Faculty Bibliography

Air quality data from satellites and low-cost sensor systems, together with output from air quality models, have the potential to augment high-quality, regulatory-grade data in countries with in situ monitoring networks and provide much-needed air quality information in countries without them. Each of these technologies has strengths and limitations that need to be considered when integrating them to develop a robust and diverse global air quality monitoring network. To address these issues, the American Thoracic Society, the U.S. Environmental Protection Agency, the National Aeronautics and Space Administration, and the National Institute of Environmental Health Sciences convened a workshop in May 2017 to bring together global experts from across multiple disciplines and agencies to discuss current and near-term capabilities to monitor global air pollution. The participants focused on four topics: 1) current and near-term capabilities in air pollution monitoring, 2) data assimilation from multiple technology platforms, 3) critical issues for air pollution monitoring in regions without a regulatory-quality stationary monitoring network, and 4) risk communication and health messaging. Recommendations for research and improved use were identified during the workshop, including a recognition that the integration of data across monitoring technology groups is critical to maximizing the effectiveness (e.g., data accuracy, as well as spatial and temporal coverage) of these monitoring technologies. Taken together, these recommendations will advance the development of a global air quality monitoring network that takes advantage of emerging technologies to ensure the availability of free, accessible, and reliable air pollution data and forecasts to health professionals, as well as to all global citizens.

BACKGROUND:Injury care involves the complex interaction of patient, physician, and environment that impacts patient complications, level of harm, and failure to rescue (FTR). FTR represents the likelihood of a hospital to be unable to rescue patients from death after in-hospital complications. OBJECTIVE:This study aimed to hypothesize that error type and number of errors contribute to increased level of harm and FTR. METHODS:Patient information was abstracted from weekly trauma performance improvement (PI) records (from January 1, 2016, to July 19, 2017), where trauma surgeons determined the level of harm and identified the factors associated with complications. Level of harm was determined by definitions set forth by the Agency for Healthcare Research and Quality. Logistic regression was used to determine the impact of individual factors on FTR and level of harm, controlling for age, gender, Charlson score, injury severity score (ISS), error (in diagnosis, technique, or judgment), delay (in diagnosis or intervention), and need for surgery. RESULTS:A total of 2216 trauma patients presented during the study period. Of 2216 patients, 224 (224/2216, 10.10 %) had complications reported at PI meetings; of these, 31 patients (31/224, 13.8 %) had FTR. PI patients were more likely to be older (mean age 51.3 years, SE 1.58, vs 46.5 years, SE 0.51; P=.008) and have higher ISS (median 22 vs 8; P<.001), compared with patients without complications. Physician-attributable errors (odds ratio [OR] 2.82; P=.001), most commonly errors in technique, and nature of injury (OR 1.91; P=.01) were associated with higher levels of harm, whereas delays in diagnosis or intervention were not. Each additional factor involved increased level of harm (OR 2.09; P<.001) and nearly doubled likelihood of FTR (OR 1.95; P=.01). CONCLUSIONS:Physician-attributable errors in diagnosis, technique, or judgment are more strongly correlated with harm than delays in diagnosis and intervention. Increasing number of errors identified in patient care correlates with an increasing level of harm and FTR.

INTRODUCTION/BACKGROUND:Smoking disproportionately affects individuals with psychiatric diagnoses. Providers can play a role in reducing tobacco-related morbidity among people with a psychiatric diagnosis by routinely screening and treating all patients for tobacco use. This study seeks to identify rates of tobacco screening, counseling, and medication orders during outpatient visits with adults who have a psychiatric diagnosis. METHODS:Data from the 2012-2015 National Ambulatory Medical Care Survey were examined to calculate the proportion of visits with people who have a psychiatric diagnosis that included tobacco screening, counseling, or smoking-cessation medications. Logistic regression was used to identify patient and visit factors associated with tobacco screening and treatment. All analyses were conducted in 2018. RESULTS:Seventy-two percent of visits included tobacco screening, 23% of visits with tobacco users included cessation counseling, and 4% of visits with tobacco users included a cessation medication order. Visits were more likely to include tobacco screening if they were for a nonpsychiatric condition, were >30 minutes, or were with a primary care physician (p<0.05). Visits were less likely to include tobacco screening if they were with a black, non-Hispanic patient or patient with Medicaid (p<0.05). Visits were more likely to include cessation counseling if they were for a nonpsychiatric condition (p<0.05), and were less likely to include counseling if they were with a Hispanic or self-pay patient (p<0.05). CONCLUSIONS:There is still room for improvement in providing equitable treatment for people with psychiatric conditions for smoking, particularly in nonprimary settings.

BACKGROUND:The Comprehensive Care for Joint Replacement (CJR) model was implemented to address the 2 most commonly billed inpatient surgical procedures, total hip arthroplasty and total knee arthroplasty. The primary purpose of this study was to review the economic implications of 1 institution's mandatory involvement in the CJR in comparison with prior involvement in the Bundled Payments for Care Improvement (BPCI) initiative. METHODS:The mean cost per episode of care was calculated using our institution's historical data. The target prices, projected savings or losses per episode of care, and projected annual savings for both BPCI and CJR were established and were comparatively analyzed. RESULTS:The CJR target prices will decrease in comparison with BPCI target prices by 24.0% for Medicare Severity-Diagnosis Related Group (MS-DRG) 469 without fracture, 22.8% for MS-DRG 469 with fracture, 26.1% for MS-DRG 470 without fracture, and 27.7% for MS-DRG 470 with fracture, resulting in a reduction in savings per episode of care by 92.8% for MS-DRG 469 without fracture, 166.0% for MS-DRG 469 with fracture, 94.9% for MS-DRG 470 without fracture, and 61.7% for MS-DRG 470 with fracture. Our institution's projected annual savings under CJR will decrease by 83.3%. CONCLUSIONS:These results suggest that the margin for savings in the CJR will be substantially reduced compared with the margin for savings in the BPCI. In hospitals that had previously devoted resources, these will have far less impact in the CJR, and hospitals new to the CJR that have not made these investments previously will require even greater resources for developing cost reduction and quality control strategies to remain financially solvent. LEVEL OF EVIDENCE/METHODS:Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE:To systematically review the literature on genomic tests for prostate cancer (PCa) and evaluate the current state of the evidence on their use in patients with newly diagnosed PCa. METHODS:We conducted a systematic review by searching PubMed, Embase, Cochrane Central, and conference abstracts from the American Urological Association published between 2010 and 2018. Studies evaluating Prolaris, Oncotype Dx, and Decipher assays were assessed for inclusion by two authors. Studies were excluded if the results were derived from surgical specimens rather than biopsy specimens. Meta-analysis was not performed owing to significant variations in methodologies, definitions and outcome measures. RESULTS:A total of 729 articles were retrieved in our initial search. After removing duplicates (270) and excluding articles deemed not relevant (432), 21 full-text articles were deemed suitable for inclusion in our analysis. The full-text articles comprised 8 studies on Prolaris, 8 studies on Oncotype Dx, and 5 studies on Decipher. For each genomic test we extracted data regarding the risk of adverse pathology, biochemical recurrence, metastasis, and prostate cancer mortality. CONCLUSION/CONCLUSIONS:The results of genomic tests that use biomarkers derived from prostate biopsy can be used in conjunction with clinicopathologic variables to improve our ability to risk stratify patients with newly diagnosed prostate cancer. Additional data are needed on the impact of using these tests on long-term patient outcomes and their cost-effectiveness. This article is protected by copyright. All rights reserved.

PURPOSE/OBJECTIVE:North American studies have reported that ∼3-7% of opioid-naïve surgical patients transition to chronic opioid use after a single prescription. We examined the risk of chronic opioid use following radical prostatectomy (RP) using nationwide Swedish data. MATERIALS AND METHODS/METHODS:For 25,703 men in National Prostate Cancer Register of Sweden who underwent RP, linkage was performed to the Prescribed Drug Register. Opioid use was assessed in three time periods: baseline (13-1 month preoperatively), perioperative (1 month before and after), and postoperative (1-12 months). Multivariable logistic regression was used to identify predictors of new late use (≥1 opioid prescription in three consecutive months >2 months after surgery). RESULTS:Overall, 16,368 (64%) men filled an opioid prescription during the 13 months before or after surgery. Use of strong opioids increased over time and use of weak opioids decreased. 1.9% of men had opioid prescriptions during the baseline period, followed by a spike around surgery (59%), which sharply decreased in the second postoperative month. However, thereafter the proportion of men with opioid prescriptions remained slightly higher (2.2%) compared to the pre-RP baseline. Among chronic late users, 57% were previous users and 43% were new chronic users. Higher cancer risk category, greater comorbidity, unmarried status, and low educational level were associated with risk of new chronic opioid use. CONCLUSIONS:Slightly more than half of Swedish filled an opioid prescription after RP, and <1% became chronic opioid users. These rates are lower than previous studies of postoperative opioid use from North America.

Global plastics production has reached 380 million metric tons in 2015, with around 40% used for packaging. Plastic packaging is diverse and made of multiple polymers and numerous additives, along with other components, such as adhesives or coatings. Further, packaging can contain residues from substances used during manufacturing, such as solvents, along with non-intentionally added substances (NIAS), such as impurities, oligomers, or degradation products. To characterize risks from chemicals potentially released during manufacturing, use, disposal, and/or recycling of packaging, comprehensive information on all chemicals involved is needed. Here, we present a database of Chemicals associated with Plastic Packaging (CPPdb), which includes chemicals used during manufacturing and/or present in final packaging articles. The CPPdb lists 906 chemicals likely associated with plastic packaging and 3377 substances that are possibly associated. Of the 906 chemicals likely associated with plastic packaging, 63 rank highest for human health hazards and 68 for environmental hazards according to the harmonized hazard classifications assigned by the European Chemicals Agency within the Classification, Labeling and Packaging (CLP) regulation implementing the United Nations' Globally Harmonized System (GHS). Further, 7 of the 906 substances are classified in the European Union as persistent, bioaccumulative, and toxic (PBT), or very persistent, very bioaccumulative (vPvB), and 15 as endocrine disrupting chemicals (EDC). Thirty-four of the 906 chemicals are also recognized as EDC or potential EDC in the recent EDC report by the United Nations Environment Programme. The identified hazardous chemicals are used in plastics as monomers, intermediates, solvents, surfactants, plasticizers, stabilizers, biocides, flame retardants, accelerators, and colorants, among other functions. Our work was challenged by a lack of transparency and incompleteness of publicly available information on both the use and toxicity of numerous substances. The most hazardous chemicals identified here should be assessed in detail as potential candidates for substitution.

BACKGROUND:The specific research aims of this study included: 1) Conduct an epidemiologic analysis of recreational sports injuries among 1500 children, ages 5-11 in Florida: and 2) Utilize the computerized pediatric concussion tool from ImPACT Applications, Inc. for baseline and follow-up testing to better understand these injuries. This research followed a prospective surveillance design utilizing a large cohort of children, ages, 5-11, who play recreational football, soccer, and baseball/softball in Florida. The study venue was a large athletic facility in Hillsborough County, Florida. The sports observed were soccer (girls' and boys'), baseball, softball, and football. Internal and external advisory boards were consulted throughout the study. METHODS:Certified Athletic Trainers (ATCs) were hired to use High School Reporting Information Online (RIO) for injuries and the Ipad-administered pediatric concussion tool developed by ImPACT Applications, Inc for baseline/follow-up concussion data. RESULTS:Over the course of the project, 26 RIO-reported injuries were reported. Football and soccer produced the greatest rate of injuries. There were 12 concussions which comprised nearly half of all the RIO injuries (46%). We conducted 882 baseline concussion tests and 13 follow-up tests over the 2 years. CONCLUSIONS:To the best of our knowledge, this is the first time data have been collected and reported on sports injuries in the study population. Future studies built on these findings will allow for the development of targeted guidelines and interventions for coaches, players, and parents so sports injury-related morbidity and mortality decrease in our youngest athletes.

BACKGROUND:Land use regression (LUR) models have been widely used to estimate air pollution exposures at high spatial resolution. However, few LUR models were developed for rapidly developing urban cores, which have substantially higher densities of population and built-up areas than the surrounding areas within a city's administrative boundary. Further, few studies incorporated vertical variations of air pollution in exposure assessment, which might be important to estimate exposures for people living in high-rise buildings. OBJECTIVE:A LUR model was developed for the urban core of Lanzhou, China, along with a model of vertical concentration gradients in high-rise buildings. METHODS:at ground level were regressed against spatial predictors, including elevation, population, road network, land cover, and land use. The vertical variations were investigated and linked to ground-level predictions with exponential models. RESULTS:differed by windows orientation with respect to traffic, by season or by time of a day. Vertical variation functions incorporated the ground-level LUR predictions, in a form that could allow for exposure assessment in future epidemiological investigations. CONCLUSIONS:showed substantial spatial variations, explained by traffic and land use patterns. Further, vertical variation of air pollution levels is significant under certain conditions, suggesting that exposure misclassification could occur with traditional LUR that ignores vertical variation. More studies are needed to fully characterize three-dimensional concentration patterns to accurately estimate air pollution exposures for residents in high-rise buildings, but our LUR models reinforce that concentration heterogeneity is not captured by the limited government monitors in the Lanzhou urban area.