Physician homicide: Reports in the National Violent Death Reporting System (2003-2018).

OBJECTIVE: To explore the occurrence, demographics, and circumstances of homicides of physicians. METHOD: Authors interrogated the National Violent Death Reporting System (NVDRS), the Centers for Disease Control and Prevention's surveillance system tracking violent deaths between 2003 and 2018 which integrates data from law enforcement and coroner/medical examiner reports. Authors identified cases of homicide decedents whose profession was physician, surgeon, or psychiatrist. Data collected included decedents' demographics as well as circumstances of death. RESULTS: Data were provided by 7-41 states as participating states increased over time. Fifty-six homicides were reported, most were male (73.2%) and white (76.8%). Most (67.9%) identified assailants reportedly knew decedents: 23.2% were perpetrated by partners/ex-partners; 10.7% by patients/patients' family members. Deaths were mainly due to gunshot wounds (44.6%), stabbing (16.1%), and blunt force trauma (16.1%). More (58.9%) homicides occurred at victims' homes than work (16.1%). CONCLUSIONS: Physician homicides are relatively rare and occur at lower rates than in the general population. Physicians were more frequently killed by partners or ex-partners than by patients. Most homicides occurred away from the workplace. Broader efforts are needed to promote interventions throughout America's violent society to reduce domestic/partner violence and gun violence.

Homicides of psychologists, physicians, nurses, pharmacists, social workers, and other health professionals: National Violent Death Reporting System data 2003-2020.

OBJECTIVE: Homicide is the extreme endpoint along the continuum of interpersonal violence. Violence in healthcare settings and directed toward healthcare workers has been a growing concern. Analysis of health professionals' homicides is needed to inform prevention interventions. METHODS: Decedent numbers, age, and sex in the National Violent Death Reporting System are reported for 10 types of health professionals: advance practice registered nurses, dentists, nurses, pharmacists, physicians, physician assistants, psychiatrists, psychologists, social workers, and veterinarians. RESULTS: Between 2003 and 2020, 944 homicides of these professionals were reported to the NVDRS. Nearly 80% of victims were women; 53% of homicides involved guns. Nurses, social workers, physicians, and pharmacists comprised the most victims. In 2020, nurses, social workers, pharmacists, and psychologists had the highest homicide rates relative to their workforce size. Few of these homicides were related to professionals' work. The number of homicides within these professions correlated highly with the size of professions' workforces. CONCLUSIONS: Health professionals' homicides constitute a small proportion of US homicides generally at lower rates than seen in the general population. Age is likely one of the protective factors. Future, more comprehensive data will provide greater insights into emerging trends to inform strategies to mitigate homicide risk in health professionals. Prevention needs to go beyond healthcare settings and address societal roots of violence.

Weight outcomes of NU-HOME: a randomized controlled trial to prevent obesity among rural children.

BACKGROUND: Rural children are at greater obesity risk than their urban peers. The NU-HOME study is an innovative collaborative effort to prevent childhood obesity in rural communities. Weight outcomes of the NU-HOME study, a family-meal focused randomized controlled trial (RCT) are described. We hypothesized that compared to control group children, intervention group children would have significantly lower weight-related post-intervention (PI) outcomes. METHODS: Participants were 114 dyads (7-10 year-old rural children and a parent). In 2017-2018 and 2018-2019, research staff measured height, weight and body fat at baseline (BL) and PI. Families were randomized to intervention (n = 58) or control (n = 56) groups without blinding. Designed with Social Cognitive Theory and community engagement, the NU-HOME program included seven monthly sessions delivered in community settings and four goal-setting calls. The program engaged entire families to improve healthy eating, physical activity, family meals and the home food environment. Multiple linear and logistic regression models tested PI outcomes of child BMIz-score, percent body fat, percent over 50th percentile BMI, and overweight/obesity status by treatment group, adjusted for BL values and demographics (n = 102). RESULTS: No statistically significant intervention effects were seen for child BMIz or overweight/obesity status. However, a promising reduction in boys' percent body fat (- 2.1, 95% CI [- 4.84, 0.63]) was associated with the intervention. CONCLUSIONS: Although our findings were in the hypothesized direction, making significant impacts on weight-related outcomes remains challenging in community trials. Comprehensive family-focused programming may require intensive multi-pronged interventions to mitigate complex factors associated with excess weight gain. CLINICAL TRIAL REGISTRATION: This study is registered with NIH ClinicalTrials.gov: NCT02973815 .

Recent Trends in Admission Diagnosis and Related Mortality in the Medically Critically Ill.

PURPOSE: With decades of declining ICU mortality, we hypothesized that the outcomes and distribution of diseases cared for in the ICU have changed and we aimed to further characterize them. STUDY DESIGN AND METHODS: A retrospective cohort analysis of 287,154 nonsurgical-critically ill adults, from 237 U.S. ICUs, using the manually abstracted Cerner APACHE Outcomes database from 2008 to 2016 was performed. Surgical patients, rare admission diagnoses (<100 occurrences), and low volume hospitals (<100 total admissions) were excluded. Diagnoses were distributed into mutually exclusive organ system/disease-based categories based on admission diagnosis. Multi-level mixed-effects negative binomial regression was used to assess temporal trends in admission, in-hospital mortality, and length of stay (LOS). RESULTS: The number of ICU admissions remained unchanged (IRR 0.99, 0.98-1.003) while certain organ system/disease groups increased (toxicology [25%], hematologic/oncologic [55%] while others decreased (gastrointestinal [31%], pulmonary [24%]). Overall risk-adjusted in-hospital mortality was unchanged (IRR 0.98, 0.96-1.0004). Risk-adjusted ICU LOS (Estimate -0.06 days/year, -0.07 to -0.04) decreased. Risk-adjusted mortality varied significantly by disease. CONCLUSION: Risk-adjusted ICU mortality rate did not change over the study period, but there was evidence of shifting disease burden across the critical care population. Our data provides useful information regarding future ICU personnel and resource needs.

Tofacitinib as a pragmatic treatment choice for alopecia areata: A retrospective review.

Alopecia areata (AA) is an immune-mediated hair loss disease for which targeted immune treatments including Janus kinase (JAK) inhibitors, for example, tofacitinib, are emerging. More literature is needed on the safety and efficacy of JAK inhibitors, and treatment has the potential to be cost prohibitive. This study was conducted to measure safety and efficacy outcomes of off-label use of tofacitinib in AA. A secondary outcome was analysis of payment methods. We reviewed 35 AA patients treated with tofacitinib in a specialty hair disease clinic between January 2013 and July 2019 for outcomes, adverse events, and feasibility of treatment. No serious adverse events were experienced. 83.9% of patients experienced clinically significant scalp regrowth, and 32.3% experienced near total/total regrowth. Though this study was confined to retrospective analysis, the results showed that tofacitinib was safe, effective, and practical for this cohort of 35 AA patients.

Depression, Quantified Medication Adherence, and Quality of Life in Renal Transplant Candidates and Recipients.

Like patients with many chronic illnesses, ESRD patients experience psychological challenges with greater incidence of depression and reduced quality of life (QoL). A series of 139 transplant candidates' depression and QoL, and a subset of 82 candidates' medication adherence were monitored, revealing heterogenous patterns of depression and adherence and reduced QoL. Twenty-eight patients who received kidney transplants were re-evaluated 6 months post-transplant revealing mixed patterns. Mean depression and quantitated adherence decreased and QoL increased. Some patients improved whereas others declined in depression and adherence. Pre-transplant depression was negatively correlated with post-transplant adherence but positively correlated with post-transplant depression. Nevertheless, the ability to predict individuals' post-transplant adherence and depression, principal objectives of pre-transplant psychological evaluations, is limited. Consequently, it is important to provide periodic screening of ESRD patients for depression and adherence pre- and post-transplant as they reflect changing states, rather than static traits, with variable patterns across patients.

Cutaneous findings in Fanconi anemia.

BACKGROUND: Fanconi anemia (FA) is a genetic disorder that results in bone marrow failure, physical abnormalities, and solid organ malignancies. The diagnosis of FA is often delayed because the early disease characteristics have not been well established. OBJECTIVE: To outline the spectrum of cutaneous findings seen in patients with FA. METHODS: A cross-sectional study in which patients with FA received a full-body skin examination. Patient characteristics are summarized with mean (SD) for continuous and count (%) for categorical variables. Poisson regression and logistic regression models were used to examine the relationships between pigmentary changes and patient characteristics. RESULTS: At least 1 cutaneous pigmentary alteration was present in 96.8% of patients, most arising before the teenage years. The most common finding was café-au-lait macules. Other findings included hypopigmented macules, skin-fold freckle-like macules, extensive sun-exposed freckling, and both hypopigmented and hyperpigmented pigment macules. LIMITATIONS: Patients received a single assessment, so the number of pigmentary changes could not be assessed over time. CONCLUSIONS: Characteristic morphology of FA includes faint and ill-defined café-au-lait macules, hypopigmented skin-fold freckle-like macules and the concurrence of hypopigmented and hyperpigmented macules. The recognition of these findings could aid clinicians in making earlier diagnoses.

Maternal and neonatal outcomes among incarcerated women who gave birth in custody.

BACKGROUND: In the United States, the population of incarcerated women has increased by more than 600% since the 1980s. With this rise, correctional facilities have faced new challenges meeting the health care needs of women, especially those who are pregnant. This retrospective cohort study sought to describe five indicators of maternal and neonatal health among women who gave birth in custody, and to compare outcomes among incarcerated women who did and did not receive enhanced pregnancy support. METHODS: We used deidentified electronic health records (EHRs) to examine maternal and neonatal birth outcomes (ie, mode of birth, low birthweight, preterm birth, APGAR score, NICU admission) among women who gave birth in custody. Regression models examined differences in outcomes between women who received enhanced pregnancy support-group prenatal education and one-on-one doula visits-and a historical control group of women who received standard prenatal care. RESULTS: Adverse maternal and neonatal birth outcomes in this sample were rare. No differences in outcomes were found between incarcerated women who received enhanced pregnancy support and the historical control group. CONCLUSIONS: Despite evidence for the benefits of enhanced pregnancy support in the general population, this study did not find differences in outcomes between incarcerated women who did and did not receive support. Integrated data from prison and hospital records are innovative, but effect measurement is limited by sample size. Future research should include primary data collection on maternal, neonatal, and dyadic outcomes longitudinally and across prisons.

Academic Psychiatry Department Names: Reflections on Research, Practice, and Education.

OBJECTIVE: Medical schools' departments reflect changes in health care and medical school organization. The authors reviewed psychiatry department name categories associated with school age, research, and primary care focus. METHODS: Department names were identified and categorized for US allopathic and osteopathic medical schools. A multinomial regression model analyzed the relationship between department name category and established year, adjusted for school type. Fisher's exact tests analyzed the relationships between name category and research/primary care foci. RESULTS: Among 147 allopathic schools, 52% had departments with names limited to psychiatry, 42% had names with psychiatry plus other terminology, and 5% had no identified psychiatry department. In 34 osteopathic schools, 12% had psychiatry departments, 12% had departments named psychiatry plus other terminology, and 75% had no identified psychiatry department. Age of school was related to departmental name: for a 1-year increase in the school's established year, the odds of having a department name other than psychiatry were 1.02 times the odds (p < 0.001) of having the name psychiatry. Newer schools were less likely to have departments with "psychiatry" in their name. Associations were found between department name and research and primary care rankings. CONCLUSIONS: Variability in the names of psychiatry departments in medical schools may suggest changing views within and about academic psychiatry. The limited presence of formal psychiatry departments in newer schools raises questions about psychiatry's impact on educational pathways, the future workforce, and participation in schools' research mission and clinical enterprise.

National Trends and Variation of Functional Status Deterioration in the Medically Critically Ill.

OBJECTIVES: Physical and psychologic deficits after an ICU admission are associated with lower quality of life, higher mortality, and resource utilization. This study aimed to examine the prevalence and secular changes of functional status deterioration during hospitalization among nonsurgical critical illness survivors over the past decade. DESIGN: We performed a retrospective longitudinal cohort analysis. SETTING: Analysis performed using the Cerner Acute Physiology and Chronic Health Evaluation outcomes database which included manually abstracted data from 236 U.S. hospitals from 2008 to 2016. PATIENTS: We included nonsurgical adult ICU patients who survived their hospitalization and had a functional status documented at ICU admission and hospital discharge. Physical functional status was categorized as fully independent, partially dependent, or fully dependent. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Functional status deterioration occurred in 38,116 patients (29.3%). During the past decade, functional status deterioration increased in each disease category, as well as overall (prevalence rate ratio, 1.15; 95% CI, 1.13-1.17; p < 0.001). Magnitude of functional status deterioration also increased over time (odds ratio, 1.03; 95% CI, 1.03-1.03; p < 0.001) with hematological, sepsis, neurologic, and pulmonary disease categories having the highest odds of severe functional status deterioration. CONCLUSIONS: Following nonsurgical critical illness, the prevalence of functional status deterioration and magnitude increased in a nationally representative cohort, despite efforts to reduce ICU dysfunction over the past decade. Identifying the prevalence of functional status deterioration and primary etiologies associated with functional status deterioration will elucidate vital areas for further research and targeted interventions. Reducing ICU debilitation for key disease processes may improve ICU survivor mortality, enhance quality of life, and decrease healthcare utilization.

Opioid exposure in haemophilia patients is common and underreported.

INTRODUCTION: In an era of increased opioid awareness, data on opioid exposure in haemophilia patients are lacking. AIM: The objectives of this study were to (a) provide a detailed description of opioid exposure in haemophilia patients based on written prescription data, (b) compare our findings to national haemophilia-specific and general population datasets and (c) identify predictors of opioid exposure in haemophilia patients. METHODS: Medical records of 183 adult and 135 paediatric patients from two haemophilia treatment centres (HTC) were reviewed over a 42-month period. Chronic exposure and acute opioid exposure were recorded, and results were compared to national haemophilia (ATHNdataset) and general population (CDC) data. RESULTS: We found that 56% of adult and 21% of paediatric patients were exposed to opioids, rates substantially higher than reported in the ATHNdataset (6%) and national population data from the CDC. In adults, but not children, severity of haemophilia was a significant predictor of opioid exposure. Most acute opioid prescriptions were not written by the HTC. CONCLUSIONS: This is the first study in the haemophilia population to examine opioid exposure based on prescription data. Opioid exposure was more common than predicted in both adult and paediatric study populations and was most often prescribed for acute pain or procedures by non-HTC providers. Haemophilia treatment centres need to take the lead in assessing pain in haemophilia patients, guiding treatment promoting non-opioid options, strengthen efforts to monitor opioid exposure and collect data on pain treatment in the haemophilia population.

Distinct Coping Profiles Are Associated With Mental Health Differences in Transgender and Gender Nonconforming Adults.

OBJECTIVE: This study assessed the unique coping strategies of transgender and gender nonconforming (TGNC) individuals in the United States used to manage gender-related stress, and examined associations between specific coping profiles and mental health. METHODS: Data were from 316 participants in the 2014-2015 Transgender Stress and Health Study, an online study of TGNC mental and sexual health. A factor analysis of the coping measure (Brief COPE) was followed by a k-means cluster analysis to evaluate distinct profiles of coping with gender-related stress. Proportional odds models and logistic regression models indicated how coping profiles related to levels of self-reported depressive symptoms and suicidality. RESULTS: A 4-factor structure was identified with three distinct profiles of coping with gender-related stress, each representative of the frequency (high or low) in which participants used functional and dysfunctional coping strategies: (a) high-functional/low-dysfunctional, (b) high-functional/high-dysfunctional, and (c) low-functional/low-dysfunctional. There were significant differences in depressive symptoms and suicidality based on distinct gender-related coping profiles. The high-functional/high-dysfunctional group reported significantly poorer mental health compared with the high-functional/low-dysfunctional group. CONCLUSION: To improve mental health outcomes in TGNC individuals, health providers and researchers should strive to not only promote functional coping strategies for managing gender-related stress but also decrease dysfunctional coping strategies.