drug treatment programs. Subjects included 23 smokers, 71% with a support partner. The program consisted of a smoking cessation curriculum, combined with facilitated group therapy for participants and partners, and individualized medication evaluation. Smoking abstinence was 87% at program completion and 80% at one month follow up, 100% abstinence in participants with support and 50% in participants without support (p < 0.05). Smoking Stage of Change at enrollment was: contemplation 22%, preparation 70%, and action 8%, with 87% movement toward action stage. In the present study, partner support enhanced short-term abstinence from smoking.