Department of Humanities and Social Sciences

OBJECTIVE: To assess long-term safety of antiseizure medication (ASM) discontinuation after resolution of acute provoked neonatal seizures and prior to hospital discharge. METHODS: Prospective, observational, comparative effectiveness cohort study of neonates with acute provoked seizures born from July 2015 to March 2018, and followed until September 2024, at nine U.S. Neonatal Seizure Registry centers with Level IV neonatal intensive care units and Level IV pediatric epilepsy programs. Duration of ASM treatment was quantified as (1) discontinuation before discharge from the neonatal seizure admission or (2) maintenance at the time of hospital discharge. Outcomes were adjusted for propensity to receive ASM at discharge. Propensity for ASM maintenance was defined among enrolled participants by a logistic regression model including seizure etiology, gestational age, therapeutic hypothermia, worst electroencephalography (EEG) background, days of EEG seizures, and discharge neurological exam (all p ≤ .1 in a joint model, except etiology, which was included for face validity). The primary outcome was non-inferiority of cognition (Wechsler Preschool and Primary Scale of Intelligence assessed at age 5-6 years). Secondary outcomes were non-inferiority of functional development (Vineland Adaptive Behavior Scale, 3rd Edition, assessed at 3-8 years) and post-neonatal epilepsy (assessed at 1-8 years). RESULTS: Among 284 children with at least one follow-up, outcomes were similar in the discontinued vs maintained ASM groups for full-scale IQ at age 5 years (adjusted difference +10 points), functional development at ages 3-8 years (adjusted difference 0 points), and post-neonatal epilepsy at ages 1-8 years (adjusted hazard ratio .93, 95% confidence interval [CI] .48-1.80). SIGNIFICANCE: Prolonged administration of ASM for several months after resolution of acute provoked neonatal seizures may expose infants to unnecessary medications. These results provide additional evidence for safety of discontinuing ASM for most neonates soon after the resolution of acute provoked seizures-a practice that is recommended in the International League Against Epilepsy (ILAE) guideline for neonatal seizure management.

ABSTRACTRecent academic and activist critiques raise important points about the ways in which coloniality, migration and racialization are often overlooked in global health research and practice. In particular, these critiques highlight how such structural forces perpetuate inequalities and exclusions, as well as processes of epistemic violence in global health. While agreeing with these critical interventions, this paper argues for a focus on care and the importance that concrete acts and systems of care in postcolonial, migratory and racialized contexts have on the suffering and vulnerability of individuals and communities. Drawing on case studies from multiple different geographic and social contexts, we argue that the perspective of racialization can highlight how multi-layered inequalities in global healthcare are shaped by the intertwined processes of coloniality and migration; thereby explaining the contextual, structural vulnerability of specific groups of people to certain health conditions and their exclusion from adequate healthcare resources. We argue that social scientists and critical global health scholars and practitioners can play a central role in bringing the three strands of research - coloniality, migration and racialization - into conversation to explore their potential for jointly advancing the care and well-being of individuals and communities in different geographical and social contexts.

Recreational cannabis outlets may influence rates of interpersonal violence, but research has yielded inconsistent findings. Modification by alcohol outlet density may help explain inconsistencies. We estimated the impacts of recreational cannabis outlets on neighborhood-level assault injury rates in California and evaluated whether alcohol outlet density moderated these associations. We applied Bayesian spatiotemporal analyses to ZIP code-level statewide data on alcohol outlets, recreational cannabis outlets, and injuries and deaths due to firearm and nonfirearm assault, from 2017 to 2019, accounting for confounders and spatial autocorrelation. Using the model posteriors, we estimated parameters corresponding to hypothetical shifts in outlet densities, overall and by age, sex, and race/ethnicity. If recreational cannabis outlets were never introduced, we estimated that nonfirearm assault injuries would have been 1.63 per 100 000 lower (95% CI, -3.08 to 0.01), but we observed no association with firearm assault injuries (risk difference [RD] per 100 000: -0.07; 95% CI, -0.34 to 0.21). These associations did not depend on alcohol outlet density, but a hypothetical 20% reduction in alcohol outlet densities was associated with fewer firearm (RD per 100 000: -1.89; 95% CI, -0.46 to 0.09) and nonfirearm (RD per 100 000: -5.67; 95% CI, -7.44 to -3.95) assault injuries. The introduction of recreational cannabis outlets may have contributed to a small increase in nonfirearm assault injuries.

This paper examines the rise of clinical decision support algorithms used to assess risk in pain management and the opioid industry’s influence on their development and implementation. To understand this influence, we conducted a qualitative study of documents related to the development of a tool that relied on artificial intelligence (AI) to suggest modifications in opioid prescribing, called NarxCare. The study began with keyword searches of the Opioid Industry Document Archive (OIDA), which contained over 3 million documents at the time of the study, to examine the pharmaceutical industry’s role in shaping the digital transformation of opioid prescribing. Our findings highlight industry-driven investments, educational campaigns, corporate policy activities, and the reliance on proprietary data that facilitated the widespread implementation of NarxCare. The increasing reliance on NarxCare raises concerns about its limited transparency, unknown reliability, and potential bias which may disproportionately affect certain patient groups based on race, socioeconomic status, or health conditions. This paper argues that the promotion of technologies like NarxCare allows the pharmaceutical industry to reinforce the narrative that opioids can be effective when prescribed responsibly, using advanced, data-driven strategies. Marketed as tools that assist clinicians in making more informed prescribing decisions, NarxCare contributes to the portrayal of the industry as a responsible actor in the regulation and distribution of opioids. Shifting attention to individual risk factors rather than systemic challenges enables the pharmaceutical industry to sidestep its role in the opioid crisis and evade scrutiny for its influence over regulation, the sponsorship of education and research, lobbying, supply chain control, and public health narratives. While NarxCare aims to improve prescribing safety, it requires critical evaluation in terms of effectiveness, ethical considerations, and the continued influence of the pharmaceutical industry in its design and implementation.

Homelessness is a public health concern in California and throughout the United States. Intimate partner violence (IPV) is a risk factor for experiencing homelessness. Few studies have examined the interplay between IPV, homelessness, and housing. Qualitative methods can provide a greater understanding of the lived experience of IPV and homelessness to identify potential solutions. We purposefully sampled 104 adults who reported experiencing IPV in the California Statewide Study of People Experiencing Homelessness (CASPEH), a representative, mixed-methods study. We administered semi-structured interviews focusing on IPV and six other topic areas pertaining to homelessness from October 2021 to May 2022. We created and applied a codebook with a multidisciplinary team using a hybrid of deductive and inductive logic. Our analysis included all participants who discussed IPV and homelessness across the seven studies. We conducted a thematic analysis using an interpretivist approach and informed by grounded theory. We found that violence within a partnership was multidimensional (physical, sexual, emotional, and financial) and bidirectional. We identified six themes: (1) IPV precipitated and prolonged homelessness; (2) Need for housing, financial stability, and material resources influenced staying in abusive relationships; (3) Alcohol and illicit substance use exacerbated violence between partners; (4) Participants struggled to find resources in domestic violence (DV) shelters; (5) The healthcare system did not provide substantial support; and (6) discrimination and stigma influenced equitable access to housing and DV resources. Experiencing IPV contributed to homelessness and impeded returns to housing. Limitations in current IPV resources impede care. We propose equitable expansion of survivor-centered services that improve access to long-term subsidized housing, prevent IPV and homelessness with flexible funding options, and facilitate rapid exits from homelessness through trauma-informed, non-congregate shelter that transitions to permanent housing.

BACKGROUND: Cannabis use and alcohol use are associated with self-harm injuries, but little research has assessed links between recreational cannabis outlet openings on rates of self-harm within communities or the interactions of cannabis outlets with the density of alcohol outlets. We estimated the associations of recreational cannabis outlets, alcohol outlets, and their interaction on rates of fatal and nonfatal self-harm injuries in California, 2017-2019. METHODS: Using California statewide data on recreational cannabis outlets, alcohol outlets, and hospital discharges and deaths due to self-harm injuries, we conducted Bayesian spatiotemporal analyses of quarterly ZIP code-level data over 3 years, accounting for confounders and spatial autocorrelation. Using the model posteriors, we estimated parameters corresponding to hypothetical shifts in outlet densities. RESULTS: If recreational cannabis outlets had never opened, we estimated that nonfatal self-harm injuries would have been -0.35 per 100,000 lower (95% credible interval [CI]: -1.25, 0.51), while fatal self-harm injuries would have been -0.004 per 100,000 lower (95% CI: -0.26, 0.25). These associations did not depend on alcohol outlet density, but a hypothetical 20% reduction in alcohol outlet densities was associated with fewer self-harm injuries (risk difference per 100,000, nonfatal: -1.59; 95% CI: -2.60, -0.59; fatal: -0.10; 95% CI: -0.37, 0.16). Associations for nonfatal incidents were strongest for people aged 15-34 years, and White and Hispanic people. CONCLUSION: We did not find evidence that the introduction of recreational cannabis outlets was associated with self-harm injuries or that cannabis and alcohol outlet densities interact, but alcohol outlet density had a strong association with nonfatal self-harm injuries.

Importance: The rise of high-potency opioids such as fentanyl makes buprenorphine initiation challenging due to the risks of precipitated withdrawal, prompting the exploration of strategies, such as low-dose initiation (LDI) of buprenorphine. However, no comparative studies on LDI outcomes exist. Objective: To evaluate outpatient outcomes associated with 2 LDI protocols of buprenorphine among individuals with opioid use disorder (OUD) using fentanyl. Design, Setting, and Participants: This cohort study analyzed data on adults with OUD who self-reported daily fentanyl use and underwent buprenorphine initiation using LDI. Data were extracted from the electronic health records of 2 substance use disorder treatment clinics using a specialty behavioral health pharmacy in San Francisco, California, from May 2021 to November 2022. Exposures: Type of LDI protocol selected by individuals: 4-day or 7-day protocol. Main Outcomes and Measures: The primary outcome was successful buprenorphine initiation, defined as self-reported LDI completion and pickup of a refill maintenance prescription, and buprenorphine retention. Logistic regression with generalized estimating equations assessed associations between LDI protocol (4-day vs 7-day) and successful initiation, adjusting for multiple attempts, age, gender identity, race and ethnicity, and housing status. Kaplan-Meier survival curves were used to estimate buprenorphine retention, and survival curves were adjusted using a fitted Cox proportional hazards regression model. Results: A total of 126 individuals (median [IQR] age, 35 [29-44] years; 90 identified as men [71%]; 26 [21%] identified as Black or African American, 20 [16%] as Latine, and 66 [52%] as White individuals) with 175 initiation attempts were included. Across attempts, 72 (41%) had a 4-day LDI protocol and 103 (59%) had a 7-day protocol. Initiation was successful in 60 attempts (34%), including 27 (38%) among 4-day protocol and 29 (28%) among 7-day protocol attempts. Buprenorphine retention rate at 28 days was 21% for a 4-day protocol and 18% for a 7-day protocol. Logistic regression found no significant differences between LDI protocols and successful initiation, while repeated LDI attempts had lower odds of success (second attempt: adjusted odds ratio [AOR], 0.30 [95% CI, 0.14-0.66]; third or more attempt: AOR, 0.22 [95% CI, 0.09-0.53]). Unadjusted and adjusted survival models did not detect a significant difference in retention between LDI protocol types. Conclusions and Relevance: This cohort study found that among people with OUD using fentanyl and attempting outpatient LDI of buprenorphine, successful buprenorphine initiation and retention rates were low. Future studies should examine interventions to improve LDI success and increase buprenorphine uptake and retention.

Objective: Abnormal mammography results can contribute to anxiety for women, and primary care physicians (PCPs) are responsible for discussing these results with women. We sought to examine PCPs’ preparedness to discuss the breast biopsy process and biopsy results with women who have received an abnormal mammogram result and the physician, practice, panel, and communication factors associated with that preparedness. Methods: Cross-sectional analysis of internal medicine and family medicine PCPs in San Francisco, CA. We used multivariable logistic regression to examine the associations. Results: Of the 588 PCPs invited, 300 (51%) completed the survey. Seventy-three percent of respondents ( n = 219) felt equipped to explain a core biopsy, but only 40% of PCPs ( n = 120) felt that they had the expertise to answer questions from women about breast biopsy results. Family medicine training, private practice setting, greater percentage of panel of older patients, and viewing the ordering physician (versus radiologist) as primarily responsible for notifying patients of abnormal results were positively associated with feeling equipped to explain the biopsy process. Challenges in communication due to cultural differences between PCP and patient were negatively associated with a physician’s sense of expertise to answer questions about biopsy results. Conclusions: PCPs reported having the expertise to discuss the results of breast biopsies with women less frequently than they reported feeling equipped to discuss the breast biopsy process. Greater uncertainty was observed when PCPs were communicating with women from different cultural backgrounds from their own.

In September 2020 the US National Institutes of Health (NIH) allocated $12 million to support engagement with historically marginalized communities hardest hit by COVID-19. The award was designed to mobilize community-engagement in pandemic response, and to support partnerships as part of the NIH Community Engagement Alliance (CEAL) Against COVID-19 Disparities. All aspects of the award were fast-tracked and NIH utilized a 'more flexible' funding mechanism (OTA) to facilitate swift distribution of funds. In this paper, we draw upon an analysis of findings from a 2021 survey conducted with 11 California CEAL sites representing urban and rural settings, private and public universities, and established and new community partners and qualitative analysis of 2020-2022 site-wide meeting minutes. We describe challenges posed at the federal (e.g., NIH funding), university, and community-university partnership levels as well as opportunities and creative workarounds. Challenges include delays in subcontracts and payments to community partners that undermined trust and reproduced unequal and hierarchical power relationships. We build upon our findings and collective experience to propose a framework for decolonized fiscal relationships between universities and community partners which contains key recommendations for funders, universities, and community partners.