Faculty Bibliography

OBJECTIVES: The emergency department (ED) has been recognized as a high-risk environment for workplace violence. Acutely agitated patients who perpetrate violence against healthcare workers represent a complex care challenge in the ED. Recommendations to improve safety are often based on expert opinion rather than empirical data. In this study we aim to describe the lived experience of staff members caring for this population in order to provide a broad perspective of ED patient violence. The findings of this study will contribute to the development of a comprehensive framework for ED agitated patient care that will guide safety interventions. METHODS: We conducted uniprofessional focus groups and individual interviews using a phenomenological approach with emergency medicine resident physicians, ED staff nurses, patient care technicians and hospital police officers at an urban hospital in New York City. Audio recordings were transcribed and coded for thematic analysis using the constant comparison method. RESULTS: We reached theoretical saturation with 31 interprofessional participants. Three broad themes emerged from our analysis: (1) ED healthcare workers provide high quality care to a marginalized patient population that concurrently poses safety threats, creating a patient care paradox; (2) teamwork is critical to safely managing this population, but hierarchy and professional silos hinder coordinated care between healthcare professionals; (3) environmental challenges and systems issues both in and outside the ED exacerbate threats to safety. CONCLUSION: The experience of ED staff members while caring for agitated patients is complex and multi-dimensional. We identified issues that coalesced into four tiers of healthcare delivery at the individual, team, environment and system levels. Future research is needed to determine applicability of our findings across institutions in order to build a comprehensive framework for ED agitated patient care

A deluge of whole-genome sequencing has begun to give insights into the patterns and processes of microbial evolution, but genome sequences have accrued in a haphazard manner, with biased sampling of natural variation that is driven largely by medical and epidemiological priorities. For instance, there is a strong bias for sequencing epidemic lineages of methicillin-resistant Staphylococcus aureus (MRSA) over sensitive isolates (methicillin-sensitive S. aureus: MSSA). As more diverse genomes are sequenced the emerging picture is of a highly subdivided species with a handful of relatively clonal groups (complexes) that, at any given moment, dominate in particular geographical regions. The establishment of hegemony of particular clones appears to be a dynamic process of successive waves of replacement of the previously dominant clone. Here we review the phylogenomic structure of a diverse range of S. aureus, including both MRSA and MSSA. We consider the utility of the concept of the 'core' genome and the impact of recombination and horizontal transfer. We argue that whole-genome surveillance of S. aureus populations could lead to better forecasting of antibiotic resistance and virulence of emerging clones, and a better understanding of the elusive biological factors that determine repeated strain replacement.

PURPOSE/OBJECTIVE:To characterize the in vivo effect of cyclopentolate on the microstructure of Schlemm canal (SC) in healthy eyes. METHODS:For healthy subjects, 81 serial horizontal enhanced depth imaging optical coherence tomography B-scans (interval between scans, ∼35 μm) of the nasal corneoscleral limbal area were obtained before and 1 hour after cyclopentolate 1% administration in 1 eye. The structures of aqueous and blood vessels in each scan were used as landmarks to select 50 overlapping scans between the 2 sets of 81 serial scans (before and after cyclopentolate administration). The SC cross-sectional area was measured in each of the 50 selected scans. After 3-dimensional reconstruction, SC volume was determined. RESULTS:Twelve eyes (12 healthy subjects) were imaged successfully before and after cyclopentolate administration. Mean age was 27.8±4.9 years (range, 25 to 38 y). Following cyclopentolate administration, mean intraocular pressure did not change significantly (13.9±1.5 to 14.2±1.5 mm Hg; P=0.19). Mean SC cross-sectional area decreased by 17%, from 3563±706 to 2959±460 μm (P<0.001). Mean SC volume in the overlapping area (approximately 1.7 mm of circumferential length of SC) decreased from 6,164,061±1,220,787 to 5,119,462±794,763 μm (P<0.001). The decrease in the mean SC cross-sectional area after cyclopentolate administration was greater in eyes with larger baseline SC cross-sectional area (P<0.001, R=0.873). CONCLUSIONS:Cyclopentolate causes a reduction in SC dimensions in healthy eyes. Future studies are warranted to determine the exact mechanism(s) of this change.

OBJECTIVE: To critically evaluate the efficacy of renin angiotensin system inhibitors (RASi) in patients with coronary artery disease without heart failure, compared with active controls or placebo. DESIGN: Meta-analysis of randomized trials. DATA SOURCES: PubMed, EMBASE, and CENTRAL databases until 1 May 2016. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomized trials of RASi versus placebo or active controls in patients with stable coronary artery disease without heart failure (defined as left ventricular ejection fraction >/=40% or without clinical heart failure). Each trial had to enroll at least 100 patients with coronary artery disease without heart failure, with at least one year's follow-up. Studies were excluded if they were redacted or compared use of angiotensin converting enzyme inhibitors with angiotensin receptor blockers. Outcomes were death, cardiovascular death, myocardial infarction, angina, stroke, heart failure, revascularization, incident diabetes, and drug withdrawal due to adverse effects. RESULTS: 24 trials with 198 275 patient years of follow-up were included. RASi reduced the risk of all cause mortality (rate ratio 0.84, 95% confidence interval 0.72 to 0.98), cardiovascular mortality (0.74, 0.59 to 0.94), myocardial infarction (0.82, 0.76 to 0.88), stroke (0.79, 0.70 to 0.89), angina, heart failure, and revascularization when compared with placebo but not when compared with active controls (all cause mortality, 1.05, 0.94 to 1.17; Pinteraction=0.006; cardiovascular mortality, 1.08, 0.93 to 1.25, Pinteraction<0.001; myocardial infarction, 0.99, 0.87 to 1.12, Pinteraction=0.01; stroke, 1.10, 0.93 to 1.31; Pinteraction=0.002). Bayesian meta-regression analysis showed that the effect of RASi when compared with placebo on all cause mortality and cardiovascular mortality was dependent on the control event rate, such that RASi was only beneficial in trials with high control event rates (>14.10 deaths and >7.65 cardiovascular deaths per 1000 patient years) but not in those with low control event rates. CONCLUSIONS: In patients with stable coronary artery disease without heart failure, RASi reduced cardiovascular events and death only when compared with placebo but not when compared with active controls. Even among placebo controlled trials in this study, the benefit of RASi was mainly seen in trials with higher control event rates but not in those with lower control event rates. Evidence does not support a preferred status of RASi over other active controls.

Big data, that is, data that are byproducts of our lives rather than designed for research purposes, are the newest of the information highway innovations. One of the important challenges to social and behavioral science data collection, curation, and dissemination for the foreseeable future is to link diverse forms of data in a way that is cumulative, representative, meaningful, and accessible to a broad range of researchers. It is critical to explore the new questions these data can address and to develop new methods to address them, including linking persons and information about them and their environments across different data platforms while maintaining confidentiality and privacy. Linking a broad array of information-from administrative data (local and state and regional), to social media (Twitter, Facebook), to census and other surveys, to ethnographic data, and data from experiments such as randomized controlled trials-to address how humans and their communities make decisions is challenging. This issue was addressed by papers presented at a conference on New Data Linkages convened by the Social Observatories Coordinating Network in 2016; those articles are brought together in this volume.