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New Rochelle, NY, September 16, 2020—Intracranial abnormalities on CT scan in patients with traumatic brain injury (TBI) can be predicted by glial fibrillary acidic protein (GFAP) levels in the blood. These interim findings from the TRACK-TBI study are published in the peer-reviewed Journal of Neurotrauma. Click here to read the article now.

GFAP’s diagnostic performance was significantly better than that of the S100B biomarker, to which it was compared. S100B is approved for use in Europe, but not in the U.S.

“GFAP substantially outperformed S100B as a TBI diagnostic biomarker of positive head CT scans,” state David Okonkwo, MD, PhD, University of Pittsburgh Medical Center, Amy Markowitz, JD, University of California, San Francisco, and coauthors.

“Our results validate a point-of-care platform prototype GFAP assay that delivers results in minutes (<15 min) versus hours for the current FDA-cleared assay,” state the authors.

“This is a particularly important study with major implications for the diagnosis and prognoses of traumatic brain injury. The large sample size and the rigorous inclusion criteria increase the impact of the reported study, which strongly reaffirms the utility of GFAP as a diagnostic marker for CT-detected lesions. It also demonstrates the utility of a point-of-care approach. As noted by the authors, the reported studies demonstrate GFAP’s utility across the spectrum of TBI, evaluated over a relatively prolonged posttraumatic time course,” says John Povlishock, PhD, Editor-in-Chief of Journal of Neurotrauma.

About the Journal
Journal of Neurotrauma is an authoritative peer-reviewed journal published 24 times per year in print and online that focuses on the latest advances in the clinical and laboratory investigation of traumatic brain and spinal cord injury. Emphasis is on the basic pathobiology of injury to the nervous system, and the papers and reviews evaluate preclinical and clinical trials targeted at improving the early management and long-term care and recovery of patients with traumatic brain injury. Journal of Neurotrauma is the official journal of the National Neurotrauma Society and the International Neurotrauma Society. Complete tables of content and a sample issue may be viewed on the Journal of Neurotrauma website.

About the Publisher
Mary Ann Liebert, Inc., publishers is known for establishing authoritative peer-reviewed journals in promising areas of science and biomedical research. A complete list of the firm’s 90 journals, books, and newsmagazines is available on the Mary Ann Liebert, Inc., publishers website.

Journal

Journal of Neurotrauma

DOI

10.1089/neu.2020.7140

DALLAS, Sept. 16, 2020 -- Heart transplant patients who received hearts from severely obese donors had similar short-term outcomes and long-term survival as patients who received hearts from non-obese donors, according to new research published today in Circulation: Heart Failure, an American Heart Association journal.

The waiting list for a heart transplant in the U.S. is continuously about 3,000 people, and only half of those people receive a donor heart within a year. There is an urgent need to expand the pool of potential heart donors; however, transplant centers are hesitant to accept hearts from obese donors. In the U.S., almost 40% of the adult population is classified as obese, and nearly 8% have severe obesity, which is defined as a body mass index (BMI) greater than or equal to 40.

"As the prevalence of obesity in the U.S. continues to rise, it directly affects the pool of organ donors," said Leora T. Yarboro, M.D., lead study author and associate professor of surgery at the University of Virginia in Charlottesville, Virginia. "Since the prevalence of severe obesity has increased significantly over the past 15 years, we wanted to investigate the outcomes of recipients of transplant hearts from donors with severe obesity."

The study used the national United Network for Organ Sharing (UNOS) database to analyze the outcomes of 26,000 heart transplants from 2003-2017. Approximately 900, or 3.5%, of the donors had severe obesity. Severely obese donors, a BMI ?40, were more likely to be older and female. In addition:

10% of severely obese donors had diabetes vs. 3% of non-obese donors;

33% of obese donors had hypertension vs. 15% of donors with BMI 67% of heart transplants from severely obese donors were size mismatched (the donor's weight was >130% of the recipient's weight), compared to only 10% of transplants from donors without severe obesity; and

transplants from donors with severe obesity increased over time (from 2.2% in 2013 to 5.3% in 2017).

The analysis demonstrated no significant differences in post-transplant outcomes for patients who received a heart from a severely obese donor. Short-term outcomes, including postoperative stroke, acute rejection of the donor heart, pacemaker need and dialysis requirement, were similar for recipients of hearts from obese and non-obese donors. There was also no difference in one-year survival rates and long-term mortality for patients with transplants from severely obese donors.

"These findings were somewhat surprising because the severely obese donors did tend to have more medical problems, such as diabetes and high blood pressure, than the non-obese donors," Yarboro said. "This study shows that with careful selection, hearts from obese donors can be used without an increased risk to the recipient. Given the continued increase in obesity in the U.S., this research has the potential to expand the critically low donor pool by increasing the number of donors and improving outcomes for the growing list of patients with end-stage heart failure."

DALLAS, Sept. 16, 2020 -- Better heart health, as measured by the American Heart Association's Life's Simple 7 (LS7) scale, was associated with a significantly lower risk of developing high blood pressure (also known as hypertension) in middle-aged, Black and white adults, according to new research published today in the Journal of the American Heart Association, an open access journal of the American Heart Association.

"High blood pressure is among the most common conditions in the U.S., and it contributes to the greatest burden of disability and largest reduction in healthy life expectancy among any disease," said Timothy B. Plante, M.D., M.H.S., lead study author and assistant professor in the department of medicine at the Larner College of Medicine at the University of Vermont in Burlington. "Even though high blood pressure causes so much death and disability, we don't know the root cause of it."

The study included 2,930 Black and white adults, ages 45 and older, from the REasons for Geographic and Racial Disparities in Stroke (REGARDS) study, who were selected using mail and telephone outreach from 2003-2007 and a second visit completed in 2013-2016. Participants with high blood pressure, defined as ?130/80 mm Hg, were excluded, leaving only those who were free from hypertension at the start of the study. Researchers examined the association of high and low LS7 scores with the risk of developing high blood pressure within 10 years.

The LS7 is a measure of a person's overall cardiovascular health. The tool incorporates seven known lifestyle behaviors and health risk factors -- body mass index; diet; smoking; physical activity; and blood pressure, cholesterol and blood sugar levels -- into a single metric to estimate cardiovascular risk. The highest possible LS7 score is 14, and there are three rankings for cardiovascular health: 10 to 14 is ideal; 5 to 9 is average; and 0 to 4 is poor.

Researchers found:

Among 2,930 participants without high blood pressure (20% Black adults, 80% white adults), the median LS7 total score was in the "average category" (9 points).

Over about a 9-year follow-up, 42% of participants developed high blood pressure. The incidence in Black adults was 52% in women and 50% in men; and among white adults, 37% of women and 42% of men developed high blood pressure.
Each one-point higher LS7 score correlated with a 6% lower risk of high blood pressure. (This result was a graded response that occurred continuously across the entire LS7 spectrum - from poor to ideal LS7 scores.) No significant difference was seen by race or sex.

The same results were produced in two separate analyses: one using the 2017 ACC/AHA updated guideline for high blood pressure of ?130/80 mm Hg, and the other using the previous high blood pressure criteria of ?140/90 mm Hg.

"Among middle-aged people without hypertension, there is still a huge benefit to seeking optimal cardiovascular health," Plante said. "These findings support the current clinical practice recommendations of lifestyle modifications such as eating better, quitting smoking and maintaining a healthy weight to all people, including those without high blood pressure."

The finding is especially important for Black Americans, who have the highest rate of high blood pressure among any group in the world and develop the condition at a younger age and with more severity.

"Focusing on a patient-centered approach can potentially optimize cardiovascular health among Black and white patients alike," Plante said. "We recommend tailoring step-wise health improvement and lifestyle changes for patients. For example, patients might not be receptive to quitting smoking today; however, if they are receptive to getting more exercise today, that would be a one-point LS7 score improvement."

The study is limited in that it only points to an association between LS7 scores and risk of developing high blood pressure. The next step is to conduct a randomized trial to confirm improving LS7 scores can help reduce the risk of high blood pressure.

"It's encouraging to see that the benefits of greater cardiovascular health, as measured by Life's Simple 7, extend to lower rates of hypertension in adults. This suggests that optimizing the behavioral risk factors central to Life's Simple 7 could be an important way for patients to manage their risk factors," said Donald Lloyd-Jones, M.D., Sc.M., FAHA, chair of the department of preventive medicine at Northwestern University, AHA President-elect and part of the group that developed the Life's Simple 7 scale and criteria. "If we can reach more people in younger and middle age with this type of lifestyle assessment, we could be looking at strong improvements in health overall."

Hennigsdorf/ Berlin, Germany, September 16, 2020 - 4TEEN4 Pharmaceuticals GmbH ("4TEEN4") announces data on the efficacy of its lead product, Procizumab, that promptly restored cardiac dysfunction in a preclinical sepsis model by inhibiting the cardiac depressant factor DPP3. The current findings indicate that DPP3 plays an important role in septic cardiomyopathy. Sepsis is a dysregulated host response to an infection that ultimately leads to organ dysfunction.

The study data (1) from the team lead by Prof. Alexandre Mebazaa have shown that high DPP3 blood values are associated with decreased heart function in a preclinical sepsis model. In this randomized, controlled study, the administration of Procizumab immediately and significantly improved heart function by increasing cardiac output, stroke volume, and left ventricular shortening fraction. Inactivation of the cardiac depressant factor DPP3 fully restored cardiac contraction and improved survival.

DPP3 is at the core of a recently discovered disease mechanism, which was previously demonstrated to be a leading cause of circulatory failure (2,3,4). The release of the cardiac depressant factor DPP3 into the bloodstream causes the inactivation of the heart-stimulating hormone, Angiotensin II, a process leading to cardiac depression, hemodynamic instability and shock.

"These findings demonstrate for the first time that DPP3 plays a role in sepsis. By inhibiting DPP3 with our antibody Procizumab, we are able to restore cardiac function in preclinical sepsis models. This paves the way for future investigations on the utility of Procizumab as a possible therapeutic option in patients with sepsis and septic shock" said Dr. Andreas Bergmann, CEO of 4TEEN4.

The antibody Procizumab offers a new approach for the treatment of life-threatening diseases related to acute circulatory failure. Preclinical safety and toxicity studies of the antibody as well as the initiation of the first-in-man studies are planned for 2021.

The SARS-CoV-2 pandemic has put the use of personal protective equipment (PPE), including face masks, under the global spotlight. However a paper published in Anaesthesia (a journal of the Association of Anaesthetists) reveals that masks do not always fit correctly and hospitals can lack the time and financial resources to ensure every healthcare worker has a mask that fits correctly.

"Satisfactory airborne protection will only be provided if the filtering facepiece respirators are properly fitted to the individual's face, providing a tight facial seal," explains senior co-author Prof Britta von Ungern-Sternberg, from the Perth Children's Hospital/ The University of Western Australia, Perth, Australia. "Airborne protection is decreased in the presence of a leak as unfiltered air will be drawn inside the mask."

Their review found that initial fit-pass rates for females compared with males were 85% and 95%, respectively. Higher initial fit-pass rates were found in Caucasians (90%) compared with Asians (84%). Particularly low initial fit-pass rates were reported in Asian females, with a reported mean of 60%.

The authors explain that correct respirator fit appears far more important for airborne protection than the filtration capacity of the material. The shape and size of the respirator in relation to the wearer's facial anthropomorphic dimensions are major factors in terms of quality of fit (meaning the absence of leak). In the USA, for example, an N95 mask must provide adequate fit to at least 95% of a defined fit-test panel comprising of 25 subjects with predefined anthropometric features to meet the National Institute for Occupational Safety and Health (NIOSH) standard. The authors say: "However, the facial dimensions of this fit-test panel are derived from a cohort in which females and Asians are underrepresented. This might explain why reported initial fit-pass rates for filtering facepiece respirators vary widely with lower rates found in females and Asians."

The paper also discusses the difference between fit-checking and fit-testing. In fit-checking, the healthcare worker (HCW) checks their own mask has a good facial seal, by not feeling an air leak using both positive and negative pressure checks and is a minimum safety standard to whenever a mask is worn. Fit-testing, on the other hand, is a standardised test measuring if a certain mask when worn by the HCW fits correctly and does not demonstrate an air leak under simulated work conditions. The authors say fit testing should form part of official hospital occupational health and safety programmes.

The European Centre for Disease Prevention and Control (ECDC) states that filtering facepiece respirators require a fit-test to ensure proper protection. Despite the presence of standards and guidelines internationally, fit-testing is not universally adopted throughout Europe or other countries, such as Australia. Equally, the Health and Safety Executive in the UK states that fit-testing should be carried out to ensure the respirator can protect the wearer. The authors note: "However, the COVID-19 pandemic highlighted a growing number of UK medical trusts running so short of filtering facepiece respirators that they are no longer insisting staff have a fit-test before they start wearing a mask while treating infected patients."

Due to the associated time and costs, some health officials propose the elimination of fit-testing and advocate that a fit-check is sufficient in determining respirator fit. However, the US NIOSH conducted a study that demonstrated protection of N95/FFP2 masks improved from 67% without fit-testing to 96% with fit-testing. Subsequently, NIOSH determined fit-check alone to be insufficient and fit-testing should be mandatory when selecting filtering facepiece respirators or elastomer half mask respirators.

The authors say :"In summary, while fit-check remains recommended prior to each use of any respirator to ensure fit on a day-to-day basis, we recommend not to use fit-check as a substitute for fit-testing to identify the size and shape of respirator that fits best."

The authors note that private companies offer fit-testing between AUS$ 50-100 (US$36-72/£28-56/€30-60) per person. They conclude: "Annual fit testing is recommended. While this cost may appear high initially, it is similar to in-person mandatory training. The cost must also be considered in relation to potential sick leave or legal costs related to infections acquired in hospital such as COVID-19 or other airborne infectious diseases, which could be much more expensive."

The authors say: "The COVID-19 pandemic has highlighted deficiencies of some healthcare facilities to protect their healthcare workers in line with national and international recommendations and the requirement for formal fit-testing programmes appears to be particularly important."

The tool, available online, is the first of its kind and was developed and validated using anonymised data from around 120,000 sepsis patients from the ICNARC national database for critical care units across England.

The new tool is particularly timely as both survivors of sepsis and COVID-19 have risks of complications or death after leaving hospital and because the winter months are associated with an increase in sepsis admissions to hospital. The free, online tool could help inform patient care pathways to prevent unplanned readmissions to hospital and excess deaths.

Sepsis is a serious complication of infection. It occurs when the body's immune system goes into overdrive in response to an infection and can lead to multiple organ failure and death. In 2017, there were an estimated 48.9 million new diagnoses of sepsis worldwide.

Previous work by this team has shown that sepsis survivors are at an increased risk of adverse events such as unplanned rehospitalisation (in 40% of sepsis survivors) and death (in 15% of sepsis survivors). The risk is at its highest in the first year after leaving hospital Currently, sepsis survivors do not receive consistent follow-up care to tackle these risks. One reason for this may be the lack of a simple tool to assess patients' risk.

The work to develop the tool was led by Dr Manu Shankar-Hari, a consultant in intensive care medicine at Guy's and St Thomas' Reader in Intensive Care Medicine at King's College London and NIHR Clinician Scientist. He said: "It is well recognised that some people who survive sepsis are at an increased risk of unplanned rehospitalisation and of death in the first year after they leave hospital.

"We provide a simple and free online tool for use. Our vision is that by providing health care professionals and sepsis survivors a simple 'score' to explicitly understand risk, it may help improve follow-up care of sepsis survivors. The score could inform how to develop clinical pathways and support sepsis survivors' choices around their ongoing care.

"Looking ahead, we hope that this online tool will help to reduce unplanned rehospitalisation and death after surviving sepsis by informing clinical trials, through better stratification of risk and evidence-based care of sepsis survivors."

The tool was developed using data from 94,748 patients. The team determined eight factors which affected risk for sepsis survivors: previous hospitalisations in the preceding year, age, socioeconomic status, pre-existing dependency (refers to how much support was required prior to hospitalisation for activities of daily living such as washing and dressing), numbers of pre-existing conditions, admission type, site of infection and admission blood haemoglobin level. Using these, they developed a statistical model that could give an overall risk score for rehospitalisation or death in the first year after leaving hospital.

The tool was then tested in a second group of 24,669 patients. The team found that the calculations were valid in this separate group.

COLUMBIA, SC -- Inflammatory bowel diseases (IBD) such as Crohn's disease and ulcerative colitis are caused by unrestrained inflammation of the gastrointestinal tract. Patients with IBD are at a higher risk of developing colorectal cancer. In a recent study published in iScience by authors from the University of South Carolina, it was shown that treatment with Δ9-tetrahydrocannabinol (THC), a cannabinoid found in the cannabis plant, prevented the development of colon cancers in mice. It was shown that THC suppressed inflammation in the colon, preventing the onset of cancers caused by a carcinogen.

This new paper is based on research studies from the laboratories of Prakash Nagarkatti, Ph.D., and Dr. Mitzi Nagarkatti, Ph.D, at the University of South Carolina (UofSC) School of Medicine Columbia, Department of Pathology, Microbiology and Immunology. The Nagarkattis published "Activation of cannabinoid receptor 2 prevents colitis-associated colon cancer through myeloid cell deactivation upstream of IL-22 production," with co-authors William Becker, Haider Alrafas, Kiesha Wilson, Kathryn Miranda, Courtney Culpepper, Ioulia Chatzistamou and Guoshuai Cai, who also work at the University of South Carolina. Prakash and Mitzi Nagarkatti have been studying the effects of botanicals, including cannabis, on inflammation for many years.

The incidence of IBD is increasing globally. This suggests that the risk of cancers that are linked to IBD also are going to increase. In fact, the risk of colon and rectal cancers is increasing at an alarming rate among young and middle-aged adults in the United States and the cause remains unknown. Thus, understanding the mechanisms of IBD and developing effective drugs to prevent IBD and associated cancers are crucial.

"The fact that we were able to show that treatment with THC prevents inflammation in the colon and at the same time inhibits the development of colon cancer supports the notion that inflammation and colon cancer are closely linked. Thus, in patients who are at a higher risk of developing colon cancer, THC or other anti-inflammatory agents may be benefical," says Prakash Nagarkatti.

The Nagarkattis are world-renowned for their work studying the anti-inflammatory properties of cannabinoids. The cannabinoids act through two receptors known as CB1 and CB2. The CB1 receptor is expressed in the brain where THC activation causes psychoactive effects. The second receptor, CB2, is expressed mainly on the immune cells, meaning that activation of CB2 receptors does not trigger psychoactivity.

"Our results showed that THC was acting through CB2 receptors, which is exciting and suggests that compounds that activate CB2 and cause no psychoactive effects may be beneficial to prevent IBD and colon cancer," said Mitzi Nagarkatti.

Researchers at CRANN and the School of Physics at Trinity College Dublin have discovered that a new material can act as a super-fast magnetic switch. When struck by successive ultra-short laser pulses it exhibits "toggle switching" that could increase the capacity of the global fibre optic cable network by an order of magnitude.

Expanding the capacity of the internet

Switching between two states - 0 and 1 - is the basis of digital technology and the backbone of the internet. The vast majority of all the data we download is stored magnetically in huge data centres across the world, linked by a network of optical fibres.

Obstacles to further progress with the internet are three-fold, specifically the speed and energy consumption of the semiconducting or magnetic switches that process and store our data and the capacity of the fibre optic network to handle it.

The new discovery of ultra-fast toggle switching using laser light on mirror-like films of an alloy of manganese, ruthenium and gallium known as MRG could help with all three problems.

Not only does light offer a great advantage when it comes to speed but magnetic switches need no power to maintain their state. More importantly, they now offer the prospect of rapid time-domain multiplexing of the existing fibre network, which could enable it to handle ten times as much data.

The science behind magnetic switching

Working in the photonics laboratory at CRANN, Trinity's nanoscience research centre, Dr Chandrima Banerjee and Dr Jean Besbas used ultra-fast laser pulses lasting just a hundred femtoseconds (one ten thousand billionth of a second) to switch the magnetisation of thin films of MRG back and forth. The direction of magnetisation can point either in or out of the film.

With every successive laser pulse, it abruptly flips its direction. Each pulse is thought to momentarily heat the electrons in MRG by about 1,000 degrees, which leads to a flip of its magnetisation. The discovery of ultra-fast toggle switching of MRG has just been published in leading international journal, Nature Communications.

Dr Karsten Rode, Senior Research Fellow in the 'Magnetism and Spin Electronics Group' in Trinity's School of Physics, suggests that the discovery just marks the beginning of an exciting new research direction. Dr Rode said:

"We have a lot of work to do to fully understand the behaviour of the atoms and electrons in a solid that is far from equilibrium on a femtosecond timescale. In particular, how can magnetism change so quickly while obeying the fundamental law of physics that says that angular momentum must be conserved?

"In the spirit of our spintronics team, we will now gather data from new pulsed-laser experiments on MRG, and other materials, to better understand these dynamics and link the ultra-fast optical response with electronic transport. We plan experiments with ultra-fast electronic pulses to test the hypothesis that the origin of the toggle switching is purely thermal."

Next year Chandrima will continue her work at the University of Haifa, Israel, with a group who can generate even shorter laser pulses. The Trinity researchers, led by Karsten, plan a new joint project with collaborators in the Netherlands, France, Norway and Switzerland, aimed at proving the concept of ultra-fast, time-domain multiplexing of fibre-optic channels.

The Public Charge Rule: What Physicians Can Do to Support Immigrant Health

As the U.S. federal government pursues immigration reform, changes to the federal public charge rule have triggered confusion and concerns among patients who are immigrants. Although federal judges temporarily blocked implementation, a decision by the U.S. Supreme Court in January 2020 allowed the proposed changes to take effect. These policy changes have resulted in many legal immigrants and their family members becoming more reluctant to apply for health insurance, food, housing and other benefits for which they are qualified. Physicians from the University of California, Irvine School of Medicine summarize current knowledge on the public benefits included in the "public charge" rule and offer suggestions for family physicians to support the health of their immigrant patients and families. The authors conclude that "family physicians can effectively respond to patient and immigrant community concerns about these changes by providing outreach education, access to primary health care, and referrals to legal and social services."

Immigrant Health and Changes to the Public-Charge Rule: Family Physicians' Response
Cynthia Haq, MD, et al
University of California, Irvine, School of Medicine, Department of Family Medicine
https://www.annfammed.org/content/18/5/458

Rural Counties With Access to Obstetrics Have Healthier Infant Birth Outcomes

Rural areas with local access to obstetrical care report better infant health outcomes, including lower infant mortality rates and fewer babies delivered underweight. The retrospective cohort study compared the birth outcomes of rural counties in Alabama with in-county obstetrical care to those without over a 12-year span from 2003 to 2017. Across all four outcome measures--including infant, perinatal, and neonatal mortality rates as well as low birthrate deliveries--counties with access to obstetrical care had significantly better infant birth outcomes. The authors were not able to control for race or other social factors and report that areas with no obstetrical care access were also more likely to have a higher percentage of underrepresented minority residents. This study does not prove a causal link between access to obstetrical care and infant health outcomes, but it does suggest that obstetrical access may play a role in these disparities. These findings have broader implications for the more than half of all rural counties in the United States that do not have access to hospital-based obstetrical care.

Effect of Access to Obstetrical Care in Rural Alabama on Perinatal, Neonatal, and Infant Outcomes: 2003-2017
John B. Waits, MD, et al
Cahaba Medical Care, Centreville, Alabama
https://www.annfammed.org/content/18/5/446

Telehealth Supports Collaborative Care Model in Addressing Mental Health Needs of Rural Patients

Traditionally, primary care clinics connect patients who have mental health care needs to specialists like psychiatrists in a collaborative care model. However, rural clinics often lack the workforce capacity to provide collaborative behavioral health services. In a new qualitative study, rural Washington primary care clinics adopted telehealth methods to connect remotely with specialists. The study found that telepsychiatric collaboration prepared primary care physicians and rural clinic staff to deliver high quality mental health care in underserved areas.

Study authors interviewed 17 clinical, support and administrative staff members of three rural primary care clinics. They found that through telepsychiatric consultation, all members of the clinic learned how to better serve the needs of mental health patients. Primary care doctors learned to work proficiently with these patients. Care managers learned to appreciate how medical issues affect mental health and how to diagnose and assess mental health issues, and consulting psychiatrists learned how to coach a primary care team, serve as educators and lead program implementation. The collaborative care model provides important benefits that other rural primary care clinics should consider adopting to help meet the needs of patients with mental health disorders.

Telepsychiatric Consultation as a Training and Workforce Development Strategy for Rural Primary Care
Morhaf Al Achkar, MD, PhD, et al
Department of Family Medicine, University of Washington, Seattle
https://www.annfammed.org/content/18/5/438

Delivering Quality Care to Rural Communities

Most of rural North America is medically underserved, with a lack of physicians, nurses, physician assistants and behavioral health clinicians who can meet the needs of people living hundreds of miles from large urban centers. Several papers in the September-October 2020 issue of Annals of Family Medicine address the need for rural primary care and investigate new methods for delivering care to rural communities, including Waits et al's analysis on benefits of local obstetrical services on birth outcomes across rural Alabama, as well as Al Achkar et al's paper on the use of telepsychiatric consultations as a means to promote collaborative mental health care in rural primary care clinics.

"Access to health care in rural communities is fragile, too often dependent on individual clinicians, philanthropy, and lucky recruitment," write John M. Westfall, MD, MPH, and Hoon Byun, DrPH, of the Robert Graham Center. In this editorial, the authors discuss research and make their own suggestions for creating best practices in delivering high quality health care to rural communities.

Editorial: Recruiting, Educating, and Taking Primary Care to Rural Communities.
John M. Westfall, MD, MPH, and Hoon Byun, DrPH
Robert Graham Center, Washington, D.C.
https://www.annfammed.org/content/18/5/386

Study Shows Synthetic Medication and Desiccated Thyroid to be Equally Effective in Treating Hypothyroidism

A study by researchers at Kaiser Permanente in Denver, Colorado evaluated the stability of thyroid stimulating hormone (TSH) in patients using synthetic medication versus those using desiccated thyroid products to treat hypothyroidism. The results showed no difference in TSH stability over a three-year period between patients taking desiccated thyroid products and those on synthetic levothyroxine, an unanticipated finding given concerns about variability among batches of desiccated thyroid, which is prescribed much less frequently than synthetic levothyroxine.

In an accompanying editorial, Jill Schneiderhan and Suzanna Zick argue in favor of a patient-centered approach as opposed to relying primarily on laboratory results when determining the best way to manage hyperthyroidism. Emerging evidence shows that for many patients taking levothyroxine, symptoms persist despite lab results indicating normal TSH values. Further, these patients may feel invalidated and not in control of their treatment decisions. Schneiderhan and Zick conclude, "[k]eeping desiccated thyroid medications as an option in our tool kit will allow for improved shared decision making, while allowing for patient preference, and offer an option for those patients who remain symptomatic on levothyroxine monotherapy."

Thyroid Stimulating Hormone Stability in Patients Prescribed Synthetic or Desiccated Thyroid Products: A Retrospective Study
Catherine S. Riggs, PharmD, et al
Kaiser Permanente Colorado, Denver
https://www.annfammed.org/content/18/5/452

Editorial: Returning to a Patient-Centered Approach in the Management of Hypothyroidism
Jill Schneiderhan, MD, and Suzanna Zick, ND, MPH
University of Michigan Medical School, Ann Arbor
https://www.annfammed.org/content/18/5/388

Risk of Peritonsillar Abscess Following Respiratory Tract Infection is Low Whether or Not Antibiotics are Prescribed

While widespread unnecessary use of antibiotics can diminish their effectiveness, reducing antibiotic prescribing may increase the risk of serious bacterial infections. This study quantifies the benefits of prescribing antibiotics for respiratory tract infections in terms of reduction in risk of peritonsillar abscess. Researchers used a large sample of 11,000 anonymized electronic health records in the United Kingdom from 2002 through 2017 to estimate the probability of peritonsillar abscess within 30 days of a consultation for a respiratory tract infection, and compared rates between people prescribed or not prescribed antibiotics. Overall, the risk of peritonsillar abscess was low, and in two-thirds of cases, patients did not consult their primary care physician prior to developing an abscess. The study concludes that antibiotics may only prevent one case of peritonsillar abscess for every 1,000 antibiotic prescriptions, and authors suggest that reducing antibiotic prescribing may not have a significant impact on incidence of peritonsillar abscess.

Peritonsillar Abscess and Antibiotic Prescribing for Respiratory Infection in Primary Care: A Population-Based Cohort Study and Decision-Analytic Model
Martin C. Gulliford, MA, FRCP, et al
King's College London, School of Population Health and Environmental Sciences and NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, United Kingdom
https://www.annfammed.org/content/18/5/390

Canadian Researchers Identify Four Barriers to Successfully Rolling Out 'Gold-Standard' Abortion Pill

Canada is the first country to facilitate provision of medical abortion in primary care settings through evidence-based deregulation of mifepristone, which is considered the 'gold standard' for medical abortion. A Canadian study investigated the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals and how these factors relate to abortion policies, systems and service access throughout the country.

Results suggest that Health Canada's initial restrictions discouraged physicians from prescribing mifepristone and were inconsistent with provincial licensing standards, thereby limiting patient access. During, and after removal of, these restrictions, researchers identified four barriers to utilizing/prescribing the drug, including the initial federal restrictions which made mifepristone "more complicated than it needs to be"; navigating the "huge bureaucratic process" of organizational implementation; challenges with diffusion and dissemination of policy information; and adoption by physicians as "a process rather than an event."

This study, the authors write, is relevant to other nations experiencing challenges to accessing family planning services. Amidst the COVID-19 pandemic, U.S. policies restricting access to mifepristone have reached the Supreme Court after a federal district court judge temporarily suspended strict FDA regulations that require patients to visit a hospital or clinic in-person to obtain mifepristone. In Canada, ongoing implementation of mifepristone will require organizations to create tailored solutions to barriers, which may include creating new medical billing codes, provincial policy advocacy efforts, specifically in Quebec, which added its own restriction requiring accredited training in surgical abortion for any mifepristone provider, and conducting physician engagement to raise awareness to access barriers.

Perspectives Among Canadian Physicians on Factors Influencing Implementation of Mifepristone Medical Abortion: A National Qualitative Study
Sarah Munro, PhD, et al
University of British Columbia, Department of Obstetrics and Gynaecology, Vancouver, British Columbia, Canada
https://www.annfammed.org/content/18/5/413

In, But Out of Touch: What Does the Loss of Touch Mean in the Clinical Setting?

Touch connects doctors and patients physically and emotionally as human beings, forming an intimate bond. The ability to touch has been hindered because of COVID-19. Touch, however, is central to the practice of medicine, including the physical examination that guides diagnoses and informs health care management.

In this narrative essay, authors Martina Ann Kelly of the University of Calgary in Alberta, Canada, and Gerard Gormley, of Queens University in Belfast, Northern Ireland, reflect on the meaning of touch in clinical practice and how virtual care is transforming this aspect of care. They write that touch is a 'silent language' that fulfills a deeper symbolic function, enabling doctors to acknowledge their patients' concerns in a tangible way.

With the current COVID-19 global pandemic, doctors' acumen now relies more on verbal histories supported by visual images, including videos or photographs. Kelly and Gormley express a sense of emotional inadequacy in sight and words, which they deem as lacking when treating patients. Though doctors have never been more connected with utilization of video conferencing for medical discussion, learning and providing patient care, the authors believe fellow family physicians should also pause to consider any unintended consequences.

In, But Out of Touch: Connecting With Patients During the Virtual Visit
Martina Ann Kelly, MB, BCh, BAO, MA, PhD, FRCGP, CCFP and Gerard J. Gormley, MB, BCh, BAO, MD, FRCGP, FHEA
University of Calgary, Cumming School of Medicine, Department of Family Medicine, Alberta, Canada and Queens University Belfast, Centre for Medical Education, Northern Ireland, United Kingdom
https://www.annfammed.org/content/18/5/461

Out-of-Pocket and Total Visit Expenditures for Primary Care Physician Visits May Affect How Primary Care Is Delivered

This study looks at trends in out-of-pocket and total visit expenditures for visits to primary care physicians. Using the 2002-2017 Medical Expenditure Panel Survey (MEPS), the authors described changes in out-of-pocket and total visit expenditures for primary care visits for Medicare, Medicaid and private insurance. Between 2002 and 2017, the proportion of primary care visits associated with private insurance or no insurance decreased, while Medicare- and Medicaid-associated visits increased. Total expenditure per visit increased for private insurance and Medicare visits. Out-of-pocket expenditures rose primarily from increases in private insurance visits with higher out-of-pocket expenditures, while Medicare and Medicaid changed minimally. If these current trends continue, the authors would expect increasing difficulty with primary care physician access, particularly for Medicaid patients.

Trends in Total and Out-of-Pocket Expenditures for Visits to Primary Care Physicians, by Insurance Type, 2002-2017
Michael E. Johansen, MD, MS and Jonathan Doo Young Yun, MD, MPH
OhioHealth, Columbus, Ohio, and Heritage College of Osteopathic Medicine at Ohio University, Dublin and Heritage College of Osteopathic Medicine at Ohio University, Dublin
https://www.annfammed.org/content/18/5/430

Improved Physician-Patient Relationships are Associated With Improved Health

This study found an association between improved physician-patient relationships and improved patient-reported health status. Researchers at Case Western Reserve University found over a one-year period that while consistent access to a provider is important, the quality of each clinical encounter is equally as important in shaping a patient's reported overall health outcomes, as measured by the SF-12 quality of life questionnaire.

The authors also found some evidence that adults with five or more diagnosed conditions experience physician-patient relationships that are significantly lower in quality than those reported by adults without multimorbidity. This discrepancy may reflect unmet physician-patient relationship needs among adults bearing multimorbidity burdens and indicate another opportunity for intervention. The study findings can potentially inform health care strategies and health policy aimed at improving patient-centered health outcomes.

Assessing the Longitudinal Impact of Physician-Patient Relationship on Functional Health
R. Henry Olaisen, MPH, PhD, et al
Case Western Reserve University, Department of Population and Quantitative Health Sciences, Cleveland, Ohio
https://www.annfammed.org/content/18/5/422

Patient Access to After-Hours Primary Care Could Prevent Some Less Urgent ER Visits

Patients who receive in-home nursing care have lower emergency room utilization if they have access to after-hours primary care. Previous research found that home nursing patients in Ontario, Canada, have an increased risk of visiting the ER after normal clinic hours on the same day they receive a home nursing visit. These ER visits may be linked to the visiting nurse identifying a health issue they are unable to appropriately address during the visit.

This study analyzed almost 12,000 patients who visited the ER after 5pm. The authors found that patients with after-hours primary care access had a smaller increased risk of an ER visit on the day a nurse came to their home compared to patients with no after-hours primary care access. These findings suggest increasing access to after-hours primary care could prevent some less-urgent ER visits.

Effect of Access to After-Hours Primary Care on the Association Between Home Nursing Visits and Same-Day Emergency Department Use
Aaron Jones, PhD, et al
McMaster University, Department of Health Research Methods, Evidence, and Impact, Hamilton, Ontario, Canada.
https://www.annfammed.org/content/18/5/406

Primary Care Clinicians Drove Increasing Use of Medicare's Chronic Care Management Codes

To address the problem of care fragmentation for Medicare recipients with multiple chronic conditions, Medicare introduced Chronic Care Management (CCM) in 2015 to reimburse clinicians for care management and coordination. The authors of this study analyzed publicly available Medicare data on all CCM claims submitted nationwide from 2015 through 2018. They compared CCM code usage and paid and denied services across a broad range of medical specialties. The study showed that CCM use increased over this four-year period, driven largely by primary care physicians. Most claims were billed to the original general CCM code, with newer codes for more complex services accounting for a small portion of overall code usage. The percentage of denied services remained consistent at around 5 percent during this period. The authors note that a limited number of clinicians currently deliver CCM services and that future work evaluating facilitators and barriers to patients' and providers' usage of CCM will be needed.

Use of Chronic Care Management Among Primary Care Clinicians
Ashok Reddy, MD, MSc, et al
University of Washington, Department of Medicine, Seattle
https://www.annfammed.org/content/18/5/455

Processes Supportive of Patient Engagement are Boosted by Full Staffing, Daily Huddles, Responsible Leadership and Performance Improvement Discussions

VA researchers whose aim was to identify organizational and contextual factors associated with greater use of patient engagement processes found that high performing clinics were more likely to have fully-staffed primary care teams, clearly defined roles for team members, leadership responsible for implementing team-based care, and team meetings to discuss performance improvement, compared to clinics that performed poorly with regard to use of patient engagement processes.

Previous research has found that patients who are actively engaged in their own care are more likely to adhere to treatment, perform regular self-monitoring, have better intermediate health outcomes, and report better mental health and physical functioning. for engaging patients in self-management include involving patients in long-term planning and goal setting, training providers in motivational interviewing, and promoting the use of shared medical appointments, group visits, peer support, and home telehealth. Improving organizational functioning of primary care teams may enhance patient engagement in care.

Care Practices to Promote Patient Engagement in VA Primary Care: Factors Associated With High Performance
David A. Katz, MD, MSc, et al
Iowa City VA Medical Center and the University of Iowa, Departments of Medicine and Epidemiology, Iowa City
https://www.annfammed.org/content/18/5/397

Innovations in Primary Care

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care's front lines. In this issue:

Wellness Wheel Mobile Outreach Clinic: A Community-Led Care Model Improving Access to Care in Indigenous Communities--Wellness Wheel is a roving primary care outreach clinic that serves rural Indigenous communities in Saskatchewan, providing community-informed health care services that are grounded in Indigenous knowledge and harm reduction, with a goal of building capacity and increasing access to testing and care for HIV, hepatitis C and other chronic disease in areas that have faced systematic exclusion.
https://www.annfammed.org/content/18/5/466

Development and Implementation of a COVID-19 Respiratory Diagnostic Center--The University of North Carolina Health System shares components of their drive-through COVID-19 screening and testing clinic, testing 1,074 patients in its first 10 days.
https://www.annfammed.org/content/18/5/464

Begin the Turn: A Mobile Recovery Program for a Targeted Urban Population-- Begin the Turn, a multidisciplinary, mobile recovery program, can deliver street-side, community-mobilized treatment to address the opioid overdose crisis among urban populations struggling with homelessness and substance use disorder.
https://www.annfammed.org/content/18/5/465

Enhanced Care Team Nurse Process to Improve Diabetes Care--A team of primary care physicians, registered nurses, pharmacists and clinical nurse specialists affiliated with the Mayo Clinic developed a nurse-led collaborative practice model for diabetes management whereby nurses engage directly with adult patients, clinicians and other health care team members to facilitate proactive, patient-centered care and support patient self-management
https://www.annfammed.org/content/18/5/463

Innovative Family Medicine and Behavioral Health Co-Precepting via Telemedicine--With the onset of the COVID-19 pandemic, faculty at Rowan University School of Osteopathic Medicine transformed their Family Medicine/Behavioral Health co-preceptorship model to allow residents to gain valuable experience in telehealth and in team-based interaction in a virtual environment.
https://www.annfammed.org/content/18/5/467

The Public Charge Rule: What Physicians Can Do to Support Immigrant Health

As the U.S. federal government pursues immigration reform, changes to the federal public charge rule have triggered confusion and concerns among patients who are immigrants. Although federal judges temporarily blocked implementation, a decision by the U.S. Supreme Court in January 2020 allowed the proposed changes to take effect. These policy changes have resulted in many legal immigrants and their family members becoming more reluctant to apply for health insurance, food, housing and other benefits for which they are qualified. Physicians from the University of California, Irvine School of Medicine summarize current knowledge on the public benefits included in the "public charge" rule and offer suggestions for family physicians to support the health of their immigrant patients and families. The authors conclude that "family physicians can effectively respond to patient and immigrant community concerns about these changes by providing outreach education, access to primary health care, and referrals to legal and social services."

Immigrant Health and Changes to the Public-Charge Rule: Family Physicians' Response
Cynthia Haq, MD, et al
University of California, Irvine, School of Medicine, Department of Family Medicine
https://www.annfammed.org/content/18/5/458

From Alzheimer's to obesity, life can change dramatically if you discover you have a genetic risk of disease. Now, a new study from the Australian Centre for Precision Health, University of South Australia is challenging these predispositions, showing that some of the genes traditionally labelled as 'bad' are not always what they seem.

Examining the three main variants (ε4, ε3, and ε2) of the apolipoprotein E (APOE) gene involved in the metabolism of fats in the body - researchers found that both the typically 'bad' variant, APOE ε4, and the 'good' variant, APOE ε2 can increase as well as decrease the risk of disease.

Overall, the research revealed APOE-associations with 18 different diseases.

Lead researcher and geneticist, UniSA's Dr Amanda Lumsden says the findings provide valuable insights about how the APOE gene impacts health and disease.

"APOE-ε4 is notoriously the greatest known risk factor for late onset Alzheimer's disease, and is also connected to cardiovascular disease risk," Dr Lumsden says.

"Yet, despite its reputation, our research shows it also has qualities that can protect against a range of illnesses, including obesity, type 2 diabetes, chronic airway obstruction, and liver disease.

"Conversely, we found that the rarer APOE ε2 gene variant - which is often considered protective and beneficial to health - can increase the risk of several conditions including peripheral vascular disease, stomach ulcers, diseases of the cervix, and bunions."

The study assessed APOE-associated risks across a spectrum of more than 950 diseases, using information from 337,484 participants in the UK Biobank. Brain neuroimaging, blood biochemistry, body measurement and lung function biomarkers for the same population were also used to support the APOE-associations.

World-renowned genetic epidemiologist and Senior Principal Research Fellow at SAHMRI, Professor Elina Hyppönen*, says the study gives hope to people who may carry a genotype that has been classified as 'harmful'.

"An awareness of a genetic susceptibility can cause notable distress, especially if there is little that can be done to prevent that disease," Professor Hyppönen says.

"Here, we show that the same variant that causes harm with respect to some diseases, can be beneficial from other aspects of health, so it's not all doom and gloom based on your genes.

"Of course, it can be helpful to understand our genetic vulnerabilities, as this can motivate us to make positive lifestyle changes that can reduce the risk.

"This is true of several diseases. In our earlier work, we showed that by living a healthy lifestyle you can help mitigate the risk of dementia, even when a person has an elevated genetic risk.

"So, despite what your genes say about predispositions to disease, there are other ways to help you stay healthy and negate the risks."

While widespread unnecessary use of antibiotics can diminish their effectiveness, reducing antibiotic prescribing may increase the risk of serious bacterial infections. This study quantifies the benefits of prescribing antibiotics for respiratory tract infections in terms of reduction in risk of peritonsillar abscess. Researchers used a large sample of 11,000 anonymized electronic health records in the United Kingdom from 2002 through 2017 to estimate the probability of peritonsillar abscess within 30 days of a consultation for a respiratory tract infection, and compared rates between people prescribed or not prescribed antibiotics. Overall, the risk of peritonsillar abscess was low, and in two-thirds of cases, patients did not consult their primary care physician prior to developing an abscess. The study concludes that antibiotics may only prevent one case of peritonsillar abscess for every 1,000 antibiotic prescriptions, and authors suggest that reducing antibiotic prescribing may not have a significant impact on incidence of peritonsillar abscess.

This study looks at trends in out-of-pocket and total visit expenditures for visits to primary care physicians. Using the 2002-2017 Medical Expenditure Panel Survey (MEPS), the authors described changes in out-of-pocket and total visit expenditures for primary care visits for Medicare, Medicaid and private insurance. Between 2002 and 2017, the proportion of primary care visits associated with private insurance or no insurance decreased, while Medicare- and Medicaid-associated visits increased. Total expenditure per visit increased for private insurance and Medicare visits. Out-of-pocket expenditures rose primarily from increases in private insurance visits with higher out-of-pocket expenditures, while Medicare and Medicaid changed minimally. If these current trends continue, the authors would expect increasing difficulty with primary care physician access, particularly for Medicaid patients.

Patients who receive in-home nursing care have lower emergency room utilization if they have access to after-hours primary care. Previous research found that home nursing patients in Ontario, Canada, have an increased risk of visiting the ER after normal clinic hours on the same day they receive a home nursing visit. These ER visits may be linked to the visiting nurse identifying a health issue they are unable to appropriately address during the visit.

This study analyzed almost 12,000 patients who visited the ER after 5pm. The authors found that patients with after-hours primary care access had a smaller increased risk of an ER visit on the day a nurse came to their home compared to patients with no after-hours primary care access. These findings suggest increasing access to after-hours primary care could prevent some less-urgent ER visits.

Primary Care Clinicians Drove Increasing Use of Medicare's Chronic Care Management Codes

To address the problem of care fragmentation for Medicare recipients with multiple chronic conditions, Medicare introduced Chronic Care Management (CCM) in 2015 to reimburse clinicians for care management and coordination. The authors of this study analyzed publicly available Medicare data on all CCM claims submitted nationwide from 2015 through 2018. They compared CCM code usage and paid and denied services across a broad range of medical specialties. The study showed that CCM use increased over this four-year period, driven largely by primary care physicians. Most claims were billed to the original general CCM code, with newer codes for more complex services accounting for a small portion of overall code usage. The percentage of denied services remained consistent at around 5 percent during this period. The authors note that a limited number of clinicians currently deliver CCM services and that future work evaluating facilitators and barriers to patients' and providers' usage of CCM will be needed.

Use of Chronic Care Management Among Primary Care Clinicians
Ashok Reddy, MD, MSc, et al
University of Washington, Department of Medicine, Seattle
https://www.annfammed.org/content/18/5/455