Birmingham Medical Research Articles

Altered fronto-limbic-motor response to stress differs between functional and epileptic seizures in a TBI model

Background and ObjectivesPsychogenic nonepileptic (functional) seizures (FS) clinically resemble epileptic seizures (ES) with both often preceded by traumatic brain injury (TBI). FS and ES emergence and occurrence after TBI may be linked to aberrant neurobehavioral stress responses. We hypothesized that neural activity signatures in response to a psychosocial stress task would differ between TBI + FS and TBI + ES after controlling for TBI status (TBI-only). MethodsIn the current multicenter study, participants were recruited prospectively from Rhode Island Hospital, Providence Rhode Island Veterans Administration Medical Center, and the University of Alabama at Birmingham Medical Center. Previous diagnoses of TBI, ES, and FS were verified based on data collected from participants, medical chart and record review, and, where indicated, results of EEG and/or video-EEG confirmatory diagnosis. TBI + ES (N = 21) and TBI + FS (N = 21) were matched for age and sex and combined into an initial group (TBI + SZ; N = 42). A TBI-only group (N = 42) was age and sex matched to the TBI with seizures (TBI + SZ) group. All participants completed an fMRI control math task (CMT) and stress math task (SMT) based on the Montreal Imaging Stress Task (MIST). ResultsThe TBI + SZ group (n = 24 female) did not differ in mood or anxiety severity compared to TBI-only group (n = 24 female). However, TBI + FS group (n = 11 female) reported greater severity of these symptoms compared to TBI + ES (n = 13 female). The linear mixed effects analysis identified neural responses that differed between TBI-only and TBI + SZ during math performance within the left premotor cortex and during auditory feedback within bilateral prefrontal cortex and hippocampus/amygdala regions. Additionally, neural responses differed between TBI + ES and TBI + FS during math performance within the right dorsolateral prefrontal cortex and bilateral amygdala during auditory feedback within the supplementary motor area. All tests comparing neural stress responses to psychiatric symptom severity failed to reach significance. DiscussionControlling for TBI and seizure status, these findings implicate specific nodes within frontal, limbic, and sensorimotor networks that may maintain functional neurological symptoms and possibly distinguish FS from ES. This study provides class II evidence of differences in neural responses to psychosocial stress between ES and FS after TBI.

The current position of wound imaging in the UK.

British Journal of NursingVol. 32, No. 12 CommentThe current position of wound imaging in the UKSteven LA JefferySteven LA JefferyE-mail Address: [email protected]Consultant Burns and Plastic Surgeon, Professor of Wound Study, Birmingham City University and Medical Director, Pioneer Wound TelehealthSearch for more papers by this authorSteven LA JefferyPublished Online:21 Jun 2023https://doi.org/10.12968/bjon.2023.32.12.S4AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Guest JF, Fuller GW, Vowden P. Cohort study evaluating the burden of wounds to the UK's National Health Service in 2017/2018: update from 2012/2013. BMJ Open. 2020;10(12):e045253. https://doi.org/10.1136/bmjopen-2020-045253 Crossref, Medline, Google ScholarRoyal College of Nursing. Valuing nursing in the UK. Staffing for safe and effective care in the UK: interventions to mitigate risks to nursing retention. 2019. https://tinyurl.com/5n7ytp7r (accessed 14 June 2023) Google ScholarRogers LC, Bevilacqua NJ, Armstrong DG, Andros G. Digital planimetry results in more accurate wound measurements: a comparison to standard ruler measurements. J Diabetes Sci Technol. 2010;4(4):799-802. https://doi.org/10.1177/193229681000400405 Crossref, Medline, Google ScholarSavage JM, Jeffery SL. Use of 3D photography in complex-wound assessment. J Wound Care. 2013;22(3):156-160. https://doi.org/10.12968/jowc.2013.22.3.156 Link, Google ScholarWynn M, Scholes L. Trial of the Minuteful mobile application for wound care in an inpatient setting. Wounds UK. 2022;18(4):37–40 Google Scholar FiguresReferencesRelatedDetails 22 June 2023Volume 32Issue 12ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 21 June 2023 Published in print 22 June 2023 Information© MA Healthcare LimitedPDF download

Physicians’ experiences with buprenorphine: A qualitative study of motivations for becoming X waivered and barriers to and facilitators of prescribing the medication for opioid use disorder

IntroductionBuprenorphine can only be prescribed for opioid use disorder (OUD) by providers with a Controlled Substance Act waiver (X waiver) from the Substance Abuse and Mental Health Services Administration. This study examines what motivates physicians to become X waivered, as well as what facilitates and hinders physicians’ abilities to prescribe buprenorphine to people with OUD. MethodsThis is a qualitative study of physicians in Birmingham, Alabama. We recruited physicians from the University of Alabama at Birmingham and Cahaba Medical Care to participate in semi-structured interviews and used a Framework-guided Rapid Qualitative Analysis technique to analyze the transcripts for themes aligned with the Social Cognitive Theory. ResultsA total of 27 physicians were interviewed between December 15th, 2021 and July 21st, 2022. The vast majority reported seeking to obtain an X waiver when their employers encouraged or mandated it. Most providers reported being eager to become waivered when first asked by their employers, while a few described some hesitancies. Essentially all participants agreed that having mentors is important when first prescribing buprenorphine and that support from social workers and counselors is needed. Most physicians discussed how stigma, administrative barriers, and a lack of community resources hinder buprenorphine prescription. ConclusionsOur findings suggest that employers are effective in encouraging X waiver certification and mentors and allied health professionals are important in ensuring providers continue buprenorphine prescription. Additionally, it is critical to address challenges to successful buprenorphine prescription, like stigma and administrative barriers.

MHealth Phone Intervention to Reduce Maternal Deaths and Morbidity in Cameroon: Protocol for Translational Adaptation.

PurposeThe purpose of this NIH-funded protocol is to adapt (Aim 1) and pilot test (Aim 2) an mHealth intervention to improve maternal and child health in Cameroon. We will adapt the 24/7 University of Alabama at Birmingham Medical Information Service via Telephone (MIST) provider support system to mMIST (mobile MIST) for peripheral providers who provide healthcare to pregnant and postpartum women and newborns in Cameroon.MethodsIn Aim 1, we apply qualitative and participatory methods (in-depth interviews and focus groups with key stakeholders) to inform the adaptation of mMIST for use in Cameroon. We use the sequential phases of the ADAPT-ITT framework to iteratively adapt mMIST incorporating qualitative findings and tailoring for local contexts. In Aim 2, we test the adapted intervention for feasibility and acceptability in Ndop, Cameroon.ResultsThis study is ongoing at the time that this protocol is published.ConclusionThe adaptation, refinement, and pilot testing of mMIST will be used to inform a larger-scale stepped wedged cluster randomized controlled effectiveness trial. If successful, this mHealth intervention could be a powerful tool enabling providers in low-resource settings to deliver improved pregnancy care, thereby reducing maternal and fetal deaths.

Proceedings of the Birmingham Medical Research Expeditionary Society and British Mountain Medicine Society Conference, September 2021.

Proceedings of the Birmingham Medical Research Expeditionary Society and British Mountain Medicine Society Conference, September 2021.

Elevated Plasma Fibrinogen Is Associated With Excessive Inflammation and Disease Severity in COVID-19 Patients.

BackgroundThe coronavirus disease-19 (COVID-19) is characterized with intense inflammatory response, cardiac involvement, and coagulopathy. Fibrinogen, as a biomarker for inflammation, cardiovascular disease, and coagulation, has not been fully investigated yet. The aim of this study was to assess the clinical application of fibrinogen in COVID-19 patients.MethodsWe retrospectively analyzed the demographic and laboratory characteristics of 119 COVID-19 patients in the University of Alabama of Birmingham Medical Center. Correlations of fibrinogen on admission with intensive care unit (ICU) admission, disease severity, and laboratory parameters were analyzed.ResultsAmong the 119 COVID-19 patients, 77.3% (92/119) had severe disease, and 59.5% (71/119) patients were admitted to the ICU. Elevated fibrinogen was detected in 67.2% (80/119) of the patients. Fibrinogen levels were significantly associated with inflammatory markers and disease severity, but not with cardiac injury biomarker high sensitivity troponin I. Patients with severe disease had increased fibrinogen levels upon admission compared to patients with non-severe disease (P = 0.001). Fibrinogen level at 528.0 mg/dl was the optimal cutoff to predict disease severity, with a sensitivity and specificity of 66.7% and 70.3% (area undty -60er the curve [AUC] 0.72, P = 0.0006).ConclusionsFibrinogen is commonly elevated in COVID-19 patients, especially in those with severe disease. Elevated fibrinogen correlates with excessive inflammation, disease severity, and ICU admission in COVID-19 patients.

Brian Hall Smith

Brian Hall Smith (also known as “BH”) was born in Wellington, Shropshire, on 31 December 1924. His parents were both headteachers and imbued him with curiosity for science and biology,...

TikTok™ and dermatology: lessons for medical education

We read with interest the article by Roche et al. inClinical and Experimental Dermatology. The authors acknowledge increasing popularity and usage of TikTok for dermatology and the dangers of harmful dissemination of health-related content.1 We offer further reflections on opportunities and risks with such platforms, specifically related to dermatology medical education.

Ambulatory Surgery vs Overnight Observation for Total Thyroidectomy: Cost Analysis and Outcomes.

ObjectiveTo compare financial impact between patients undergoing ambulatory (same-day discharge) vs overnight admission after total thyroidectomy while showing associated surgical outcomes.Study DesignRetrospective review.SettingUniversity of Alabama at Birmingham Medical Center from October 2011 and July 2017.MethodsPatients undergoing total thyroidectomy without concurrent procedures were selected for review. Demographics, comorbidities, admission status, postoperative outcomes including minor and major complications, charges, and costs were collected. Admission status was categorized as inpatient (admission to hospital ≥1 night) or outpatient (discharged from the postoperative recovery unit). Costs were obtained from all related hospital, clinic, and emergency department visits at the University of Alabama at Birmingham within 30 days of the original surgery. After statistical analysis, outcomes and costs were compared between inpatient and outpatient total thyroidectomy patients.ResultsOf 870 total thyroidectomy patients included for analysis, 367 (42.2%) met outpatient criteria. A total of 169 patients (19.4%) had a complication, and only hypocalcemia occurred significantly more in the inpatient group (14.3% vs 9.26%; P < .05). No complications occurred more frequently in the outpatient population. There were no mortalities. There was a statistically significant difference between the total cost of inpatient and outpatient thyroidectomies, with outpatient surgery costing on average $2367.27 less per patient (P < .0001).ConclusionOutpatient total thyroidectomy can lead to cost reduction in highly selected patients who have few comorbidities while remaining safe for the patient.

Toward Understanding the Value of Missing Social Determinants of Health Data in Care Transition Planning.

Social determinants of health play an important role in the likelihood of readmission and therefore should be considered in care transition planning. Unfortunately, some social determinants that can be of value to care transition planners are missing in the electronic health record. Rather than trying to understand the value of data that are missing, decision makers often exclude these data. This exclusion can lead to failure to design appropriate care transition programs, leading to readmissions. This article examines the value of missing social determinants data to emergency department (ED) revisits, and subsequent readmissions. A deidentified data set of 123,697 people (18+ years), with at least one ED visit in 2017 at the University of Alabama at Birmingham Medical Center was used. The dependent variable was all-cause 30-day revisits (yes/no), while the independent variables were missing/nonmissing status of the social determinants of health measures. Logistic regression was used to test the relationship between likelihood of revisits and social determinants of health variables. Moreover, relative weight analysis was used to identify relative importance of the independent variables. Twelve social determinants were found to be most often missing. Of those 12, only "lives with" (alone or with family/friends) had higher odds of ED revisits. However, relative logistic weight analysis suggested that "pain score" and "activities of daily living" (ADL) accounted for almost 50% of the relevance for ED revisits when compared among all 12 variables. In the process of care transition planning, data that are documented are factored into the care transition plan. One of the most common challenges in health services practice is to understand the value of missing data in effective program planning. This study suggests that the data that are not documented (i.e., missing) could play an important role in care transition planning as a mechanism to reduce ED revisits and eventual readmission rates.

David Powys Wynn Roberts

David Powys Wynn Roberts (known to colleagues as “DPW”) was born and educated in Llangollen. After graduating from Birmingham Medical School he undertook national service, and served with the Royal...

Longitudinal assessments of plasma ADAMTS13 biomarkers predict recurrence of immune thrombotic thrombocytopenic purpura

AbstractImmune thrombotic thrombocytopenic purpura (iTTP) is primarily caused by immunoglobulin G (IgG)–type autoantibodies that bind and inhibit plasma ADAMTS13 activity and/or accelerate its clearance from circulation. Approximately 50% of patients with iTTP who achieve initial clinical response to therapy experience recurrence (ie, exacerbation and/or relapse); however, a reliable biomarker that predicts such an event is currently lacking. The present study determines the role of longitudinal assessments of plasma ADAMTS13 biomarkers in predicting iTTP exacerbation/recurrence. Eighty-three unique iTTP patients with 97 episodes from the University of Alabama at Birmingham Medical Center between April 2006 and June 2019 were enrolled. Plasma levels of ADAMTS13 activity, antigen, and anti-ADAMTS13 IgG on admission showed no significant value in predicting iTTP exacerbation or recurrence. However, persistently low plasma ADAMTS13 activity (<10 U/dL; hazard ratio [HR], 4.4; 95% confidence interval [CI], 1.6-12.5; P = .005) or high anti-ADAMTS13 IgG (HR, 3.1; 95% CI, 1.2-7.8; P = .016) 3 to 7 days after the initiation of therapeutic plasma exchange was associated with an increased risk for exacerbation or recurrence. Furthermore, low plasma ADAMTS13 activity (<10 IU/dL; HR, 4.8; 95% CI, 1.8-12.8; P = .002) and low ADAMTS13 antigen (<25th percentile; HR, 3.3; 95% CI, 1.3-8.2; P = .01) or high anti-ADAMTS13 IgG (>75th percentile; HR, 2.6; 95% CI, 1.0-6.5; P = .047) at clinical response or remission was also predictive of exacerbation or recurrence. Our results suggest the potential need for a more aggressive approach to achieve biochemical remission (ie, normalization of plasma ADAMTS13 activity, ADAMTS13 antigen, and anti-ADAMTS13 IgG) in patients with iTTP to prevent the disease recurrence.

Turabali M H Chakera

Turabali M H Chakera (“Turab”) was born in Dar Es Salaam, Tanganyika (now Tanzania, Africa), the middle child in a family of five children. After initial education in east Africa,...

Cheryl Ann Britton

Cheryl Ann Britton was born and raised in Bradford, where she attended Bradford Girls Grammar School. After qualifying from the University of Birmingham Medical School, she worked as a house...

The Effect of Epsilon-Aminocaproic Acid on the Development of Shunt-Dependent Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage: a Case-Control Study

The use of epsilon-aminocaproic acid (EACA) and other anti-fibrinolytic agents has been explored to prevent re-hemorrhage following subarachnoid hemorrhage (SAH) secondary to aneurysmal rupture. One reported complication includes increased rates of hydrocephalus (HCP) due to EACA administration. Herein, we present a single-institution case-control study investigating the relationship between EACA administration and the development of shunt-dependent HCP. All patients were managed by a single neurosurgeon at the University of Alabama at Birmingham (UAB) Medical Center who treated SAH patients with EACA. A power analysis was performed to determine the sample size, and 57 patients who required a ventriculoperitoneal shunt (VPS) for management of obstructive hydrocephalus after failing an external ventricular drain wean protocol were selected. Control patients with initial obstructive hydrocephalus who did not require VPS were matched by demographic factors. The overall rate of VPS placement was 44%; the odds ratio of VPS placement after treatment with EACA was 0.63. The presence of intraventricular hemorrhage or a poor clinical exam on presentation was closely associated with eventual placement of a VPS, with the odds ratio for a Fisher CT grade 4 hemorrhage being 13.89 and a clinical exam corresponding to a Hunt and Hess score of III and IV being 17.18 and 11.00, respectively. The administration of EACA does not appear to increase the incidence of shunt-dependent HCP following SAH and may therefore be employed if clinically needed. Intraventricular hemorrhage or a poor clinical exam on presentation does appear to increase the incidence of shunt-dependent HCP following SAH.

Manubhai Dahyabhai Tailor

Manubhai Dahyabhai Tailor, popularly known as “Manu,” moved to UK from Eldoret, Kenya, in 1955 and from 1957 to 1962 he read medicine at the University of Birmingham Medical School....

Shashikant C Patel

Shashikant C Patel, popularly known as “Shashi,” was born in Eldoret, Kenya, Africa. He moved to the UK at the age of 16, after completing his primary and secondary education....

Head and Neck Anatomy: Effect of Focussed Near-Peer Teaching on Anatomical Confidence in Undergraduate Medical Students

To assess the effect of near-peer head and neck anatomy teaching on undergraduates and to quantify the benefit from a focussed teaching course. Near-peer teaching involves colleagues within close seniority and age proximity teaching one another on a specified topic. Small group teaching sessions were delivered to medical students on 3 key areas of ENT anatomy. Participants were given a precourse and postcourse questionnaire to determine the benefit attained from the course. An undergraduate anatomy course taking place at the University of Birmingham Medical School. A total of 30 medical students: 15 preclinical (years 1-2) and 15 clinical (years 3-5) medical students participated from a single institution. A total of 71% of students expressed inadequate teaching of head and neck anatomy in undergraduate curriculum. All students (n = 30) expressed benefit from the course, however the patterns of learning differed: preclinical students showed a significant improvement in both their ability to name anatomical structures and their application (p < 0.05). Near-peer learning provides benefit to all medical undergraduates in the context of teaching anatomy which may make it a valuable teaching tool for the future of medical education.

Perceived Stress and the Fatigue Symptom Cluster in Childhood Brain Tumor Survivors.

To explore and estimate relationships among the elements of the symptom cluster in survivors of brain tumors aged 8-12 years during early survivorship. Child participants completed treatment at least six months and less than six years prior to enrollment at Children's Hospital of Alabama in Birmingham or Cook Children's Medical Center in Fort Worth, Texas. With cross-sectional methods, the authors measured child-perceived stress, sleep-wake disturbance (SWD) (parent report), and fatigue. Children also provided saliva samples for cortisol measurement (stress response) and completed actigraphy sleep monitoring. Mild to moderate stress, SWD, and fatigue were reported, and a wide range of sleep times and cortisol levels were noted. Meaningful effect sizes in relationships between variables were found. The stress, SWD, and fatigue symptom cluster in survivorship necessitates routine nursing assessment.

Clinical factors and biomarkers predict outcome in patients with immune-mediated thrombotic thrombocytopenic purpura.

Immune-mediated thrombotic thrombocytopenic purpura is characterized by severe thrombocytopenia and microangiopathic hemolytic anemia. It is primarily caused by immunoglobin G type autoantibodies against ADAMTS13, a plasma metalloprotease that cleaves von Willebrand factor. However, reliable markers predictive of patient outcomes are yet to be identified. Seventy-three unique patients with a confirmed diagnosis of immune-mediated thrombotic thrombocytopenic purpura between April 2006 and December 2017 were enrolled from the Univeristy of Alabama at Birmingham Medical Center. Clinical information, laboratory values, and a panel of special biomarkers were collected and/or determined. The results demonstrated that the biomarkers associated with endothelial injury (e.g., von Willebrand factor antigen and collagen-binding activity), acute inflammation (e.g., human neutrophil peptides 1-3 and histone/deoxyribonucleic acid complexes), and activation of the complement alternative pathway (e.g., factors Bb and iC3b) were all significantly increased in patients with acute immune-mediated thrombotic thrombocytopenic purpura compared to those in the healthy controls. Moreover, failure to normalize platelet counts within 7 days or failure to markedly reduce serum lactate dehydrogenase by day 5, low total serum protein or albumin, and high serum troponin levels were also predictive of mortality, as were the prolonged activated partial thromboplastin time, high fibrinogen, and elevated serum lactate dehydrogenase, Bb, and sC5b-9 on admission. These results may help to stratify patients for more intensive management. The findings may also provide a framework for future multicenter studies to identify valuable prognostic markers for immune-mediated thrombotic thrombocytopenic purpura.