Bio

Ryan Brewster is a Neonatal-Perinatal Medicine Fellow at the Stanford University School of Medicine. His scholarship focuses on building, scaling, and evaluating technology-enabled models of care delivery, with an emphasis on child health equity. Ongoing initiatives include implementing pediatric home hospital, studying the use of artificial intelligence for medical translation and interpretation, and expanding tele-neonatology services globally. Prior to his clinical fellowship, he was a Harvard HealthTech Fellow and Ariadne Labs Research Fellow. His work has led to over 80 peer-reviewed publications and conference presentations that have been featured in Forbes, CNN, STAT News, and the New York Times.

Dr. Brewster completed his residency training in the Boston Combined Residency Program (Boston Children’s Hospital/Harvard Medical School and Boston Medical Center/Boston University School of Medicine) as part of the Leadership in Equity and Advocacy Track and is a graduate of the Stanford University School of Medicine (MD) and Middlebury College (BA).

Professional Education

  • Certificate, Stanford Graduate School of Business Ignite (2019)

All Publications

  • Evaluating human-in-the-loop strategies for artificial intelligence-enabled translation of patient discharge instructions: a multidisciplinary analysis. NPJ digital medicine Brewster, R. C., Tse, G., Fan, A. L., Elborki, M., Newell, M., Gonzalez, P., Hoq, A., Chang, C., Chowdhury, M., Geeti, A., Hana, M., Hassan, H., Ibrahim, O., Keseyan, L., Li, Q., Mamoon, M., Nageye, M., Ohannessian, A., Eisenberg, I. R., Sallam, M., Soto, G. S., Su, C., Tachdjian, R., Ray, M., Lev, H., Hron, J. D., Shaar, N., Kuzma, N., Khan, A. 2025; 8 (1): 629

    Abstract

    Machine translation supported by artificial intelligence (AI) may enhance linguistically-concordant care for patients speaking languages other than English. This assessment of free-text inpatient discharge instructions in Arabic, Armenian, Bengali, simplified Chinese, Somali, and Spanish compared linguist, clinician, and family caregiver evaluations of translations generated by (1) ChatGPT-4o, (2) professional linguists, and (3) human-in-the-loop (AI-generated, professional linguist post-edited). Likert scales (1-5; higher is better) evaluated linguistic and clinical characteristics of each translation. ChatGPT-4o exhibited variable performance relative to professional translations, with poorest ratings for digitally underrepresented languages (Armenian and Somali). Conversely, human-in-the-loop translations achieved comparable, often better, outcomes to professional translations for all languages, (e.g., Armenian mean overall quality: 3.9 [95% CI 3.7-4.2] vs. professional 3.6 [3.4-3.9], p = 0.01), were most frequently preferred (46.5% vs. 28.4%) and had shorter mean translation time (7.1 [5.4-8.8] vs. 16.8 [13.7-19.9] min, p < 0.001). Human-in-the-loop strategies may enable safe, efficient, equitable machine translation application in clinical practice.

    View details for DOI 10.1038/s41746-025-02055-6

    View details for PubMedID 41136708

    View details for PubMedCentralID 7573792

  • Characteristics and Safety of Consumer Chatbots for Emergent Adolescent Health Concerns. JAMA network open Brewster, R. C., Zahedivash, A., Tse, G., Bourgeois, F., Hadland, S. E. 2025; 8 (10): e2539022

    View details for DOI 10.1001/jamanetworkopen.2025.39022

    View details for PubMedID 41129154

    View details for PubMedCentralID PMC12550634

  • Adverse Childhood Experiences and Unmet Health Care Needs Due to Cost and the COVID-19 Pandemic: A Nationally Representative Analysis of US Adolescents JOURNAL OF ADOLESCENT HEALTH Khazanchi, R., Brewster, R. C. L., Tolliver, D. G., Heard-Garris, N. J., Vasan, A., Winkelman, T. N. A., Hadland, S. E. 2025; 77 (3): 514-523

    Abstract

    Adverse childhood experience (ACE) exposure and poor mental health are closely intertwined. In 2020, the prevalence of both began precipitously increasing among adolescents. We explored associations of individual and cumulative ACE exposure with cost and COVID-19 pandemic-related unmet health needs to assess ACEs as risk markers for broader structural adversity.We conducted a nationally representative analysis of 5,536 adolescents (weighted N = 20,294,070) aged 13-17 years using the 2019 and 2021 National Health Interview Survey. Outcomes included mental health symptoms, preventive care access, cost and COVID-19-related unmet needs, and health care use. We estimated associations with lifetime exposure to 4 ACEs using marginal effects from multivariable logistic regressions.Millions of adolescents were exposed to parental incarceration (7.8%, N = 1,407,670), neighborhood violence (6.9%, N = 1,567,483), a guardian with serious mental illness (10.3%, N = 2,088,957), and/or a guardian with alcohol or drug problems (11.4%, N = 2,304,953). Overall, 77.7% (N = 15,758,023), 13.2% (N = 2,671,342), and 9.2% (N = 1,864,704) were exposed to 0, 1, and 2+ of these ACEs. In adjusted models, compared with exposure to 0 ACEs, exposure to 1 or 2+ ACEs was positively associated with anxiety and depression symptom frequency, urgent care and emergency department use, trouble paying medical bills, delayed and forgone mental health care due to cost, and delayed and forgone care due to the COVID-19 pandemic.Adolescents exposed to ACEs experienced mutually reinforcing disadvantages: a worse mental health symptom burden, yet greater barriers to accessing needed medical and mental health care. ACEs must be reconceptualized as markers of structural-rather than individual-adversity and addressed through structural and policy interventions.

    View details for DOI 10.1016/j.jadohealth.2025.02.001

    View details for Web of Science ID 001567896700011

    View details for PubMedID 40183723

    View details for PubMedCentralID PMC12354138

  • Take the Lead on Lead: Feasibility of a Telemedicine-Based Clinic for Lead Poisoning Prevention and Management ACADEMIC PEDIATRICS Brewster, R. C. L., Acosta, K., Story, D., Bayuh, F., Shah, S., Woolf, A., Buncher, N., Hauptman, M. 2025; 25 (6): 102844

    Abstract

    Despite there being no safe amount of lead in the body, most public health and clinical interventions are focused on secondary prevention. A greater emphasis on early outreach may reduce cumulative lead exposure. Towards this end, we aimed to assess the feasibility of a virtual model for lead poisoning prevention and management among at-risk populations.We developed the Take the Lead on Lead (TLOL) clinic, a telemedicine-based program to facilitate educational visits, lead identification, and individualized resource allocation. We recruited patients aged 9 months-5 years with detectable, but low, BLLs (≥2 μg/dL and <10 μg/dL) from two urban academic medical centers in Boston, MA. Virtual visits featured a remote residential inspection to identify potential lead hazards and inform targeted counseling. Families also received a lead testing and temporary mitigation kit, community referrals, and follow-up BLL surveillance, as indicated.Among 35 participants, most were Black, non-Latinx (51.4%) with residence in homes constructed before 1970 (60%). Potential lead hazards were visualized in the majority of homes that underwent a virtual home inspection (71.4%). On a post-participation survey, most families found that TLOL participation addressed their clinical concerns; provided actionable resources; and helped identify lead sources.The TLOL program enabled detailed residential lead identification and early resource access with high levels of participant satisfaction. Further work is needed to assess the efficacy and cost-effectiveness of telemedicine-based care models applied towards lead poisoning prevention efforts.

    View details for DOI 10.1016/j.acap.2025.102844

    View details for Web of Science ID 001499408400001

    View details for PubMedID 40253003

    View details for PubMedCentralID PMC12317827

  • Evaluating a Large Language Model in Translating Patient Instructions to Spanish Using a Standardized Framework JAMA PEDIATRICS Ray, M., Kats, D. J., Moorkens, J., Rai, D., Shaar, N., Quinones, D., Vermeulen, A., Mateo, C. M., Brewster, R. C. L., Khan, A., Rader, B., Brownstein, J. S., Hron, J. D. 2025; 179 (9): 1026-1033

    Abstract

    Patients and caregivers who use languages other than English in the US encounter barriers to accessing language-concordant written instructions after clinical visits. Large language models (LLMs), such as OpenAI's GPT-4o, may improve access to translated patient materials; however, rigorous evaluation is needed to ensure clinical standards are met.To determine whether GPT-4o can generate high-quality Spanish translations of personalized patient instructions comparable to those performed by professional human translators.This cross-sectional study compared LLM translations to professional human translations using equivalence testing. The personalized pediatric instructions used were derived from real clinical encounters at a large US academic medical center and translated between January 2023 and December 2023. Patient instructions in English were translated into Spanish by GPT-4o and professional human translators. The source English texts were translated using GPT-4o on August 2, 2024. Both sets of translations were evaluated by 3 independent professional medical translators.Patient instructions were translated using GPT-4o with an engineered prompt, and these translations were compared with those produced by professional human translators.The primary outcome was translation quality, assessed using the Multidimensional Quality Metrics (MQM) framework to generate an overall MQM score (rated on a 0-100 scale). Secondary outcomes included a general preference rating and error rates for types of translation errors.This study included 20 source files of pediatric patient instructions. Equivalence testing showed no significant difference in translation quality between GPT-4o and human translations, with a mean difference of 1.6 points (90% CI, 0.7-2.5), falling within a predefined equivalence margin of plus or minus 5 MQM points. The LLM yielded fewer mistranslation errors, and a mean (SE) of 52% (6%) of professional translator ratings preferred the LLM translations.In this cross-sectional study, GPT-4o generated Spanish translations of pediatric patient instructions that were comparable in quality to those by professional human translators as evaluated using a standardized framework. While human review of LLM translation remains essential in health care, these findings suggest that GPT-4o could reduce the translation workload for Spanish, potentially freeing resources to support languages of lesser diffusion.

    View details for DOI 10.1001/jamapediatrics.2025.1729

    View details for Web of Science ID 001527158800001

    View details for PubMedID 40622720

    View details for PubMedCentralID PMC12235533

  • Family Perceptions of Pediatric Acute Hospital Care at Home in the United States: A Qualitative Analysis HOSPITAL PEDIATRICS Brewster, R. C. L., Thomas Day, R., Butler, A., Lin, E., Levine, D. M., Berry, J. G. 2025; 15 (7): 607-615

    Abstract

    Acute hospital care at home has emerged as an alternative to conventional hospitalization with comparable, if not better, clinical outcomes and patient experience in adults and internationally. To date, no programs serve a pediatric population in the United States. We aimed to qualitatively assess the perceptions of patient caregivers toward pediatric home hospital (HH) to inform family-centered design and implementation.Semistructured interviews were performed with a purposive sample of family caregivers of children who were recently hospitalized at an urban freestanding children's hospital. Interviews focused on experiences with previous hospitalization along with perceptions of pediatric HH that emphasized potential benefits and challenges. Qualitative data were coded and analyzed using thematic analysis to construct core themes.Among 20 caregiver participants, we identified 3 central themes. Relative to inpatient hospitalization, which was associated with disruptions to family routine and psychosocial stressors among other challenges, (1) family caregivers were largely receptive to the HH concept and described numerous potential benefits, including improved physical comfort, patient behavior, and hospital capacity management; (2) concerns about caregiver burden, clinical monitoring and safety, and scalability to different geographies and household conditions were noted as barriers to HH implementation; and (3) participants emphasized the importance of pediatric expertise among HH clinicians.HH was perceived to address many of the unintended consequences of conventional hospitalization with the potential to deliver more family-centered care. However, attention to unique clinical, psychosocial, and operational challenges are required to adapt existing models to the pediatric population in the United States.

    View details for DOI 10.1542/hpeds.2025-008334

    View details for Web of Science ID 001565643500009

    View details for PubMedID 40571291

  • Childcare Affordability and Benefits Among Resident Physicians JAMA NETWORK OPEN Brewster, R. C. L., Butler, A., Tanson, K., Kunhiabdullah, S., Kesselheim, J., Michelson, C. D. 2025; 8 (5): e2511089

    View details for DOI 10.1001/jamanetworkopen.2025.11089

    View details for Web of Science ID 001489616300009

    View details for PubMedID 40377943

    View details for PubMedCentralID PMC12084837

  • Artist's Statement: Boarding ACADEMIC MEDICINE Brewster, R. C. L. 2025; 100 (4): 425

    View details for DOI 10.1097/ACM.0000000000005934

    View details for Web of Science ID 001455250200009

    View details for PubMedID 40136248

  • Bacterial and Parasitic Stool Studies Have Limited Utility in Pediatric Hematopoietic Stem Cell Transplant Patients PEDIATRIC BLOOD & CANCER Nagy, M., Wychera, C., Schemm, J., Brewster, R., Duncan, C. N. 2025; 72 (5): e31617

    Abstract

    Diarrhea is a common complication among pediatric hematopoietic stem cell transplantation (HCT) recipients. Although many of the cases are secondary to graft-versus-host disease (GVHD), stool microbiological studies are often performed to evaluate an underlying infectious etiology. The aim of this study was to assess the frequency and utility of stool studies in children who have undergone HCT.Demographics, clinical characteristics, and stool study results (viral, parasitic, and bacterial) of all patients who underwent HCT at a large, academic, freestanding children's hospital between January 2006 and December 2023 were obtained. Statistical analysis conducted included t tests, chi-square, and linear regression.Overall, 1381 HCT recipients (9.2 ± 6.6 years) were included. Altogether, 6509 stool studies were obtained among 741 (54%) patients. Salmonella, Shigella, Yersinia, Campylobacter, and Escherichia coli (SSYCE) studies were sent on 363 (26%, 2252 studies) patients with 1 (0.04%) positive result. Clostridium difficile was sent on 706 (51%, 2055 studies) patients, with 156 positive studies (7.6%). Stool ova and parasite testing was sent on 143 (10%, 242 studies) patients, with two positive results (0.8%). Viral studies were sent on 638 (46%, 1960 studies) patients, with 107 positive studies (5.5%).While testing for Clostridium difficile and enteric viruses may have value in the work-up of pediatric HCT patients, SSYCE and O&P studies hold little to no value. Clinical practices surrounding routine stool microbiological studies should be reconsidered.

    View details for DOI 10.1002/pbc.31617

    View details for Web of Science ID 001426231200001

    View details for PubMedID 39979777

  • Enhancing healthcare equity by using open-source pediatric medical devices in low resource settings: An exploratory international survey of pediatric clinicians. PloS one Wu, A. G., Brewster, R. C., Carroll, R. W. 2025; 20 (10): e0334108

    Abstract

    Children in low-resource settings suffer from a high burden of treatable diseases that could be addressed with contextually appropriate technologies. However, numerous barriers to providing such technology to children in these settings exist. We propose that using open-source medical devices, where any qualified operator can freely make, modify, or distribute a product, may be a viable strategy to increase access to medical therapies in low-resource settings. However, given the novelty of open-source models, we sought to conduct an exploratory global survey on the perspectives and opinions of medical providers on the feasibility of this approach. Among 101 surveys completed by providers representing 34 countries, we found that the majority (89%) of respondents lacked experience working with open-source devices in low-resource settings; many respondents felt comfortable with providing an open-source pediatric medical device in a low-resource setting; lack of funding was the most significant barrier to successfully deploying these technologies; locally identified need was the most important factor to consider when conducting such projects; and respondents from the USA found no ethical issues with implementing open-source devices in low-resource settings, but respondents from outside the USA did find ethical issues with the same work. Our survey shows that most respondents in relevant specialties did not have experience working in either pediatric global health or with open-source medical devices in low-resource settings. Our survey may have revealed a potential unexplored frontier in addressing inequities in health care by enhancing access to equipment and technologies in areas of the world with the highest burdens of treatable pediatric disease, while also identifying ethical and cultural obstacles that warrant consideration.

    View details for DOI 10.1371/journal.pone.0334108

    View details for PubMedID 41134832

  • US FDA Approval of Pediatric Artificial Intelligence and Machine Learning-Enabled Medical Devices JAMA PEDIATRICS Brewster, R. C. L., Nagy, M., Wunnava, S., Bourgeois, F. T. 2025; 179 (2): 212-214

    View details for DOI 10.1001/jamapediatrics.2024.5437

    View details for Web of Science ID 001381234200001

    View details for PubMedID 39680415

    View details for PubMedCentralID PMC11791695

  • Bacterial (Non-Clostridium Difficile) and Parasitic Stool Studies Have Limited Utility in Pediatric Hematopoietic Stem Cell Transplant Patients Nagy, M., Wychera, C., Schemm, J., Brewster, R., Duncan, C. ELSEVIER. 2024: 7386

    View details for DOI 10.1182/blood-2024-204248

    View details for Web of Science ID 001412849200003

  • Implementing Acute Hospital Care at Home in Pediatrics PEDIATRICS Brewster, R. C. L., Wickremasinghe, W., Levine, D. M. 2024; 154 (2)

    View details for DOI 10.1542/peds.2023-064794

    View details for Web of Science ID 001339171900039

    View details for PubMedID 38978510

  • Performance of ChatGPT and Google Translate for Pediatric Discharge Instruction Translation. Pediatrics Brewster, R. C., Gonzalez, P., Khazanchi, R., Butler, A., Selcer, R., Chu, D., Aires, B. P., Luercio, M., Hron, J. D. 2024; 154 (1)

    Abstract

    BACKGROUND AND OBJECTIVES: Patients who speak languages other than English face barriers to equitable healthcare delivery. Machine translation systems, including emerging large language models, have the potential to expand access to translation services, but their merits and limitations in clinical practice remain poorly defined. We aimed to assess the performance of Google Translate and ChatGPT for multilingual translation of pediatric discharge instructions.METHODS: Twenty standardized discharge instructions for pediatric conditions were translated into Spanish, Brazilian Portuguese, and Haitian Creole by professional translation services, Google Translate and ChatGPT-4.0, and evaluated for adequacy (preserved information), fluency (grammatical correctness), meaning (preserved connotation), and severity (clinical harm), along with assessment of overall preference. Domain-level ratings and preferred translation source were summarized with descriptive statistics and compared with professional translations.RESULTS: Google Translate and ChatGPT demonstrated similar domain-level ratings to professional translations for Spanish and Portuguese. For Haitian Creole, compared with both Google Translate and ChatGPT, professional translations demonstrated significantly greater adequacy, fluency meaning, and severity scores. ChatGPT (33.3%, P < .001) and Google Translate (23.3%, P = .024) contained more potentially clinically significant errors (severity score ≤3) for Haitian Creole than professional translations (8.3%). Professional Haitian Creole (48.3%) and Portuguese (43.3%), but not Spanish (15%), translations were most frequently preferred among translation sources.CONCLUSIONS: Machine translation platforms have comparable performance to professional translations for Spanish and Portuguese but shortcomings in quality, accuracy, and preference persist for Haitian Creole. Diverse multilingual training data are needed, along with regulations ensuring safe and equitable applications of machine translation in clinical practice.

    View details for DOI 10.1542/peds.2023-065573

    View details for PubMedID 38860299

  • Impact of the COVID-19 Pandemic on Childhood Lead Testing and Blood Lead Levels ACADEMIC PEDIATRICS Brewster, R. C. L., Azad, A. D., Acosta, K., Starmer, A., Sprecher, E., Rea, C., Gray, K. P., Regan, S., Wilson, J., Bayuh, F., Buncher, N., Hauptman, M. 2024; 24 (5): 810-814

    Abstract

    To evaluate the effect of the COVID-19 pandemic on childhood lead testing and blood lead levels.A retrospective analysis of lead tests and results was performed across 3 urban medical centers during the pre-COVID-19 (March 10, 2019-March 9, 2020) and COVID-19 (March 10, 2020-March 10, 2022) periods. Interrupted time series analysis with quasi-Poisson regression was used to evaluate changes in lead testing between study periods. The relationship between sociodemographic features with detectable (≧2 µg/dL) and elevated (≧3.5 µg/dL) blood lead levels (BLLs) was assessed with multivariable logistic regression.Among a total of 16,364 lead tests across 10,362 patients, weekly testing rates significantly decreased during COVID-19 (relative risk (RR) 0.64, 95% (confidence interval) CI 0.53-0.78). Census tracts with the greatest proportion of pre-1950s housing had a stronger association with detectable BLLs during the COVID-19 period (pre-COVID-19 adjusted odds ratio (aOR) 1.73, 95% CI 1.35-2.20; aOR 2.58, 95% CI 2.13-3.12; interaction P value .014). When limited to 1 year following COVID-19 (March 10, 2020-March 10, 2021), the association between both elevated BLLs (pre-COVID-19: aOR 1.49, 95% CI 0.87-2.53; COVID-19: aOR 3.51, 95% CI 1.98-6.25; interaction P value .032) and detectable BLLs with pre-1950s housing were greater during the COVID-19 period (pre-COVID-19: aOR 1.73, 95% CI 1.35-2.20; COVID-19: aOR 2.56, 95% CI 1.95-3.34; interaction P value .034).The COVID-19 pandemic led to a significant reduction in lead surveillance and magnified the effect of known risk factors for lead exposure. Concerted clinical, public health, and community advocacy are needed to address care gaps and excess cases of lead poisoning.

    View details for DOI 10.1016/j.acap.2023.11.014

    View details for Web of Science ID 001292006100001

    View details for PubMedID 37979935

    View details for PubMedCentralID PMC11949626

  • A Proof-of-Concept Model for Implementing a "Smart-NICU" to Improve Infant Mortality JOURNAL OF INTENSIVE CARE MEDICINE Hilker, S., Mancho, A., Srivatsava, G., Raman, D., Mathias, S., Brewster, R., Britto, C. 2024; 39 (10): 974-979

    Abstract

    Low- and middle-income countries face limited critical care capacity due to constraints in staffing, resources, and technology. "Smart ICUs" that integrate telehealth to augment care delivery, communication, and data integration have the potential to bridge these gaps and reduce preventable morbidity and mortality. While their efficacy has been well validated in adult populations, applications of Smart-ICU services in the neonatal population have not been studied. Neonatal intensive care units (NICUs) in India using a common Smart-NICU platform, developed by CloudPhysician, utilize a hub-and-spokes framework along with locally designed technology to facilitate remote patient care in collaboration with local health systems. In this article, we investigate the operational characteristics and performance outcomes for Smart-NICU deployment from the 18 NICUs and 214 beds deployed to date. These findings highlight the potential impact of Smart-NICUs and establish generalizable principles for implementation in low-resource settings.

    View details for DOI 10.1177/08850666241247532

    View details for Web of Science ID 001204880100001

    View details for PubMedID 38632953

  • A pragmatic calibration of the ROX index to predict outcome of nasal high-flow therapy in India JOURNAL OF CRITICAL CARE Brewster, R., Mathias, S., Sarvode, S., Unnikrishnan, D., Raman, D., Foy, B., Britto, C., Cloudphysician Tele-ICU Consortium 2024; 82: 154812

    Abstract

    Identifying thresholds at which the ROX index would satisfactorily predict HFNC failure across heterogenous resourced contexts is necessary for clinical use.Patients ≥18 years admitted to 30 diverse ICUs across 10 states in India who required HFNC for respiratory support were retrospectively included in this study. Patient data and hourly ROX indices were then analyzed and contextualized to clinical outcomes as well as with ROX index thresholds in other regions of the world.Among the 614 patients included, 276 (44.9%) required respiratory escalation. Pneumonia was the most common diagnosis on admission. Receiver operating characteristic curve analysis revealed that a baseline ROX score of 7.86 was similar to 4.88 in other populations which was confirmed by Kaplan-Mier curves (hazard ratio,3.58 (2.72-4.69, p < 0.001)). ROX scores at 11.84 or 5.89 had roles in screening and confirming HFNC failure. The index performed poorly in a subset of patients who died without respiratory escalation. The ROX index was most predictive in the initial hours of ICU admission and a longer duration of HFNC was associated with more severe outcomes.When optimally calibrated this index can using a method that can reliably predict the risk of HFNC failure among ICU patients from diverse settings.

    View details for DOI 10.1016/j.jcrc.2024.154812

    View details for Web of Science ID 001235182900001

    View details for PubMedID 38608348

  • Impact of the COVID-19 Pandemic on Blood Lead Testing in Children in the United States POPULATION HEALTH MANAGEMENT Kaufman, H. W., Niles, J. K., Brewster, R. C. L., Acosta, K., Shah, S. H., Hauptman, M. 2024; 27 (3): 199-205

    Abstract

    The study objective was to evaluate the impact of the coronavirus disease (COVID-19) pandemic on pediatric blood lead testing in the United States. Clinical laboratory pediatric (ages <6 years) blood lead level (BLL) tests performed by Quest Diagnostics, January 2019-March 2022, were analyzed. Patients were categorized by age, by sex, and, through matching by ZIP code with US Census data, for race, ethnicity, pre-1950 housing, and poverty estimates. Over 2.8 million results from children (<6 years old) from all 50 states and the District of Columbia were included. Compared to March-May 2019, BLL testing was lower by 53.6% in March-May 2020 and lower by 14.6% in March-May 2021. Testing rebounded more for children in predominantly White non-Hispanic communities and among children living in communities, based on ZIP codes, with the least pre-1950 housing stock and lowest poverty rates. The proportion of children with BLL at or above the United States Centers for Disease Control and Prevention reference values of 3.5 and 5.0 µg/dL fell by 19% and 24%, respectively, in 2021 versus 2019. In conclusion, pediatric BLL testing has rebounded from sharp declines during the early pandemic period but unevenly. Declines in the proportion of children with elevated BLL should be interpreted with caution, as testing rebounds were less robust among communities with the highest risk of lead poisoning, notably communities with the oldest housing stock and higher poverty rates. More public health efforts are needed to address lead toxicity throughout the United States, especially in communities that did not experience a full rebound subsequent to the early COVID-19 pandemic period.

    View details for DOI 10.1089/pop.2023.0298

    View details for Web of Science ID 001198238200001

    View details for PubMedID 38587281

    View details for PubMedCentralID PMC11971586

  • Open source approaches for pediatric global health technologies. Journal of medical engineering & technology Brewster, R. C., Wu, A., Carroll, R. W. 2023; 47 (8): 371-375

    Abstract

    Access to medical technologies is a critical component of universal access to care; however, the advancement of technologies for children has historically lagged behind those for adults. The small market size, anatomic and physiologic variability, and legal and ethical implications pose unique barriers to developing and commercialising paediatric biomedical innovations. These challenges are magnified in low-resource settings (LRS), which often lack appropriate regulatory oversight, support for service contracts, and supply chain capacity. The COVID-19 pandemic exposed shortcomings in the traditional industry model for medical technologies, while also catalysing open-source approaches to technology development and dissemination. Open-source pathways - where products are freely licenced to be distributed and modified - addressed key shortages in critical equipment. Relatedly, we argue that open-source approaches can accelerate paediatric global health technology development. Open-source approaches can be tailored to clinical challenges independent of economic factors, embrace low-cost manufacturing techniques, and can be highly customisable. Furthermore, diverse stakeholders, including families and patients, are empowered to participate in collaborative communities of practice. How to regulate the development, manufacture, and distribution of open-source technologies remains an ongoing area of exploration. The need for democratised innovation must be carefully balanced against the imperatives of safety and quality for paediatric-specific solutions. This can be achieved, in part, through close coordination between national regulatory agencies and decentralised networks where products can be peer-reviewed and tested. Altogether, there is significant potential for open source to advance more equitable and sustainable medical innovations for all children.

    View details for DOI 10.1080/03091902.2024.2343682

    View details for PubMedID 38717814

  • The 2022 to 2023 Amoxicillin Shortage and Acute Otitis Media Treatment PEDIATRICS Brewster, R. C. L., Khazanchi, R., Butler, A., OMeara, D., Bagchi, D., Michelson, K. A. 2023; 152 (3)

    View details for DOI 10.1542/peds.2023-062482

    View details for Web of Science ID 001160276400041

    View details for PubMedID 37555262

    View details for PubMedCentralID PMC10895544

  • Evaluation of Housing Affordability Among US Resident Physicians JAMA NETWORK OPEN Brewster, R. C. L., Butler, A., Michelson, C. D., Kesselheim, J. 2023; 6 (6): e2320455

    View details for DOI 10.1001/jamanetworkopen.2023.20455

    View details for Web of Science ID 001054031500001

    View details for PubMedID 37368404

    View details for PubMedCentralID PMC10300675

  • A Prescription for Internet: Feasibility of a Tablet Loaner Program to Address Digital Health Inequities APPLIED CLINICAL INFORMATICS Brewster, R. C. L., Zhang, J., Stewart, M., Kaur, R., Arellano, M., Bourgeois, F. 2023; 14 (02): 273-278

    Abstract

    The coronavirus disease 2019 pandemic accelerated the adoption of telehealth technologies. Persistent disparities in telecommunication devices, internet connectivity, and digital literacy, however, undermine the potential for telemedicine to reduce barriers to health care access. Health systems may have a role in addressing these structural inequities. We describe the operationalization and feasibility of an internet-enabled tablet loaner program at a freestanding children's hospital.Between October 2020 and October 2021, pediatricians enrolled families through ambulatory clinics at an academic urban freestanding children's hospital. Eligibility criteria included difficulty accessing virtual care due to lack of stable internet or device. Tablets featured an unlimited data package, access to the patient portal, and virtual visit platform. A private technology company managed device configuration and distribution. To characterize program impact, we compared the proportion of completed clinical encounters during the intervention compared with a preintervention period (March 2020-October 2020) and conducted a qualitative survey with program participants. Participant and visit characteristics were obtained from the electronic medical record and summarized with descriptive statistics.A total of 111 families participated in the tablet loaner program, the majority of whom were Hispanic (51.4%) and black, non-Hispanic (26.1%), and publicly insured (64.9%). Between the preintervention and intervention periods, there was a significant increase in completed video- and phone-based virtual visits (75.3 vs. 79.1%, p = 0.038). The proportion of video-based only visits increased from 82.9 to 88.9%. p < 0.001. Families reported that the tablet improved the patient's ability to receive medical care (93.7%) and was easy to use (93.9%).The tablet loaner initiative was associated with an improvement in markers of virtual visit engagement and health care experience. Efforts to expand telemedicine equity must consider technological access and digital literacy as well as broad coalitions across industry, government, and community organizations.

    View details for DOI 10.1055/a-2016-7417

    View details for Web of Science ID 000970371600001

    View details for PubMedID 36669761

    View details for PubMedCentralID PMC10097475

  • The utilization of clinical decision support tools to identify neonatal hypothermia and its associated risk factors: A prospective observational study PLOS GLOBAL PUBLIC HEALTH Muhindo, M., Bress, J., Armas, J., Danziger, E., Wu, A., Brewster, R. C. L. 2023; 3 (2): e0000982

    Abstract

    Hypothermia (axillary temperature less than 36.5°) is a major source of neonatal morbidity and mortality, with a disproportionate burden of disease in low- and middle-income countries. Despite the importance of thermoregulation on newborn outcomes, the global epidemiologic landscape of neonatal hypothermia is poorly characterized. Clinical decision support (CDS) software provides point-of-care recommendations to guide clinical management and may support data capture in settings with limited informatics infrastructure. Towards this end, we conducted a prospective observational study of the NoviGuide, a novel CDS platform for newborn care, at four health facilities in Uganda between September 2022 to May 2021. Data were extracted from clinical information (e.g. axillary temperature, birth weight, gestational age) entered into the NoviGuide by nurses and midwives on newborns within 24 hours of delivery. Descriptive statistics and multivariable logistic regression were used to evaluate neonatal temperature profiles and the association between hypothermia and clinical features. Among 1,027 completed assessments, 30.5% of entries had neonatal hypothermia with significant variation across study sites. On multivariable logistic regression analysis, we found that hypothermia was independently associated with pre-term birth (Adjusted Odd's Ratio [aOR] 2.62, 95% Confidence interval [CI] 1.38-4.98), sepsis/concern for sepsis (aOR 2.73, 95% CI 2.90-3.94), and hypoglycemia/concern for hypoglycemia (aOR 1.78, 95% CI 1.17-2.72). Altogether, neonatal hypothermia was commonly entered into the NoviGuide and associated clinical characteristics aligned with previous studies based on conventional data collection instruments. Our results should be contextualized within unique technical and operational features of CDS tools, including a bias towards acutely ill patients and limited quality control. Nonetheless, this study demonstrates that a CDS used voluntarily by clinicians has the potential to fill key data gaps and drive quality improvement towards reducing neonatal hypothermia in low resource settings.

    View details for DOI 10.1371/journal.pgph.0000982

    View details for Web of Science ID 001417594000001

    View details for PubMedID 36962972

    View details for PubMedCentralID PMC10022021

  • Persistent Lactic Acidosis in an Infant With Milk Protein Allergy CLINICAL PEDIATRICS Rabinowitz, D. G., Brewster, R. C. L., Juttukonda, L. J., Bodamer, O. A., Palma, M. J. 2023; 62 (8): 951-955

    View details for DOI 10.1177/00099228221148076

    View details for Web of Science ID 000905627300001

    View details for PubMedID 36579865

  • A Community-Based COVID-19 Vaccine Education Initiative PEDIATRICS Edwards, J. G., Cheston, C. C., Kelly, C. A., Brewster, R. C. L., Williams, A. R., Mell, A. J. 2022; 150 (6)

    Abstract

    Coronavirus disease 2019 (COVID-19) has had a disparate impact on Black and Latinx communities. Even before the COVID-19 pandemic, inaccessibility and distrust of the medical community rooted in historical oppression led to hesitancy about medical interventions. In Boston, COVID-19 vaccination rates of Black and Latinx adolescents lagged behind their white and Asian peers. In response, Boston Medical Center created community vaccine clinic sites across Suffolk County. Pediatric resident physicians subsequently partnered with Boston Medical Center to establish an accompanying education program entitled "Ask-a-Doc" to help improve health literacy and address vaccine hesitancy that focused on Black and Latinx adolescents. In partnership with multidisciplinary stakeholders, including Boston Public School leaders, Ask-a-Doc pediatric resident physicians staffed 46 community vaccine events in 15 zip codes. At these events, 1521 vaccine doses were administered, with most administered to Black and Latinx community members. As of January 1, 2022, 67% of 51 first-year pediatric resident physicians had participated. Ask-A-Doc is an example of a community-based intervention that directly targets health inequities and misinformation and demonstrates that pediatric resident physicians can meaningfully engage in community outreach with sufficient protected time, resources, and institutional support. The resulting connections may lead to greater trust and credibility within systematically oppressed communities.

    View details for DOI 10.1542/peds.2022-057374

    View details for Web of Science ID 000918445100019

    View details for PubMedID 36349517

  • "My Body, Whose Choice?" A Call to Advance Reproductive Justice in Pediatric Training PEDIATRICS Isbell, T., Brewster, R., Soderborg, T., Javalkar, K. 2022; 150 (1)

    View details for DOI 10.1542/peds.2021-054936

    View details for Web of Science ID 000918236400010

    View details for PubMedID 35445273

  • COVID-19-Associated Croup in Children. Pediatrics Brewster, R. C., Parsons, C., Laird-Gion, J., Hilker, S., Irwin, M., Sommerschield, A., Michaelis, K. A., Lam, M., Parsons, A., Mansbach, J. M. 2022; 149 (6)

    View details for DOI 10.1542/peds.2022-056492

    View details for PubMedID 35257175

  • Managing Persistent Hypertension and Tachycardia Following Septic Shock, Limb Ischemia, and Amputation: The Role for beta-Blockade. Clinical pediatrics Brewster, R., Lee, J., Nguyen, E., Ward, V. 2021; 60 (4-5): 226–29

    View details for DOI 10.1177/00099228211006704

    View details for PubMedID 33853367

  • Evaluation of Absolute Lymphocyte Count at Diagnosis and Mortality Among Patients With Localized Bone or Soft Tissue Sarcoma. JAMA network open Brewster, R., Purington, N., Henry, S., Wood, D., Ganjoo, K., Bui, N. 2021; 4 (3): e210845

    Abstract

    Importance: Host-related immune factors have been implicated in the development and progression of diverse malignant neoplasms. Identifying associations between immunologic laboratory parameters and overall survival may inform novel prognostic biomarkers and mechanisms of antitumor immunity in localized bone and soft tissue sarcoma.Objective: To assess whether lymphopenia at diagnosis is associated with overall survival among patients with localized bone and soft tissue sarcoma.Design, Setting, and Participants: This retrospective cohort study analyzed patients from the Stanford Cancer Institute with localized bone and soft tissue sarcoma between September 1, 1998, and November 1, 2018. Patients were included if laboratory values were available within 60 days of diagnosis and, if applicable, prior to the initiation of chemotherapy and/or radiotherapy. Statistical analysis was performed from January 1, 2019, to November 1, 2020.Exposures: Absolute lymphocyte count within 60 days of diagnosis and antimicrobial exposure, defined by the number of antimicrobial agent prescriptions and the cumulative duration of antimicrobial administration within 60 days of diagnosis.Main Outcomes and Measures: The association between minimum absolute lymphocyte count at diagnosis and 5-year overall survival probability was characterized with the Kaplan-Meier method and multivariate Cox proportional hazards regression models. Multivariable logistic regressions were fitted to evaluate whether patients with lymphopenia were at greater risk of increased antimicrobial exposure.Results: Among 634 patients, the median age at diagnosis was 53.7 years (interquartile range, 37.5-66.8 years), and 290 patients (45.7%) were women, with a 5-year survival probability of 67.9%. There was a significant inverse association between lymphopenia at diagnosis and overall survival (hazard ratio [HR], 1.82; 95% CI, 1.39-1.40), resulting in a 13.5% 5-year survival probability difference compared with patients who did not have lymphopenia at diagnosis (60.2% vs 73.7% for those who never had lymphopenia). In addition, poorer survival was observed with higher-grade lymphopenia (grades 3 and 4: HR, 2.44; 95% CI, 1.68-3.55; grades 1 and 2: HR, 1.60; 95% CI, 1.18-2.18). In an exploratory analysis, patients with increased antibiotic exposure were more likely to have lymphopenia (odds ratio, 1.96; 95% CI, 1.26-3.07 for total number of antimicrobial agents; odds ratio, 1.70; 95% CI, 1.10-2.57 for antimicrobial duration) than antimicrobial-naive patients.Conclusions and Relevance: This study suggests that an abnormally low absolute lymphocyte count at diagnosis is associated with higher mortality among patients with localized bone and soft tissue sarcoma; therefore, lymphopenia may serve as a reliable prognostic biomarker. Potential mechanisms associated with host immunity and overall survival include a suppressed antitumor response and increased infectious complications, which merit future investigation.

    View details for DOI 10.1001/jamanetworkopen.2021.0845

    View details for PubMedID 33666664

  • Gut microbiome profiling of a rural and urban South African cohort reveals biomarkers of a population in lifestyle transition. BMC microbiology Oduaran, O. H., Tamburini, F. B., Sahibdeen, V., Brewster, R., Gomez-Olive, F. X., Kahn, K., Norris, S. A., Tollman, S. M., Twine, R., Wade, A. N., Wagner, R. G., Lombard, Z., Bhatt, A. S., Hazelhurst, S. 2020; 20 (1): 330

    Abstract

    BACKGROUND: Comparisons of traditional hunter-gatherers and pre-agricultural communities in Africa with urban and suburban Western North American and European cohorts have clearly shown that diet, lifestyle and environment are associated with gut microbiome composition. Yet, little is known about the gut microbiome composition of most communities in the very diverse African continent. South Africa comprises a richly diverse ethnolinguistic population that is experiencing an ongoing epidemiological transition and concurrent spike in the prevalence of obesity, largely attributed to a shift towards more Westernized diets and increasingly inactive lifestyle practices. To characterize the microbiome of African adults living in more mainstream lifestyle settings and investigate associations between the microbiome and obesity, we conducted a pilot study, designed collaboratively with community leaders, in two South African cohorts representative of urban and transitioning rural populations. As the rate of overweight and obesity is particularly high in women, we collected single time-point stool samples from 170 HIV-negative women (51 at Soweto; 119 at Bushbuckridge), performed 16S rRNA gene sequencing on these samples and compared the data to concurrently collected anthropometric data.RESULTS: We found the overall gut microbiome of our cohorts to be reflective of their ongoing epidemiological transition. Specifically, we find that geographical location was more important for sample clustering than lean/obese status and observed a relatively higher abundance of the Melainabacteria, Vampirovibrio, a predatory bacterium, in Bushbuckridge. Also, Prevotella, despite its generally high prevalence in the cohorts, showed an association with obesity. In comparisons with benchmarked datasets representative of non-Western populations, relatively higher abundance values were observed in our dataset for Barnesiella (log2fold change (FC)=4.5), Alistipes (log2FC=3.9), Bacteroides (log2FC=4.2), Parabacteroides (log2FC=3.1) and Treponema (log2FC=1.6), with the exception of Prevotella (log2FC=-4.7).CONCLUSIONS: Altogether, this work identifies putative microbial features associated with host health in a historically understudied community undergoing an epidemiological transition. Furthermore, we note the crucial role of community engagement to the success of a study in an African setting, the importance of more population-specific studies to inform targeted interventions as well as present a basic foundation for future research.

    View details for DOI 10.1186/s12866-020-02017-w

    View details for PubMedID 33129264

  • The Effect of Socioeconomic Status on Age at Diagnosis and Overall Survival in Patients with Intracranial Meningioma. The International journal of neuroscience Brewster, R., Deb, S., Pendharkar, A. V., Ratliff, J., Li, G., Desai, A. 2020: 1–12

    Abstract

    Background: Intracranial meningiomas are the most common primary tumors of the central nervous system. How socioeconomic status (SES) impacts treatment access and outcomes for brain tumor subtypes is an emerging area of research. Few studies have examined the relationship between SES and meningioma survival and management with reference to relevant clinical factors, including age at diagnosis. We studied the independent effects of SES on receiving surgery and survival probability in patients with intracranial meningiomaMethods: 54,282 patients diagnosed with intracranial meningioma between 2003-2012 from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute database were included. Patient SES was divided into tertiles. Patient age groups included "older" (>65, the median patient age) and "younger". Multivariable linear regression and Cox proportional hazards model were used with SAS v9.4. Results were adjusted for race, sex, and tumor grade. Kaplan Meier survival curves were constructed according to SES tertiles and age groups.Results: Meningioma prevalence increased with higher SES tertile. Higher SES tertile was also associated with younger age at diagnosis (OR= 0.890, p <0.05), an increased likelihood of undergoing gross total resection (GTR) (OR =1.112, p<0.05), and a trend towards greater 5-year survival probability (HR =1.773, p=0.0531). Survival probability correlated with younger age at diagnosis (HR =2.597, p<0.001), but not with GTR receipt.Conclusion: The findings from this national longitudinal study on patients with meningioma suggest that SES affects age at diagnosis and treatment access for intracranial meningiomas patients. Further studies are required to understand and address the mechanisms underlying these disparities.

    View details for DOI 10.1080/00207454.2020.1818742

    View details for PubMedID 32878534

  • Using Telemedicine and Infographics for Physician-Guided Home Drain Removal. OTO open Go, B. C., Brewster, R., Patel, R., Rajasekaran, K. 2020; 4 (2): 2473974X20933566

    Abstract

    Objective: Measures to decrease hospital length of stay and outpatient visits are crucial during the coronavirus disease 2019 (COVID-19) pandemic. Physician-guided home drain removal presents a potential opportunity for mitigating viral spread and transmission.Methods: A prospective case series on patients undergoing major head and neck surgery with Jackson-Pratt drain placement was conducted. Patients were shown an infographic detailing drain care and removal at preoperative assessment and prior to discharge. At a 1-week follow-up telemedicine visit, patients were instructed to remove the drain under physician guidance. Patients were assessed 7 days after to determine complication rate and satisfaction.Results: Twenty-five patients were enrolled with 100% patients undergoing successful drain removal at home with caregiver support. There were no complications reported at the 7-day postdrain removal time point, and overall patient satisfaction was high.Discussion: Infographics and telemedicine are 2 synergistic strategies to guide safe and effective home drain removal.Implications for Practice: This study demonstrates how telemedicine and an infographic can be effectively used in physician-guided home drain removal. During a time like the COVID-19 pandemic, innovative measures are necessary to curb transmission and infection rates. We propose a unique and replicable yet safe solution to limit unnecessary exposure and encourage other surgical providers to adopt a similar strategy.

    View details for DOI 10.1177/2473974X20933566

    View details for PubMedID 32548544

  • Justice is the Best Medicine. And, Yes, You Can Call Us by Our Pronouns. AMA journal of ethics Brewster, R. 2020; 22 (3): E253–254

    Abstract

    One recent essay suggests that emphasis on social justice in medical education is done at the expense of clinicians' technical competency. This response to that stance is a digitally illustrated series that contextualizes patient health as both physiological and determined by social, economic, and cultural conditions.

    View details for DOI 10.1001/amajethics.2020.253

    View details for PubMedID 32220273

  • Optimizing telemedicine encounters for oral and maxillofacial surgeons during the COVID-19 pandemic. Oral surgery, oral medicine, oral pathology and oral radiology Moon, H. S., Wang, T. T., Rajasekaran, K. n., Brewster, R. n., Shanti, R. M., Panchal, N. n. 2020

    Abstract

    The coronavirus disease 2019 (COVID-19) pandemic has changed conventional patterns of medical practice across all health disciplines, including oral and maxillofacial surgery. The use of telemedicine has rapidly expanded to uphold safety strategies of physical distancing and disease transmission reduction while maintaining uninterrupted care of patients. To date, there are no specific guidelines to optimize telemedicine encounters in oral and maxillofacial surgery. The goal of this article is to provide best practices for both oral and maxillofacial surgeons and their patients to effectively use telemedicine for the duration of the COVID-19 pandemic and beyond.

    View details for DOI 10.1016/j.oooo.2020.08.015

    View details for PubMedID 32981876

  • Optimizing your telemedicine visit during the COVID-19 pandemic: Practice guidelines for patients with head and neck cancer. Head & neck Prasad, A. n., Brewster, R. n., Newman, J. G., Rajasekaran, K. n. 2020

    Abstract

    The COVID-19 epidemic has resulted in many hospitals and practices to cancel in-person outpatient clinic visits, where head and neck patients receive their critical longitudinal care. Out of necessity, most practices have been encouraged to use telemedicine as a method to maintain a continuum of care with their patients. As a result, the prevalence of telemedicine has grown rapidly during this pandemic, without allowing the physicians and patients to be adequately educated on how best to utilize the services. There is a steep learning curve as we have learned, and our goal is to provide guidelines for both patients and physicians, as well as a valuable patient handout in preparation for their visit.

    View details for DOI 10.1002/hed.26197

    View details for PubMedID 32343458

  • How to perform a nasopharyngeal swab - an otolaryngology perspective. The American journal of medicine Kaufman, A. C., Brewster, R. n., Rajasekaran, K. n. 2020

    View details for DOI 10.1016/j.amjmed.2020.05.004

    View details for PubMedID 32492374

    View details for PubMedCentralID PMC7261357

  • Preparing for Telemedicine Visits: Guidelines and Setup. Frontiers in medicine Prasad, A. n., Brewster, R. n., Rajasekaran, D. n., Rajasekaran, K. n. 2020; 7: 600794

    View details for DOI 10.3389/fmed.2020.600794

    View details for PubMedID 33324665

    View details for PubMedCentralID PMC7724018

  • Microbiota modification in hematology: still at the bench or ready for the bedside? Severyn, C. J., Brewster, R., Andermann, T. M. AMER SOC HEMATOLOGY. 2019: 303–14

    View details for Web of Science ID 000538564000044

  • Cutaneous Patches to Monitor Myoelectric Activity of the Gastrointestinal Tract in Postoperative Pediatric Patients PEDIATRIC GASTROENTEROLOGY HEPATOLOGY & NUTRITION Taylor, J. S., de Ruijter, V., Brewster, R., Navalgund, A., Axelrod, L., Axelrod, S., Dunn, J. C. Y., Wall, J. K. 2019; 22 (6): 518–26

    View details for DOI 10.5223/pghn.2019.22.6.518

    View details for Web of Science ID 000496920200003

  • Socioeconomic Predictors of Surgical Resection and Survival for Patients With Osseous Spinal Neoplasms CLINICAL SPINE SURGERY Deb, S., Brewster, R., Pendharkar, A., Veeravagu, A., Ratliff, J., Desai, A. 2019; 32 (3): 125–31

    View details for DOI 10.1097/BSD.0000000000000738

    View details for Web of Science ID 000464982800008

  • Frameless Robot-Assisted Deep Brain Stimulation Surgery: An Initial Experience. Operative neurosurgery (Hagerstown, Md.) Ho, A. L., Pendharkar, A. V., Brewster, R., Martinez, D. L., Jaffe, R. A., Xu, L. W., Miller, K. J., Halpern, C. H. 2019

    Abstract

    BACKGROUND: Modern robotic-assist surgical systems have revolutionized stereotaxy for a variety of procedures by increasing operative efficiency while preserving and even improving accuracy and safety. However, experience with robotic systems in deep brain stimulation (DBS) surgery is scarce.OBJECTIVE: To present an initial series of DBS surgery performed utilizing a frameless robotic solution for image-guided stereotaxy, and report on operative efficiency, stereotactic accuracy, and complications.METHODS: This study included the initial 20 consecutive patients undergoing bilateral robot-assisted DBS. The prior 20 nonrobotic, frameless cohort of DBS cases was sampled as a baseline historic control. For both cohorts, patient demographic and clinical data were collected including postoperative complications. Intraoperative duration and number of Microelectrode recording (MER) and final lead passes were recorded. For the robot-assisted cohort, 2D radial errors were calculated.RESULTS: Mean case times (total operating room, anesthesia, and operative times) were all significantly decreased in the robot-assisted cohort (all P-values<.02) compared to frameless DBS. When looking at trends in case times, operative efficiency improved over time in the robot-assisted cohort across all time assessment points. Mean radial error in the robot-assisted cohort was 1.40±0.11mm, and mean depth error was 1.05±0.18mm. There was a significant decrease in the average number of MER passes in the robot-assisted cohort (1.05) compared to the nonrobotic cohort (1.45, P<.001).CONCLUSION: This is the first report of application of frameless robotic-assistance with the Mazor Renaissance platform (Mazor Robotics Ltd, Caesarea, Israel) for DBS surgery, and our findings reveal that an initial experience is safe and can have a positive impact on operative efficiency, accuracy, and safety.

    View details for PubMedID 30629245

  • Surveying Gut Microbiome Research in Africans: Toward Improved Diversity and Representation. Trends in microbiology Brewster, R. n., Tamburini, F. B., Asiimwe, E. n., Oduaran, O. n., Hazelhurst, S. n., Bhatt, A. S. 2019

    Abstract

    Descriptive and translational investigations into the human gut microbiome (GM) are rapidly expanding; however, studies are largely restricted to industrialized populations in the USA and Europe. Little is known about microbial variability and its implications for health and disease in other parts of the world. Populations in Africa are particularly underrepresented. What limited research has been performed has focused on a few subject domains, including the impact of long-term lifestyle and dietary factors on GM ecology, its maturation during infancy, and the interrelationships between the microbiome, infectious disease, and undernutrition. Recently, international consortia have laid the groundwork for large-scale genomics and microbiome studies on the continent, with a particular interest in the epidemiologic transition to noncommunicable disease. Here, we survey the current landscape of GM scholarship in Africa and propose actionable recommendations to improve research capacity and output.

    View details for DOI 10.1016/j.tim.2019.05.006

    View details for PubMedID 31178123

  • Microbiota modification in hematology: still at the bench or ready for the bedside? Hematology. American Society of Hematology. Education Program Severyn, C. J., Brewster, R. n., Andermann, T. M. 2019; 2019 (1): 303–14

    Abstract

    Growing evidence suggests that human microbiota likely influence diverse processes including hematopoiesis, chemotherapy metabolism, and efficacy, as well as overall survival in patients with hematologic malignancies and other cancers. Both host genetic susceptibility and host-microbiota interactions may impact cancer risk and response to treatment; however, microbiota have the potential to be uniquely modifiable and accessible targets for treatment. Here, we focus on strategies to modify microbiota composition and function in patients with cancer. First, we evaluate the use of fecal microbiota transplant to restore microbial equilibrium following perturbation by antibiotics and chemotherapy, and as a treatment of complications of hematopoietic stem cell transplantation (HSCT), such as graft-versus-host disease and colonization with multidrug-resistant organisms. We then address the potential use of both probiotics and dietary prebiotic compounds in targeted modulation of the microbiota intended to improve outcomes in hematologic diseases. With each type of therapy, we highlight the role that abnormal, or dysbiotic, microbiota play in disease, treatment efficacy, and toxicity and evaluate their potential promise as emerging strategies for microbiota manipulation in patients with hematologic malignancies and in those undergoing HSCT.

    View details for DOI 10.1182/hematology.2019000365

    View details for PubMedID 31808861

  • Microbiota modification in hematology: still at the bench or ready for the bedside? Blood advances Severyn, C. J., Brewster, R. n., Andermann, T. M. 2019; 3 (21): 3461–72

    Abstract

    Growing evidence suggests that human microbiota likely influence diverse processes including hematopoiesis, chemotherapy metabolism, and efficacy, as well as overall survival in patients with hematologic malignancies and other cancers. Both host genetic susceptibility and host-microbiota interactions may impact cancer risk and response to treatment; however, microbiota have the potential to be uniquely modifiable and accessible targets for treatment. Here, we focus on strategies to modify microbiota composition and function in patients with cancer. First, we evaluate the use of fecal microbiota transplant to restore microbial equilibrium following perturbation by antibiotics and chemotherapy, and as a treatment of complications of hematopoietic stem cell transplantation (HSCT), such as graft-versus-host disease and colonization with multidrug-resistant organisms. We then address the potential use of both probiotics and dietary prebiotic compounds in targeted modulation of the microbiota intended to improve outcomes in hematologic diseases. With each type of therapy, we highlight the role that abnormal, or dysbiotic, microbiota play in disease, treatment efficacy, and toxicity and evaluate their potential promise as emerging strategies for microbiota manipulation in patients with hematologic malignancies and in those undergoing HSCT.

    View details for DOI 10.1182/bloodadvances.2019000365

    View details for PubMedID 31714965

  • Meningioma transcription factors link cell lineage with systemic metabolic cues. Neuro-oncology Du, Z., Brewster, R., Merrill, P. H., Chmielecki, J., Francis, J., Aizer, A., Abedalthagafi, M., Sholl, L. M., Geffers, L., Alexander, B., Santagata, S. 2018; 20 (10): 1331-1343

    Abstract

    Tumor cells recapitulate cell-lineage transcriptional programs that are characteristic of normal tissues from which they arise. It is unclear why such lineage programs are fatefully maintained in tumors and if they contribute to cell proliferation and viability.Here, we used the most common brain tumor, meningioma, which is strongly associated with female sex and high body mass index (BMI), as a model system to address these questions. We screened expression profiling data to identify the transcription factor (TF) genes which are highly enriched in meningioma, and characterized the expression pattern of those TFs and downstream genes in clinical meningioma samples as well as normal brain tissues. Meningioma patient-derived cell lines (PDCLs) were used for further validation and characterization.We identified 8 TFs highly enriched in meningioma. Expression of these TFs, which included sine oculis homeobox 1 (SIX1), readily distinguished meningiomas from other primary brain tumors and was maintained in PDCLs and even in pulmonary meningothelial nodules. In meningioma PDCLs, SIX1 and its coactivator eyes absent 2 (EYA2) supported the expression of the leptin receptor (LEPR), the cell-surface receptor for leptin (LEP), the adipose-specific hormone that is high in women and in individuals with high BMI. Notably, these transcriptional regulatory factors, LEPR and LEP, both contributed to support meningioma PDCLs proliferation and survival, elucidating a survival dependency on both a core transcriptional program and a metabolic cell-surface receptor.These findings provide one rationale for why lineage TF expression is maintained in meningioma and for the epidemiological association of female sex and obesity with meningioma risk.

    View details for DOI 10.1093/neuonc/noy057

    View details for PubMedID 29660031

    View details for PubMedCentralID PMC6120365

  • The Search for Meaning ACADEMIC MEDICINE Brewster, R., Vyas, D. 2018; 93 (6): 823

    View details for DOI 10.1097/ACM.0000000000002185

    View details for Web of Science ID 000435369500016

  • Endoscope-assisted repair of CSF otorrhea and temporal lobe encephaloceles via keyhole craniotomy. Journal of neurosurgery Roehm, P. C., Tint, D., Chan, N., Brewster, R., Sukul, V., Erkmen, K. 2018; 128 (6): 1880-1884

    Abstract

    OBJECTIVE Temporal lobe encephaloceles and cerebrospinal fluid otorrhea from temporal bone defects that involve the tegmen tympani and mastoideum are generally repaired using middle fossa craniotomy, mastoidectomy, or combined approaches. Standard middle fossa craniotomy exposes patients to dural retraction, which can lead to postoperative neurological complications. Endoscopic and minimally invasive techniques have been used in other surgeries to minimize brain retraction, and so these methods were applied to repair the lateral skull base. The goal of this study was to determine if the use of endoscopic visualization through a middle fossa keyhole craniotomy could effectively repair tegmen defects. METHODS The authors conducted a retrospective review of 6 cases of endoscope-assisted middle fossa repairs of tegmen dehiscences at a tertiary care medical center within an 18-month period. RESULTS All cases were successfully treated using a keyhole craniotomy with endoscopic visualization and minimal retraction. Surgical times did not increase. There were no major postoperative complications, recurrences of encephaloceles, or cerebrospinal fluid otorrhea in these patients. CONCLUSIONS Endoscopic visualization allows for smaller incisions and craniotomies and less risk of brain retraction injury without compromising repair integrity during temporal encephalocele and tegmen repairs.

    View details for DOI 10.3171/2017.1.JNS161947

    View details for PubMedID 28799867

  • Superior semicircular canal dehiscence syndrome. Journal of neurosurgery Bi, W. L., Brewster, R., Poe, D., Vernick, D., Lee, D. J., Eduardo Corrales, C., Dunn, I. F. 2017; 127 (6): 1268-1276

    Abstract

    Superior semicircular canal dehiscence (SSCD) syndrome is an increasingly recognized cause of vestibular and/or auditory symptoms in both adults and children. These symptoms are believed to result from the presence of a pathological mobile "third window" into the labyrinth due to deficiency in the osseous shell, leading to inadvertent hydroacoustic transmissions through the cochlea and labyrinth. The most common bony defect of the superior canal is found over the arcuate eminence, with rare cases involving the posteromedial limb of the superior canal associated with the superior petrosal sinus. Operative intervention is indicated for intractable or debilitating symptoms that persist despite conservative management and vestibular sedation. Surgical repair can be accomplished by reconstruction or plugging of the bony defect or reinforcement of the round window through a variety of operative approaches. The authors review the etiology, pathophysiology, presentation, diagnosis, surgical options, and outcomes in the treatment of this entity, with a focus on potential pitfalls that may be encountered during clinical management.

    View details for DOI 10.3171/2016.9.JNS16503

    View details for PubMedID 28084916

  • Germline and somatic BAP1 mutations in high-grade rhabdoid meningiomas. Neuro-oncology Shankar, G. M., Abedalthagafi, M., Vaubel, R. A., Merrill, P. H., Nayyar, N., Gill, C. M., Brewster, R., Bi, W. L., Agarwalla, P. K., Thorner, A. R., Reardon, D. A., Al-Mefty, O., Wen, P. Y., Alexander, B. M., van Hummelen, P., Batchelor, T. T., Ligon, K. L., Ligon, A. H., Meyerson, M., Dunn, I. F., Beroukhim, R., Louis, D. N., Perry, A., Carter, S. L., Giannini, C., Curry, W. T., Cahill, D. P., Barker, F. G., Brastianos, P. K., Santagata, S. 2017; 19 (4): 535-545

    Abstract

    Patients with meningiomas have widely divergent clinical courses. Some entirely recover following surgery alone, while others have relentless tumor recurrences. This clinical conundrum is exemplified by rhabdoid meningiomas, which are designated in the World Health Organization Classification of Tumours as high grade, despite only a subset following an aggressive clinical course. Patient management decisions are further exacerbated by high rates of interobserver variability, biased against missing possibly aggressive tumors. Objective molecular determinants are needed to guide classification and clinical decision making.To define genomic aberrations of rhabdoid meningiomas, we performed sequencing of cancer-related genes in 27 meningiomas from 18 patients with rhabdoid features and evaluated breast cancer [BRCA]1-associated protein 1 (BAP1) expression by immunohistochemistry in 336 meningiomas. We assessed outcomes, germline status, and family history in patients with BAP1-negative rhabdoid meningiomas.The tumor suppressor gene BAP1, a ubiquitin carboxy-terminal hydrolase, is inactivated in a subset of high-grade rhabdoid meningiomas. Patients with BAP1-negative rhabdoid meningiomas had reduced time to recurrence compared with patients with BAP1-retained rhabdoid meningiomas (Kaplan-Meier analysis, 26 mo vs 116 mo, P < .001; hazard ratio 12.89). A subset of patients with BAP1-deficient rhabdoid meningiomas harbored germline BAP1 mutations, indicating that rhabdoid meningiomas can be a harbinger of the BAP1 cancer predisposition syndrome.We define a subset of aggressive rhabdoid meningiomas that can be recognized using routine laboratory tests. We implicate ubiquitin deregulation in the pathogenesis of these high-grade malignancies. In addition, we show that familial and sporadic BAP1-mutated rhabdoid meningiomas are clinically aggressive, requiring intensive clinical management.

    View details for DOI 10.1093/neuonc/now235

    View details for PubMedID 28170043

    View details for PubMedCentralID PMC5464371

  • Genomic landscape of intracranial meningiomas. Journal of neurosurgery Bi, W. L., Abedalthagafi, M., Horowitz, P., Agarwalla, P. K., Mei, Y., Aizer, A. A., Brewster, R., Dunn, G. P., Al-Mefty, O., Alexander, B. M., Santagata, S., Beroukhim, R., Dunn, I. F. 2016; 125 (3): 525-35

    Abstract

    Meningiomas are the most common primary intracranial neoplasms in adults. Current histopathological grading schemes do not consistently predict their natural history. Classic cytogenetic studies have disclosed a progressive course of chromosomal aberrations, especially in high-grade meningiomas. Furthermore, the recent application of unbiased next-generation sequencing approaches has implicated several novel genes whose mutations underlie a substantial percentage of meningiomas. These insights may serve to craft a molecular taxonomy for meningiomas and highlight putative therapeutic targets in a new era of rational biology-informed precision medicine.

    View details for DOI 10.3171/2015.6.JNS15591

    View details for PubMedID 26771848

  • Oncogenic PI3K mutations are as common as AKT1 and SMO mutations in meningioma. Neuro-oncology Abedalthagafi, M., Bi, W. L., Aizer, A. A., Merrill, P. H., Brewster, R., Agarwalla, P. K., Listewnik, M. L., Dias-Santagata, D., Thorner, A. R., Van Hummelen, P., Brastianos, P. K., Reardon, D. A., Wen, P. Y., Al-Mefty, O., Ramkissoon, S. H., Folkerth, R. D., Ligon, K. L., Ligon, A. H., Alexander, B. M., Dunn, I. F., Beroukhim, R., Santagata, S. 2016; 18 (5): 649-55

    Abstract

    Meningiomas are the most common primary intracranial tumor in adults. Identification of SMO and AKT1 mutations in meningiomas has raised the possibility of targeted therapies for some patients. The frequency of such mutations in clinical cohorts and the presence of other actionable mutations in meningiomas are important to define.We used high-resolution array-comparative genomic hybridization to prospectively characterize copy-number changes in 150 meningiomas and then characterized these samples for mutations in AKT1, KLF4, NF2, PIK3CA, SMO, and TRAF7.Similar to prior reports, we identified AKT1 and SMO mutations in a subset of non-NF2-mutant meningiomas (ie, ∼9% and ∼6%, respectively). Notably, we detected oncogenic mutations in PIK3CA in ∼7% of non-NF2-mutant meningiomas. AKT1, SMO, and PIK3CA mutations were mutually exclusive. AKT1, KLF4, and PIK3CA mutations often co-occurred with mutations in TRAF7. PIK3CA-mutant meningiomas showed limited chromosomal instability and were enriched in the skull base.This work identifies PI3K signaling as an important target for precision medicine trials in meningioma patients.

    View details for DOI 10.1093/neuonc/nov316

    View details for PubMedID 26826201

    View details for PubMedCentralID PMC4827048

  • How a Lumbar Diskectomy Influenced Medical Malpractice and the Landscape of Health Care. World neurosurgery Yang, B. W., Bi, W. L., Smith, T. R., Brewster, R., Gormley, W. B., Dunn, I. F., Laws, E. R. 2016; 86: 88-92

    Abstract

    Jeff Chandler was one of Hollywood's top leading men in the 1950s and 1960s. In 1961, at the peak of his career, Chandler died of complications following an aortic-iliac injury during a routine lumbar diskectomy. The subsequent public outcry and malpractice suit resulted in an unprecedented settlement award.Chandler's lawsuit marked a pivotal time in the evolution of medical malpractice and monetary awards. Before 1960, malpractice legal claims were rare, with little impact on the practice of medicine. Chandler's award, however, dwarfed the average malpractice verdict for its time and would influence the relationship between medicine and the legal world. This case helped issue a radical increase in total expenditure on medical liability insurance, frequency of successful claims, average numbers of neurosurgical malpractice suits, and financial award sizes. The trend ensuing from this time has continued to the contemporary era. To link Chandler's case to the current malpractice climate, we highlight the relationship of the case with 3 factors comprising the legal argument for the perpetuation of medical malpractice: 1) contingency fees, 2) citizen juries, and 3) the nature of tort law.This case illustrates an inflection point in American medical malpractice expenditure increases beginning in the 1960s to a current estimated $55.6 billion. As we investigate ways to provide value in health care, it is important to consider the historical factors that have influenced the status quo when seeking strategies to reform the malpractice system on both sides of the value equation: quality and cost.

    View details for DOI 10.1016/j.wneu.2015.09.039

    View details for PubMedID 26409087

  • Evita's lobotomy. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia Young, G. J., Bi, W. L., Smith, T. R., Brewster, R., Gormley, W. B., Dunn, I. F., Laws, E. R., Nijensohn, D. E. 2015; 22 (12): 1883-8

    Abstract

    For 60 years, the details about Eva Perón's illness and lobotomy at the end of her life have been obscured from the public. Here, we examine the sociopolitical factors that may have contributed to this secrecy. The first involves Eva Perón's political status and the personality cult surrounding her image, including partisan efforts to present her as a patron saint of Peronism. The second involves the social perceptions, which are often stigmatizing, regarding disease in political or public figures. Notably, neuropsychiatric illness and associated indications for treatment were viewed as oligarchic by the Perón regime, and admission to a lobotomy may have been perceived as anti-Peronist. A third factor involves the growing ignominy of prefrontal lobotomy as a surgical modality, which may have precluded operative exposés. A final factor may be that Eva Perón's lobotomy was in fact performed for behavior and personality modification, and not just for pain control. A brief history of lobotomy is presented, highlighting its adoption as a procedural panacea for psychiatric illnesses, relief of intractable pain from cancer, and management of belligerent behavior, and its subsequent fall from clinical favor. Although a shroud of secrecy still surrounds Eva Perón's prefrontal lobotomy, these factors provide a potential rationale for the circumstances, as well as foster a discussion of cultural elements that may still play a role in the public perception of psychosurgery today.

    View details for DOI 10.1016/j.jocn.2015.07.005

    View details for PubMedID 26463273

  • The Assassination of Abraham Lincoln and the Evolution of Neuro-Trauma Care: Would the 16th President Have Survived in the Modern Era? World neurosurgery Yan, S. C., Smith, T. R., Bi, W. L., Brewster, R., Gormley, W. B., Dunn, I. F., Laws, E. R. 2015; 84 (5): 1453-7

    Abstract

    Abraham Lincoln was the 16(th) President of the United States of America. On April 14, 1865, shortly after his re-election and the conclusion of the Civil War, Lincoln was shot and killed by John Wilkes Booth. Although numerous physicians tended to the President shortly after his injury, he passed away the next morning. Today, we recognize Lincoln as one of the greatest Presidents in American history. His assassination profoundly influenced the future of the United States, especially as the country was coming back together again following the Civil War. Testaments to his lasting legacy can be seen in many places, from the stone carving of him on Mount Rushmore to his image gracing the $5 bill. What if the President had survived his injury? Would he have had a different outcome utilizing current critical care treatment? Neurotrauma care in 1865 was not yet developed, and head wounds such as the one Lincoln sustained were almost always fatal. The medical attention he received is considered by historians and physicians today to be excellent for that time. We look at the evolution of neurotrauma care during the last 150 years in the US. Particular focus is paid to the advancement of care for penetrating brain injuries in modern trauma centers.

    View details for DOI 10.1016/j.wneu.2015.06.011

    View details for PubMedID 26092530

  • The neurosurgeon as baseball fan and inventor: Walter Dandy and the batter's helmet. Neurosurgical focus Brewster, R., Bi, W. L., Smith, T. R., Gormley, W. B., Dunn, I. F., Laws, E. R. 2015; 39 (1): E9

    Abstract

    Baseball maintains one of the highest impact injury rates in all athletics. A principal causative factor is the "beanball," referring to a pitch thrown directly at a batter's head. Frequent morbidities elicited demand for the development of protective gear development in the 20th century. In this setting, Dr. Walter Dandy was commissioned to design a "protective cap" in 1941. His invention became widely adopted by professional baseball and inspired subsequent generations of batting helmets. As a baseball aficionado since his youth, Walter Dandy identified a natural partnership between baseball and medical practice for the reduction of beaning-related brain injuries. This history further supports the unique position of neurosurgeons to leverage clinical insights, inform innovation, and expand service to society.

    View details for DOI 10.3171/2015.3.FOCUS1552

    View details for PubMedID 26126408