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Medical Care for Patients With Mental Health and/or Substance-Use Disorders: A Qualitative Investigation of Emergency Department Patient Experiences and Recommendations
No full textObjectives: (1) To investigate the healthcare experiences of individuals with mental health and/or substance use disorders (SUDs) who seek medical care in the emergency department (ED) for physical health concerns (e.g., abdominal pain), and (2) to explore recommendations for improving these patients' care experiences. Although this population suffers from a high disease burden and disproportionately seeks care in the ED, surprisingly little research has examined their experiences.
Study setting and design: Qualitative study employing grounded theory and semi-structured interviews with patients with mental health and/or SUD(s) (identified via health records) seeking care for a physical health concern during an ED visit to an academic medical center in the Northeastern USA. Longer follow-up interviews were conducted via telephone. Interviews occurred between February 2018 and January 2019.
Data sources and analytical sample: We transcribed and coded digital recordings of interviews with 50 patients at two time periods. We used constant comparative analysis throughout interviewing, coding, and analysis.
Principal findings: Most participants were White (80%), non-Hispanic (84%), and female (72%). Three key themes emerged, revealing a broad range of negative and positive patient care experiences that are influenced by provider, treatment, and healthcare system factors. Findings demonstrate that stigma and perceived biases due to mental health and/or SUDs extend to medical care experiences not directly related to these conditions (e.g., dismissive, rushed, unprofessional care, medical errors). Participants also identified positive care experiences (e.g., attentive, communicative, efficient, quality care), which informed recommendations for improving care.
Conclusions: Understanding care experiences of vulnerable patient populations is critically important for informing interventions to improve their healthcare quality and safety. Findings underscore the need for additional education and training for providers, integrated behavioral healthcare, and widespread changes to the healthcare system. Localized interventions that target stigma and mismatches between patients' care expectations and ED capabilities are also needed.No embarg
Racial disparities and trends in anticoagulant use among ambulatory care patients with atrial fibrillation and atrial flutter in the United States from 2007 to 2019
Full text linkIntroduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly increasing the risk of stroke. The introduction of direct oral anticoagulants (DOACs) since 2010 has transformed anticoagulation therapy, offering an alternative to warfarin with improved safety profiles. Despite the increased adoption of DOACs, disparities in their use among different racial and ethnic groups in the United States remain understudied.
Methods: This study utilized a repeated cross-sectional design, analyzing data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2019. The study population included adults diagnosed with AF or atrial flutter (AFL). We analyzed the temporal trends of DOAC and warfarin use from 2007 to 2019. We examined the prevalence of DOAC versus warfarin use and assessed associations between race/ethnicity, patient characteristics, and DOAC utilization from 2011 to 2019. Multivariable modified Poisson regression models were used to calculate adjusted prevalence ratios (aPR) for the associations.
Results: From 2011 to 2019, NAMCS recorded 3,224 visits involving AF or AFL, representing a weighted estimate of 103.6 million visits. DOAC use increased significantly, with apixaban becoming the predominant anticoagulant by 2016. The rate of DOAC adoption was slower for non-Hispanic Black compared to non-Hispanic White patients over time (aPR 0.75; 95% CI, 0.63-0.90). Patients with Medicaid insurance were also less likely to use DOACs (aPR 0.14; 95% CI: 0.04-0.46).
Conclusion: Despite the shift from warfarin to DOACs for AF and AFL treatment, significant racial and socioeconomic disparities persist. Non-Hispanic Black patients adopted to DOAC use more slowly than non-Hispanic White patients, widening the treatment gap over time. Those with Medicaid insurance are less likely to use DOACs compared to those with private insurance. These findings highlight the need for targeted strategies to ensure equitable access to advanced anticoagulant therapies.No embarg
Intracerebroventricular SPAST-AAV9 gene therapy prevents the manifestation of symptoms in a mouse model of SPG4 Hereditary Spastic Paraplegia
No full textHereditary Spastic Paraplegia type 4 is characterized by gait impairments, progressive spasticity and weakness of the lower limbs, resulting from degeneration of the corticospinal tracts. The disease is caused by mutations of the SPAST gene, which encodes a major isoform of spastin called M87 and a minor isoform called M1. Owing to its N-terminal hydrophobic domain not shared by M87, M1 is the isoform that becomes toxic when mutated. Loss-of-function of either M1 or M87 or both may also play a role in the disease, sensitizing corticospinal motor neurons to the toxicity of mutant M1. Here we pursued silence-and-replace gene therapy, which addresses both gain-of-toxicity and loss-of-function components of the disease. We generated an adeno-associated serotype 9 viral vector containing micro-RNA to stop the expression from the endogenous SPAST gene and cDNA to express healthy human M1 and M87. The vector was introduced by intracerebroventricular injections into newborn pups of SPAST-C448Y, a mouse model of the disease that expresses human mutant spastin and displays adult-onset corticospinal degeneration and gait defects. The treatment successfully replaced both isoforms of endogenous spastin with healthy spastin, at physiological levels, and prevented the onset and progression of corticospinal degeneration and gait defects.No embarg
Aub, Vasa and Armi concentration in phase separated nuage is dispensable for piRNA biogenesis and transposon silencing
Full text linkThe piRNA biogenesis machinery localizes to phase separated nuage granules, but nuage function is not well understood. We therefore assayed nuage composition, piRNA expression and transposon silencing in Drosophila mutants that disrupt piRNA precursor production and nuclear export, ping-pong amplification and phased piRNA biogenesis. These mutations destabilize the genome and activate Chk2 signaling and chk2/mnk double mutants were therefore analyzed in parallel. Aub and Vasa are required for ping-pong amplification and Armi promotes phased piRNA processing. We show that Chk2 activation releases Aub and Vasa from nuage and that piRNA precursors are required for nuage localization of the ping-pong and phased biogenesis machinery. However, this analysis also indicates that Vasa, Aub, and Armi concentration in nuage is dispensable for piRNA production and transposon silencing, indicating that dispersed cytoplasmic proteins can drive these processes. We speculate that nuage sequesters silencing effectors, which are released by Chk2 in response to transposon mobilization.1 year2026/12/1
Long-term cost-effectiveness of a mobile health intervention delivered by clinical pharmacists and community health workers for type 2 diabetes management in urban African American and Latinx populations
Full text linkPurpose: Type 2 diabetes imposes a significant economic burden on healthcare systems. Interdisciplinary healthcare teams can offer patient-centered care by integrating medical, behavioral, and social support services. This approach has the potential to lower complication rates while reducing healthcare expenditures. This study evaluated the cost-effectiveness of an evidence-based clinical pharmacist and community health worker team-based mobile health intervention for diabetes adherence support (mDAS), compared to usual care, among urban African American and Latinx individuals with elevated glycated hemoglobin (HbA1c).
Methods: Direct medical costs from a health system perspective and quality-adjusted life-years (QALYs) were compared between the intervention and usual care groups, using a Markov state transition model to simulate the occurrence of cardiovascular and renal complications. Model inputs were derived from published literature and electronic health records. Comprehensive sensitivity and scenario analyses were conducted to assess the robustness of model findings.
Results: Compared to usual care, the mDAS intervention resulted in higher QALYs and lower costs over 5-year, 10-year, and lifetime horizons. Incremental QALYs and cost savings were 0.01, 0.03, and 0.17 and 2,393, and $6,829, respectively. Benefits were more pronounced with longer time horizons. Sensitivity analyses indicated that while the magnitude of cost savings diminished as the risk of complications decreased, the intervention consistently resulted in lower costs and higher QALYs.
Conclusion: The mDAS intervention resulted in cost savings and long-term health benefits, indicating its potential value for policymakers, healthcare systems, and insurers.1 year2026-11-2
Dynamic Appraisal of Situational Aggression Score at Emergency Department Triage Is Associated With Behavioral Intervention: A Cross-Sectional Study
No full textObjective: Incidents of aggression and hostility towards staff in emergency departments (EDs) have escalated in frequency and severity, posing a serious threat to the well-being of patients and healthcare providers. Research on predictive tools for identifying individuals at risk of violent behavior in the ED remains scarce. The objective of this study was to assess the association between the Dynamic Appraisal of Situational Aggression (DASA) score assigned at triage and physical restraint or medications administered for safety during an ED encounter.
Methods: From January 11, 2023 to December 31, 2023, patients ≥ age 18 were assigned a DASA score during triage at five EDs. Subjects' triage DASA scores, demographic characteristics, and clinical outcomes were abstracted from the electronic health record. Subjects were risk-stratified into validated DASA risk categories for aggression (low, moderate, high, or imminent). Outcomes were measured by documented physical restraint or the administration of injected antipsychotic medication with or without a benzodiazepine. Modified Poisson regressions were used to calculate the crude and adjusted prevalence ratios (PRs) of any intervention (physical restraints and medication administration) by DASA score.
Results: 159,154 qualifying ED encounters were identified (mean age 51.5, 53.5% female). Increasing DASA score was associated with increasing PR of any behavioral intervention: physical restraint and/or safety medication administration. An imminent-risk DASA score was associated with an adjusted PR of 4.71 (CI 3.65-6.06, p < 0.001) for any intervention, 3.63 (CI 3.25-4.05, p < 0.001) for physical restraint, and 5.26 for any medication administration (CI 4.08-6.78, p < 0.001) compared to patients with a DASA score of 0.
Conclusions: Elevated DASA scores at ED triage were associated with an increased risk of patient restraint and safety medication administration during the ED encounter. Future research should assess how proactive interventions based on DASA scores influence violence risk and investigate the predictive value of consecutive DASA evaluations throughout ED encounters.No embarg
Food security and barriers to healthy diet in pregnancies with or at risk for hypertensive disorders
No full textFood insecurity is a major public health issue in the United States. The aim of this study was to examine maternal food insecurity and barriers to healthy diet in pregnant individuals with or at risk for hypertensive disorders of pregnancy (HDP). Among 53 pregnant individuals, 32.1% reported experiencing food insecurity. Food insecure individuals were significantly more likely to report barriers involving skills to plan/cook healthy foods, transportation, and home appliances/space. As healthy eating is one of the safest treatments for hypertension in pregnancy, it is essential to identify and address food insecurity in this population.No embarg
Treatment of a severe vascular disease using a bespoke CRISPR-Cas9 base editor in mice
No full textPathogenic missense mutations in the alpha actin isotype 2 (ACTA2) gene cause multisystemic smooth muscle dysfunction syndrome (MSMDS), a genetic vasculopathy that is associated with stroke, aortic dissection and death in childhood. Here we perform mutation-specific protein engineering to develop a bespoke CRISPR-Cas9 enzyme with enhanced on-target activity against the most common MSMDS-causative mutation ACTA2 R179H. To directly correct the R179H mutation, we screened dozens of configurations of base editors to develop a highly precise corrective A-to-G edit with minimal deleterious bystander editing that is otherwise prevalent when using wild-type SpCas9 base editors. We create a murine model of MSMDS that shows phenotypes consistent with human patients, including vasculopathy and premature death, to explore the in vivo therapeutic potential of this strategy. Delivery of the customized base editor via an engineered smooth muscle-tropic adeno-associated virus (AAV-PR) vector substantially prolongs survival and rescues systemic phenotypes across the lifespan of MSMDS mice, including in the vasculature, aorta and brain. Our results highlight how bespoke mutant-specific CRISPR-Cas9 enzymes can improve mutation correction with base editors.No embarg
Clinician Risk Tolerance and Rates of Admission From the Emergency Department for Medicare Patients
No full textStudy objective: To characterize the association between emergency department (ED) clinician risk tolerance and the decision to admit, a common and high-cost decision.
Methods: In this observational cohort study, data on 100% of traditional Medicare beneficiaries for all ED visits in Massachusetts from October 2015 through September 2020 were linked to surveys of clinician risk tolerance. We estimated a generalized mixed-effect linear regression model to assess the association between the risk scales, divided into tertiles, and the decision to admit. The main outcome measure was ED disposition, defined as admitted or discharged to home. Risk tolerance was measured using 4 related scales: the Risk-Taking Scale, the Stress from Uncertainty Scale, the Fear of Malpractice Scale, and the Need for (Cognitive) Closure Scale.
Results: The total study sample included 421,301 ED visits seen by 889 emergency clinicians. Patients were predominantly women (57.4%), and the average age was 72.6 years. Mean clinician age was 46.5 years. In total, 77.1% were physicians, 59.3% were men, and 86.6% were White. We found a consistent relationship between lower risk tolerance and higher admission rates. This magnitude of the relationship was stronger for conditions with a higher rate of admissions.
Conclusion: The risk scales were significantly associated with the tendency to admit. This suggests that clinician risk tolerance meaningfully contributes to variation in clinician behavior and points to the potential utility for interventions that interface with clinician behavior to affect admission rates.No embarg
Perceived Barriers and Facilitators to Healthy Eating in Pregnant People With or at Risk for Hypertensive Disorders of Pregnancy
No full textOBJECTIVE: To explore pregnancy-specific barriers and facilitators impacting healthy eating among patients with or at risk for hypertensive disorders of pregnancy (HDP).
METHODS: Pregnant people with or at risk for HDP were recruited from a large academic medical center for an electronic survey with open-ended questions. Qualitative data were analyzed using thematic analysis.
RESULTS: Among 50 participants (mean age 31.0 ± 5.4 years, 30% Hispanic), 66% reported barriers to healthy eating. Major themes included lack of access because of determinants of health, intrinsic factors (e.g., choices, motivation), time, uncertainty about what constitutes "healthy," and preexisting medical conditions (pregnancy-related/unrelated). Most participants (67.4%) identified facilitators, including menu/grocery guidance, external support (e.g., from experts or family), discipline/routine, and improving access.
CONCLUSIONS AND IMPLICATIONS: Considering that access, education, and food preferences may hinder healthy eating, pregnant individuals with or at risk for HDP may benefit from food insecurity screening/interventions and tailored, income-specific nutritional guidance.No embarg