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The emergence of the COVID-19 pandemic significantly changed the prenatal care experience, specifically regarding medical appointments and social opportunities. It is critical to capture this change through the narratives of pregnant people, particularly those of marginalized populations, whose voices may often be underrepresented in the literature. This mixed-methods paper summarizes the experiences of 40 pregnant Black/African American (AA) women during the COVID-19 pandemic. A cross-sectional, online survey was administered between 2020 and 2021 to assess prenatal health and the impacts of the COVID-19 pandemic on patients' pregnancy experience. Coping behaviors during the pandemic were self-reported using the COPE-IS. Univariate analyses were conducted. An additional analysis of participants (n = 4) was explored through a week-long qualitative exercise using a photo documentation procedure. Photo-Elicitation Interviews (PEI) were conducted to capture and center their pandemic pregnancy experiences. Sources of stress during the pandemic varied, with the most common being financial concerns (n = 19, 47.5%). Over half of the sample (n = 18, 54.5%) self-reported increases in their positive coping behaviors during the pandemic, such as communicating with friends and family, talking to healthcare providers, listening to music, and engaging in spiritual practices–such as prayer. The four PEI study participants reflected on the impacts of social distancing on their prenatal experience and mentioned hospital and provider-related weariness due to their race. The findings of this study suggest that during the COVID-19 pandemic, Black/AA pregnant women in Charlotte, NC used social support, mindfulness practices, self-advocacy, and health literacy to navigate challenges present during their prenatal health experience. This paper highlights the personal, social, and structural experiences of pregnant women during a public health crisis so that responsive and effective programs or policies can be planned in the future. [ABSTRACT FROM AUTHOR]

Introduction: Action 3 of the UN Decade of Healthy Ageing plan is to deliver integrated care to improve older adults' lives. Integrated care is vital in meeting the complex needs of people with dementia but little is known about how this is or could be delivered in low and middle income countries (LMIC). This paper provides insights into previously unknown care system structures and on the potential and reality of delivering integrated care in Central America for people with dementia. Methods: A social network analysis (SNA) methodology was adopted to engage with providers of services for older adults and families with dementia in Guatemala, El Salvador, Honduras, Costa Rica and Panama. Sixty-eight (68) semi-structured interviews were completed, 57 with organisations and 11 with families. Results: Across the five countries there was evidence of fragmentation and low integration within the dementia care systems. A variety of services and types of providers are present in all five countries, and high levels of diversified connections exist among organisations of differing disciplines. However, unawareness among network members about other members that they could potentially form active links with is a barrier on the path to integration. Conclusion: This innovative and robust study demonstrates SNA can be applied to evaluate LMIC care systems. Findings provide baselines of system structures and insights into where resources are needed to fortify integration strategies. Results suggest that Central American countries have the building blocks in place to develop integrated care systems to meet the needs of people with dementia, but the links across service providers are opportunistic rather than context based coordinated integration policies. [ABSTRACT FROM AUTHOR]

After three years of global rampage, the COVID-19 epidemic, the most serious infectious disease to occur worldwide since the 1918 influenza pandemic, is nearing its end. From the global experience, medical control and social control are the two main dimensions in the prevention and control of COVID-19. From the perspective of "two types of control", namely medical control and social control, this paper finds that the political system, economic structure, and cultural values of the United States greatly limit the government's ability to impose social control, forcing it to adopt medical control to fight the virus in a single dimension. In contrast, China's political system, economic structure, and cultural values allow its government to adopt stringent, extensive, and frequent social control, as well as medical control to fight the virus. This approach departs from the traditional pathway of fighting the epidemic, i.e., "infection–treatment–immunization", thereby outpacing the evolution of the virus and controlling its spread more rapidly. This finding helps explain why the Chinese government adopted a strict "zeroing" and "dynamic zeroing" policy during the first three years, at the cost of enormous economic, social, and even political legitimacy. It was not until late 2022, when the Omicron variant with the waning virulence became prevalent, that China chose to "coexist" with the virus, thus avoiding a massive epidemic-related death. While the United States adopted a pulsed-style strategy at the beginning of the epidemic, i.e., "relaxation–suppression–relaxation–suppression", and began to "coexist" with the virus in just one year, resulting in a large number of excess deaths associated with the epidemic. The study contributes to explaining the difference in the interplay between public health priorities and COVID-19 response strategies in China and the United States, based on the specific public health context and the perspective of "medical control" and "social control". [ABSTRACT FROM AUTHOR]

This systematic study aims at analyzing the differences between the approach of the European healthcare systems to the pharmaceutical market and the American one. This paper highlights the opportunities and the limitations given by the application of managed entry agreements (MEAs) in European countries as opposed to the American market, which does not regulate pharmaceutical prices. Data were collected from the Organisation for Economic Co-operation and Development (OECD), the European Medicines Agency, and the national healthcare agencies of US and European countries. A literature review was undertaken in PubMed, Scopus, MEDLINE, and Google for a period ten years (2010–2019). The period 2020–2021 was considered to compare health expenditure before and after the SARS-CoV-2 pandemic. Scarce information from national agencies has been given in terms of MEAs related to the COVID-19 pandemic. The comparison between the United States approach and the European one shows the importance of a market access regulation to reduce the cost of therapies, increasing the efficiency of national healthcare systems and the advantages in terms of quality and accessibility to the final users: patients. Nevertheless, it seems that the golden age of MEAs for Europe was during the examined period. Except for Italy, countries will move to other forms of reimbursements to obtain higher benefits, reducing the costs of an inefficient implementation and outcomes in the medium term. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to examine modifiable mediators for socioeconomic disparities in childhood obesity in the United States.Methods: This study used the data of 1,211 mother-child dyads from a US national birth cohort from pregnancy to 6 years post partum. Socioeconomic status was indicated by maternal education (college graduate vs. less) and family income (>185% vs. ≤185% of the poverty line). Single- and multiple-factor mediation analyses were conducted for socioeconomic disparities in childhood obesity at 6 years, adjusting for demographics.Results: The confounder-adjusted relative risk of childhood obesity was 1.79 for low maternal education and 1.42 for low family income. Low-maternal-education-related obesity was individually mediated by maternal preconception BMI (percentage of indirect effect, 8.8%), smoking during pregnancy (7.0%), infant weight gain (14.4%), child sleep duration (11.4%), and TV viewing during weekdays at 6 years (4.9%). Low-family-income-related obesity was mediated by maternal preconception BMI (18.5%), smoking during pregnancy (6.3%), child sleep duration (12.8%), and the home learning environment at 6 years (26.2%). In multiple-mediator analysis, significant mediators together mediated 54.0% of maternal-education-related or 39.4% of family-income-related disparities.Conclusions: Maternal preconception BMI, smoking during pregnancy, infant weight gain, child sleep, TV viewing, and the home learning environment substantially mediated socioeconomic disparities in childhood obesity in the United States. [ABSTRACT FROM AUTHOR]

INTRODUCTION Electronic nicotine delivery system (ENDS) and liquid characteristics affect nicotine and toxicant exposure and use behaviors. Little is known about how adults who frequently use ENDS transition between ENDS device/liquid groupings. METHODS A total of 379 US adults (≥21 years) using ENDS frequently (≥5 days/ week) self-reported and uploaded photos of their most used ENDS device and liquid in three waves of online surveys (May 2020 -- November 2021). Device/ liquid grouping was defined by device (i.e. disposable/refillable tank/refillable pod or cartridge/disposable pod or cartridge, adjustable/no adjustable settings) and liquid (i.e. salt/freebase) characteristics. Participants using the same grouping across waves were considered stable users. RESULTS The most prevalent wave (W) 1 grouping was tank (freebase, adjustable settings; 36.8%). From W1 to W3, the number of disposable device (salt, no adjustable settings) users increased 156.4% and the number of disposable pod/cartridge (salt, no adjustable settings) users decreased 15.2%. In W2 and W3, compared to stable users, participants using tank (freebase, adjustable settings) in W1 and another grouping in W2 and/or W3 reported significantly higher nicotine concentrations (mg/mL) (W2: 15.1 vs 5.5, p<0.001; W3: 22.9 vs 5.6, p<0.001) and lower device power (watt) (W2: 46.8 vs 58.7, p=0.02; W3: 34.0 vs 57.2, p<0.001). CONCLUSIONS Over a 1.5-year period, a rapid growth in disposable device (salt, no adjustable settings) use and a decrease in disposable pod/cartridge (salt, no adjustable settings) use were observed. Participants who transitioned from tank (freebase, adjustable settings) to other groupings were more likely to increase liquid nicotine concentration and reduce device power compared to stable users. [ABSTRACT FROM AUTHOR]

INTRODUCTION E-cigarette use among youth and young adults remains of public health concern. Pod-based e-cigarettes, including JUUL, significantly changed the e-cigarette landscape in the US. Using an online survey, we explored the socio-behavioral correlates, predisposing factors, and addictive behaviors, among young adult pod-mod users within a University in Maryland, USA. METHODS In total, 112 eligible college students aged 18--24 years, recruited from a University in Maryland, who reported using pod-mods were included in this study. Participants were categorized into current/non-current users based on past- 30-day use. Descriptive statistics were used to analyze participants' responses. RESULTS The mean age of the survey participants was 20.5 ± 1.2 years, 56.3% were female, 48.2% White, and 40.2% reported past-30-day (current) use of pod-mods. The mean age of first experimentation with pod-mods was 17.8 ± 1.4 years, while the mean age of regular use was 18.5 ± 1.4 years, with the majority (67.9%) citing social influence as the reason for initiation. Of the current users, 62.2% owned their own devices, and 82.2% predominantly used JUUL and menthol flavor (37.8%). A significant proportion of current users (73.3%) reported buying pods in person, 45.5% of whom were aged <21 years. Among all participants, 67% had had a past serious quit attempt. Among them, 89.3% neither used nicotine replacement therapy nor prescription medications. Finally, current use (adjusted odds ratio, AOR=4.52; 95% CI: 1.76--11.64), JUUL use (AOR=2.56; 95% CI: 1.08-6.03), and menthol flavor (AOR=6.52; 95% CI: 1.38-30.89) were associated with reduced nicotine autonomy, a measure of addiction. CONCLUSIONS Our findings provide specific data to inform the development of public health interventions targeted at college youth, including the need for more robust cessation support for pod-mod users. [ABSTRACT FROM AUTHOR]

Background Comparing body fat and the effect of body fat on metabolic abnormalities in Chinese and USA teenagers may provide clues for the early prevention and control of cardiovascular disease (CVD). We aimed to compare the prevalence of glucose and lipid metabolism abnormalities, body fat amount and distribution, and the effect of body fat on glucose and lipid metabolism in Chinese and US teenagers. Methods We included 5424 Chinese teenagers (48.5% male) from the China Child and Adolescent Cardiovascular Health (CCACH) study and 8704 USA teenagers (55.6% male) from the USA National Health and Nutrition Examination Survey (NHANES). Blood lipid, blood glucose, and body fat indicators were obtained using the same standardised measurements. Results The prevalence of dyslipidaemia in Chinese teenagers was of those in the USA (hypercholesterolaemia = 3.5% vs 7.4%; high low-density lipoprotein cholesterol (LDL-C) = 3.6% vs 5.0%; low high-density lipoprotein cholesterol (HDL-C)=9.9% vs 14.3%; hypertriglyceridaemia=3.7% vs 10.1%) (P<0.05). However, with the increase in body mass index (BMI), the prevalence of high LDL-C increased more in Chinese than in US teenagers, even exceeding them in the obese group (2.7% in non-overweight to 9.7% in overweight group in China, P<0.05; 3.5% in non-overweight to 6.5% in the obese group in the USA, P<0.05). The prevalence of impaired fasting glucose was higher in China than in the USA (28.0% vs 17.5%, P<0.05). Besides, Chinese adolescents are more likely to accumulate fat in the abdomen, and the per-unit fat increase would bring a higher risk of dyslipidaemia in Chinese boys than in USA boys. Conclusions Dyslipidaemia was more prevalent in US teenagers than in Chinese teenagers, but with the increase in BMI, the prevalence of high LDL-C increased more in Chinese than in US teenagers. Impaired fasting glucose (IFG) was significantly more prevalent in China than in the USA. The unfavoured body fat and higher risk of body fat on metabolic disorders in Chinese teenagers suggest that Chinese teenagers should pay more attention to the adverse effect of body fat on metabolic abnormalities. [ABSTRACT FROM AUTHOR]

Context/problem: Comparative analysis of relative and absolute mortality differentials between socioeconomic groups are now available. These show consistently increasing relative increases in mortality differentials but complex trends in absolute mortality differentials. Objective: This paper provides an analysis of relative and absolute trends in mortality by cause of death and socioeconomic group (SEG) from 1984 to 2008 among men and active women aged 30-64 years in Ireland and compares these results with recent European and US studies to give an overview of trends. Methods: This paper uses mortality data from the Irish Central Statistics Office from 1984 to 2008 to calculate standardized death rates by age, sex, socioeconomic status and cause of death showing trends in SEG inequalities in mortality in Ireland. These show which specific causes of death are driving all-cause mortality trends. Results: SEG differentials in all-cause mortality among men and women have been increasing since the 1980s. Some of this increase reflects larger falls in cardiovascular causes among advantaged groups, but the trend is largely accounted for by increasing inequalities in mortality in digestive, neoplasm and external causes of deaths. Conclusions: These findings are in line with international findings that show that socioeconomic differentials in digestive, neoplasm and external cause deaths are driving general socioeconomic differentials in all-cause mortality. External cause deaths may have been influenced by levels of economic activity, particularly in construction, during the economic boom among manual workers. Furthermore, deaths from digestive diseases during the 1990s and 2000s may well be the result of increases in liver disease associated with excessive alcohol consumption. [ABSTRACT FROM AUTHOR]

Background: The purpose of this paper is to describe the Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) study, a cooperative implementation science initiative involving the National Institute on Drug Abuse, six research centers, a coordinating center, and Juvenile Justice Partners representing seven US states. While the pooling of resources across centers enables a robust implementation study design involving 36 juvenile justice agencies and their behavioral health partner agencies, co-producing a study protocol that has potential to advance implementation science, meets the needs of all constituencies (funding agency, researchers, partners, study sites), and can be implemented with fidelity across the cooperative can be challenging. This paper describes (a) the study background and rationale, including the juvenile justice context and best practices for substance use disorders, (b) the selection and use of an implementation science framework to guide study design and inform selection of implementation components, and (c) the specific study design elements, including research questions, implementation interventions, measurement, and analytic plan.Methods/design: The JJ-TRIALS primary study uses a head-to-head cluster randomized trial with a phased rollout to evaluate the differential effectiveness of two conditions (Core and Enhanced) in 36 sites located in seven states. A Core strategy for promoting change is compared to an Enhanced strategy that incorporates all core strategies plus active facilitation. Target outcomes include improvements in evidence-based screening, assessment, and linkage to substance use treatment.Discussion: Contributions to implementation science are discussed as well as challenges associated with designing and deploying a complex, collaborative project.Trial Registration: NCT02672150 . [ABSTRACT FROM AUTHOR]

Background: Lone parents and their children experience higher than average levels of adverse health and social outcomes, much of which are explained by high rates of poverty. Many high income countries have attempted to address high poverty rates by introducing employment requirements for lone parents in receipt of welfare benefits. However, there is evidence that employment may not reduce poverty or improve the health of lone parents and their children.Methods: We conducted a systematic review of qualitative studies reporting lone parents' accounts of participation in welfare to work (WtW), to identify explanations and possible mechanisms for the impacts of WtW on health and wellbeing. Twenty one bibliographic databases were searched. Two reviewers independently screened references and assessed study quality. Studies from any high income country that met the criteria of focussing on lone parents, mandatory WtW interventions, and health or wellbeing were included. Thematic synthesis was used to investigate analytic themes between studies.Results: Screening of the 4703 identified papers and quality assessment resulted in the inclusion of 16 qualitative studies of WtW in five high income countries, USA, Canada, UK, Australia, and New Zealand, covering a variety of welfare regimes. Our synthesis found that WtW requirements often conflicted with child care responsibilities. Available employment was often poorly paid and precarious. Adverse health impacts, such as increased stress, fatigue, and depression were commonly reported, though employment and appropriate training was linked to increased self-worth for some. WtW appeared to influence health through the pathways of conflict and control, analytical themes which emerged during synthesis. WtW reduced control over the nature of employment and care of children. Access to social support allowed some lone parents to manage the conflict associated with employment, and to increase control over their circumstances, with potentially beneficial health impacts.Conclusion: WtW can result in increased conflict and reduced control, which may lead to negative impacts on mental health. Availability of social support may mediate the negative health impacts of WtW. [ABSTRACT FROM AUTHOR]

Background: Positive person-centered attributes of inpatient rehabilitation need to be identified from the patient's perspective to be further developed and sustained. Purpose: To identify which attributes patients openly evoke as being great care experiences, using an open appreciative inquiry during the inpatient rehabilitation stay. Methods: Qualitative secondary analysis of appreciative patient comments during a bedside patient experience rounding facilitated by a neutral party was performed. Two independent analysts employed an inductive, summative form of content analysis. Results: Among 150 patients rounded, 122 provided categorizable appreciative accounts. Over two-thirds of the patients (67.2%) focused on "staff attributes" in their great-experience accounts. Those attributes were mostly interpersonal such as being "attentive & caring—beyond clinical duty" and being "encouraging (but not too hard) & reassuring". These interpersonal staff attributes were reported with words showing deep levels of personal significance or patient appreciation. Beyond staff attributes, the perceived quality of "patient care" (31.1%) and opportunities for "leisure and social activities" (9.0%) were also frequently evoked. Amenities like food or customer service were the least evoked, rarely so as an exclusive attribute (0.8% for each). Conclusions: The human(e) factor, especially the interpersonal qualities of staff, emerged as greatly appreciated from the patient experience perspective during inpatient rehabilitation. These experiences help identify which person-centered attributes of care might be further developed and sustained. [ABSTRACT FROM AUTHOR]

To mitigate COVID-19 exposure risks in methadone clinics, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a temporary modification of regulations in March 2020 to permit, with state concurrence, extended take-home methadone doses. The modification allowed for up to 28 days of take-home methadone for stable patients and 14 days for those less stable. Using both interrupted time series and difference-in-differences methods, this study examined the association between the policy change and fatal methadone overdoses, comparing states that permitted the expansion of take-home doses with states that did not. The findings suggest the pandemic emergency take-home policy did not increase methadone-involved mortality. [ABSTRACT FROM AUTHOR]

BACKGROUND: Exposure to arsenic (As) in well water is a well-documented public health issue for Maine and New Hampshire, as well as for other states in the United States and abroad. Arsenic contamination of well water in these locations is primarily attributed to metasedimentary bedrock that leaches As into groundwater. However, As can also enter groundwater reserves from soils contaminated by the historical use of arsenical pesticides. Approximately half of the households in Maine and New Hampshire rely on private wells, many of which have elevated As. Arsenic exposure has been associated with an increased risk of cancer, cardiovascular disease, reduced infection resistance, and lower intelligence quotient in children. Despite these known health impacts, well water testing and treatment are not universal. OBJECTIVES: We have approached the problem of low well water testing rates in Maine and New Hampshire communities by developing the All About Arsenic (AAA) project, which engages secondary school teachers and students as citizen scientists in collecting well water samples for analysis of As and other toxic metals and supports their outreach efforts to their communities. METHODS: We assessed this project’s public health impact by analyzing student data relative to existing well water quality datasets in both states. In addition, we surveyed private well owners who contributed well water samples to the project to determine the actions taken to mitigate As in well water. RESULTS: Students collected 3,070 drinking water samples for metals testing, and 752 exceeded New Hampshire’s As standard of 5 ppb. The AAA data has more than doubled the amount of information available to public health agencies about well water quality in multiple municipalities across both states. Students also collected information about well types and treatment systems. Their data reveal that some homeowners did not know what type of wells they had or whether they had filtration systems. Those with filtration systems were often unaware of the type of system, what the system was filtering for, or whether the system was designed to remove As. Through interviews with pilot survey participants, we learned that some had begun mitigating their exposure to As and other toxic metals in response to test results from the AAA project. DISCUSSION: A school-based approach to collecting and analyzing private well water samples can successfully reach communities with low testing rates for toxic elements, such as As and other metals. Importantly, information generated through the program can impact household decision-making, and students can influence local and state policymaking by sharing information in their communities. [ABSTRACT FROM AUTHOR]

Objectives: Providing personal demographic information is routine practice in the United States, and yet, little is known about the impacts of this process. This study aims to examine the experiences and perspectives of Multiracial/ethnic adults in the United States when disclosing racial/ethnic identity. Methods: Seventeen semistructured interviews were conducted with adults identifying as Multiracial/ethnic. The Multiracial/ethnic identities of participants included Black or African American and White; Black or African American, American Indian or Alaska Native (AI/AN) and Hispanic or Latino; Black or African American and Hispanic or Latino; Black or African American and AI/AN; AI/AN and White and Asian, Native Hawaiian or Pacific Islander and White. Multiple participants reported identifying with multiple ethnic groups for any single broad category. Three identified as sexual minorities. Nine were Millennials; six were Gen X; one was Gen Z; one was Baby Boomer. Qualitative data were analyzed using staged hybrid inductive–deductive thematic analysis. Results: Disclosure of racial and ethnic identities presents a unique stressor for Multiracial/ethnic populations due to methods used to obtain data, perceived mismatch of identity and phenotype and exposure to prejudice. Social norms, constructs and movements impact the categories that a Multiracial/ethnic person indicates to external parties. Conclusions: The stress and negative feelings that Multiracial/ethnic adults face when identifying their race/ethnicity underscore the broader implications of standard demographic questions on feelings of inclusivity and visibility within a population. Patient or Public Contribution: Gathering data on individuals' racial and ethnic backgrounds is a standard practice, and yet, it can pose challenges for those who identify with multiple groups or do not see their identities reflected in the options provided. Such individuals may feel excluded or experience unfair treatment when disclosing their identity, leading to significant stress. As the frequency of this data collection increases, it is essential that the questions are posed empathetically and equitably, with a strong commitment to enhancing inclusivity throughout the process. [ABSTRACT FROM AUTHOR]

Childbearing motivation may be conceptualized as based upon psychological traits and shaped by experiences during childhood, adolescence, and early adult life. This paper explores what those traits and developmental experiences are. Two measures of childbearing motivation, one positive and the other negative, are described. Using a sample of 362 married men and 354 married women, the paper systematically examines the factors associated with these measures. In addition to a set of basic personality traits, these factors include parental characteristics, teenage experiences, and a number of variables from young adult behavior domains such as marriage, education, work, religion, and parental relationships. Stepwise multiple regression analyses lead to two final constrained, simultaneous-equation regression models. These models indicate the importance of both personality traits and diverse life-cycle experiences in the development of childbearing motivation, the differential gender distribution of predictors, and the different experiential antecedents of positive and negative motivation. [ABSTRACT FROM AUTHOR]

Since the 2015 U.S. Supreme Court ruling that marriages of same-sex couples are legal in all states in the union, federal surveys have adapted to the shifting legal climate and included new measures that more directly identify same-sex and different-sex cohabiting and married couples. In this research note comparing the largest and most recent federal surveys—the 2019 American Community Survey and Current Population Survey—we find consistent levels of cohabitation and marriage across surveys. While the vast majority (90%) of different-sex couples were married, we report a more even split in cohabitation and marriage among same-sex couples. Our evaluation of sociodemographic characteristics of married and cohabiting couples indicates that differences were less prominent among same-sex couples than among different-sex couples, suggesting weaker sociodemographic selection into marriage among the former. However, factors affecting same-sex and different-sex couples’ decisions to live together and marry may differ because of legal and social climates that still present unique obstacles for same-sex couples. Researchers need to acknowledge these differences in assessments of the implications of marriage for health and well-being. [ABSTRACT FROM AUTHOR]

Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran. [ABSTRACT FROM AUTHOR]

Objectives: To explore (1) differences in validity and feasibility ratings for geriatric surgical standards across a diverse stakeholder group (surgeons vs. nonsurgeons, health care providers vs. nonproviders, including patient-family, advocacy, and regulatory agencies); (2) whether three multidisciplinary discussion subgroups would reach similar conclusions.Data Source/study Setting: Primary data (ratings) were reported from 58 stakeholder organizations.Study Design: An adaptation of the RAND-UCLA Appropriateness Methodology (RAM) process was conducted in May 2016.Data Collection/extraction Methods: Stakeholders self-administered ratings on paper, returned via mail (Round 1) and in-person (Round 2).Principal Findings: In Round 1, surgeons rated standards more critically (91.2 percent valid; 64.9 percent feasible) than nonsurgeons (100 percent valid; 87.0 percent feasible) but increased ratings in Round 2 (98.7 percent valid; 90.6 percent feasible), aligning with nonsurgeons (99.7 percent valid; 96.1 percent feasible). Three parallel subgroups rated validity at 96.8 percent (group 1), 100 percent (group 2), and 97.4 percent (group 3). Feasibility ratings were 76.9 percent (group 1), 96.1 percent (group 2), and 92.2 percent (group 3).Conclusions: There are differences in validity and feasibility ratings by health professions, with surgeons rating standards more critically than nonsurgeons. However, three separate discussion subgroups rated a high proportion (96-100 percent) of standards as valid, indicating the RAM can be successfully applied to a large stakeholder group. [ABSTRACT FROM AUTHOR]

Fructosamine is a measure of short-term glycemic control, which has been suggested as a useful complement to glycated hemoglobin (HbA1c) for the diagnosis and monitoring of diabetes. To date, a single genome-wide association study (GWAS) including 8,951 U.S. White and 2,712 U.S. Black individuals without a diabetes diagnosis has been published. Results in Whites and Blacks yielded different association loci, near RCN3 and CNTN5, respectively. In this study, we performed a GWAS on 20,731 European-ancestry blood donors and meta-analyzed our results with previous data from U.S. White participants from the Atherosclerosis Risk in Communities (ARIC) study (Nmeta = 29,685). We identified a novel association near GCK (rs3757840, βmeta = 0.0062; minor allele frequency [MAF] = 0.49; Pmeta = 3.66 × 10-8) and confirmed the association near RCN3 (rs113886122, βmeta = 0.0134; MAF = 0.17; Pmeta = 5.71 × 10-18). Colocalization analysis with whole-blood expression quantitative trait loci data suggested FCGRT as the effector transcript at the RCN3 locus. We further showed that fructosamine has low heritability (h2 = 7.7%), has no significant genetic correlation with HbA1c and other glycemic traits in individuals without a diabetes diagnosis (P > 0.05), but has evidence of shared genetic etiology with some anthropometric traits (Bonferroni-corrected P < 0.0012). Our results broaden knowledge of the genetic architecture of fructosamine and prioritize FCGRT for downstream functional studies at the established RCN3 locus. [ABSTRACT FROM AUTHOR]

Background: Family caregivers are family members or friends of care recipients who assist with activities of daily living, medication management, transportation, and help with finances among other activities. As a result of their caregiving, family caregivers are often considered a population at risk of experiencing increased stress, isolation, and loneliness. During the COVID-19 pandemic in the US, social isolation and decrease in social activities were a top concern among older adults and their family caregivers. Using secondary analysis of survey data as part of a multi-site implementation trial of a caregiver skills training program, we describe differences in caregiver experiences of loneliness before and during the COVID-19 pandemic. Methods: Health and wellbeing surveys of family caregivers were collected on 422 family caregivers of veterans before and during COVID-19. Logistic regression modeling examined whether the loneliness differed between caregiver groups pre vs during COVID-19, using the UCLA 3-item loneliness measure. Rapid directed qualitative content analysis of open-ended survey questions was used to explore the context of how survey responses were affected by the COVID-19 pandemic. Results: There were no significant differences in loneliness between caregivers pre vs during COVID-19. In open-ended responses regarding effects of COVID-19, caregivers described experiencing loneliness and social isolation; why they were unaffected by the pandemic; and how caregiving equipped them with coping strategies to manage negative pandemic-related effects. Conclusion: Loneliness did not differ significantly between pre vs during COVID-19 caregivers. Future research could assess what specific characteristics are associated with caregivers who have resiliency, and identify caregivers who are more susceptible to experiencing loneliness. Understanding caregiver loneliness could assist other healthcare systems in developing and implementing caregiver support interventions. [ABSTRACT FROM AUTHOR]

6–11-year-old children provide a critical window for physical activity (PA) interventions. The Virtual Fitness Buddy ecosystem is a precision health PA intervention for children integrating mixed reality technology to connect people and devices. A cluster randomized, controlled trial was conducted across 19 afterschool sites over two 6-month cohorts to test its efficacy in increasing PA and decreasing sedentary behavior. In the treatment group, a custom virtual dog via a mixed reality kiosk helped children set PA goals while sharing progress with parents to receive feedback and support. Children in the control group set PA goals using a computer without support from the virtual dog or parents. 303 children had 8+ hours of PA data on at least one day of each of the 3 intervention time intervals. Conversion of sedentary time was primarily to light-intensity PA and was strongest for children with low baseline moderate-to-vigorous PA than children above 45 min of baseline moderate-to-vigorous PA. Findings suggest that the VFB ecosystem can promote sustainable PA in children and may be rapidly diffused for widespread public health impact. [ABSTRACT FROM AUTHOR]

Simple Summary: Although women 70 years of age and older represent a large percentage of newly diagnosed breast cancer cases, older individuals are drastically underrepresented in clinical trials. Most women diagnosed with breast cancer at 70 years of age and older present with hormone receptor-positive (HR+) breast cancer. Cyclin-dependent kinase (CDK) 4/6 inhibitor-based therapy has become the standard of care for metastatic HR+ breast cancer. This study reports that metastatic breast cancer patients ≥70 years of age receiving CDK4/6 inhibitor-based treatment, particularly when combined with an aromatase inhibitor, experience prolonged progression-free survival but display no such prolongation in overall survival and report more frequent adverse effects to treatment. The reported findings can aid in the development of optimized treatments based on age and help older patients weigh treatment options. The largest portion of breast cancer patients diagnosed after 70 years of age present with hormone receptor-positive (HR+) breast cancer subtypes. Cyclin-dependent kinase (CDK) 4/6 inhibitor treatment, in conjunction with endocrine therapy, has become standard-of-care for metastatic HR+ breast cancer. In total, 320 patients with metastatic breast cancer receiving CDK4/6 inhibitor combined with fulvestrant or an aromatase inhibitor were enrolled in an ongoing observational study or were included in an IRB-approved retrospective study. All patients receiving CDK4/6 inhibitor-based therapy that were ≥70 years of age (n = 111) displayed prolonged progression-free survival (27.6 months) as compared to patients <70 years of age (n = 209, 21.1 months, HR = 1.38, p < 0.05). Specifically, patients receiving a CDK4/6 inhibitor with an aromatase inhibitor who were ≥70 years of age (n = 79) displayed exceptionally prolonged progression-free survival (46.0 months) as compared to patients receiving the same treatment who were <70 years of age (n = 161, 21.8 months, HR = 1.71, p < 0.01). However, patients ≥70 years of age also experienced more frequent adverse responses to CDK4/6 inhibitor-based treatment leading to dose reduction, hold, or discontinuation than the younger cohort (69% and 53%, respectively). Treatment strategies that may decrease toxicity without affecting efficacy (such as dose titration) are worth further exploration. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate the use of after‐visit instructions (AVIs) in an academic rheumatology clinic and assess the impact of standardized AVIs (sAVIs) and teach‐back (TB) on comprehension of health information. Methods: A retrospective review of adult patients seen between October 1 and 8, 2021, at the rheumatology clinic collected data on patient demographics, clinical features, and the presence, content, and readability of AVIs. During a subsequent prospective proof‐of‐concept study, routinely scheduled patients seen at the rheumatology clinic were randomized into three groups: control (received standard of care), received sAVIs only, and received sAVIs plus TB. Patients completed a health literacy questionnaire, satisfaction survey, and a one‐ to two‐week postvisit telephone survey to assess AVI comprehension. Results: Out of 316 retrospective patient visits, 82 (25.9%) received AVIs. Among 210 of 316 patients (66.5%) with management changes, 76 (36.1%) received AVI, with 74.2% of the instructions considered concordant with the provider's note. Use of AVIs was higher with management changes, new patient visits, and medical trainee/teaching clinics. AVIs were written at a median 6.8 grade level. A total of 75 patients completed the prospective study: 31 (41.3%) were in the control group, 19 (25.3%) were in the group that received sAVIs only, and 25 (33.3%) were in the group that received AVIs with TB. There were no differences in overall postvisit survey comprehension/retention scores among the three patient groups evaluated. Conclusion: Although a lack of AVI use was identified, implementation of sAVIs did not appear to impact patient retention or comprehension of discharge health information. [ABSTRACT FROM AUTHOR]

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

Greater attention is being paid to issues surrounding end-of-life care for aging adults with developmental disabilities. The purpose of this qualitative study was to explore the end-of-life experiences of two aging adults with developmental disabilities and life-limiting serious illnesses who received care in settings in the United States. Using a comparative case study design, data from three sources (records, staff, surrogates) were collected sequentially and triangulated via within and cross-case analyses. Although the setting and design limit the generalizability of these findings, the feasibility of delivering high quality care to adults with developmental disabilities as they age and experience terminal illnesses is supported. Insights are presented regarding how nurses can address barriers by adapting policies and practices to accommodate the distinct needs that arise as people with developmental disabilities age, become seriously ill, and reach life's end. [ABSTRACT FROM AUTHOR]

Background: Incorporating evidence-based integrated treatment for dual disorders into typical care settings has been challenging, especially among those serving Veterans who are homeless. This paper presents an evaluation of an effort to incorporate an evidence-based, dual disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking-Veterans Edition (MISSION-Vet) into case management teams serving Veterans who are homeless, using an implementation strategy called Getting To Outcomes (GTO).Methods: This Hybrid Type III, cluster-randomized controlled trial assessed the impact of GTO over and above MISSION-Vet Implementation as Usual (IU). Both conditions received standard MISSION-Vet training and manuals. The GTO group received an implementation manual, training, technical assistance, and data feedback. The study occurred in teams at three large VA Medical Centers over 2 years. Within each team, existing sub-teams (case managers and Veterans they serve) were the clusters randomly assigned. The trial assessed MISSION-Vet services delivered and collected via administrative data and implementation barriers and facilitators, via semi-structured interview.Results: No case managers in the IU group initiated MISSION-Vet while 68% in the GTO group did. Seven percent of Veterans with case managers in the GTO group received at least one MISSION-Vet session. Most case managers appreciated the MISSION-Vet materials and felt the GTO planning meetings supported using MISSION-Vet. Case manager interviews also showed that MISSION-Vet could be confusing; there was little involvement from leadership after their initial agreement to participate; the data feedback system had a number of difficulties; and case managers did not have the resources to implement all aspects of MISSION-Vet.Conclusions: This project shows that GTO-like support can help launch new practices but that multiple implementation facilitators are needed for successful execution of a complex evidence-based program like MISSION-Vet.Trial Registration: ClinicalTrials.gov NCT01430741. [ABSTRACT FROM AUTHOR]

The term latent tuberculosis (TB) was coined two centuries ago to describe post-mortem tuberculous pathology in the absence of ante-mortem tuberculosis manifestations. However, the meaning of the term has changed with each passing century, engendering confusion. In the early 20th century, with the advent of microbiological assays for live tubercle bacteria, latent TB switched from the host to refer to the bacteria from post-mortem tissues of nontuberculous hosts. Then in the late 20th century, the definition of latent TB infection returned to the host, this time referring to those with immunoreactivity to Mycobacterium tuberculosis antigens. Based on this new definition, latent TB infection is unique among bacterial infectious diseases, in that supportive evidence of the infection state is sought by the absence of the causative bacterium and its clinical manifestations. The use of indirect bedside and laboratory tests to denote infection creates clinical and research confusion, as the tests for immunoreactivity suffer from recognized limitations in sensitivity and specificity. We propose that the concept of latent TB infection be separated from that of tuberculous immunoreactivity in the interest of correct diagnosis and focused treatment, correct formulation and interpretation of research questions and better allocation of programmatic resources for TB elimination. To this end, we suggest new terminology to course-correct our thinking about tuberculous infection (TBI) which is subdivided into tuberculous infection-no disease (TBInd) and the long-accepted term for the disease, tuberculosis (TB). [ABSTRACT FROM AUTHOR]

In this paper, we have traced changes in the patterns of first marriage in the United States for cohorts of men and women born in 1880 through 1965 and for the years from 1900 through 1983. There were striking changes in marriage rates associated with each of the world wars and with the depression of the 1930s. In addition to these short-term fluctuations, a long-term shift in marriage rates is observed over the period from after World War II until about 1970. By the end of the 1970s, however, marriage rates had returned to levels similar to those observed before the war. The basic similarity in the timing of changes in marriage rates across age levels and for both men and women, blacks and whites, is a striking characteristic of these marriage curves. There are also, however, important differences among these groups with respect to the magnitude and slopes of the shifts. The postwar marriage boom was strongest among the young (those under age 24) and among whites. Similarly, the declines in marriage rates observed in the 1970s were greatest among the young. The marriage rates for teenagers display trends that diverge in many respects from those of older persons. For example, the marriage rates of male teenagers did not show the "peaks" and "valley" associated with World War II for older age groups and female teenagers. Moreover, there is little sign of the postwar marriage boom among black teenagers of either sex. Indeed, the marriage rates of black teenagers began to decline soon after the war, and by the 1970s the marriage rates of both male and female black teenagers had fallen below those of their white counterparts, reversing the pattern that had existed through the first half of this century. During the twenty-five or so years of the postwar marriage boom, which we believe can be characterized best as a period phenomenon, there were trends-eddies within the mainstream-which are probably most easily interpreted as the consequence of a cohort effect.(ABSTRACT TRUNCATED AT 400 WORDS) [ABSTRACT FROM AUTHOR]

Recent work with samples of black and white urban American women showed a clear behavioral sequence relating age at menarche to age at first intercourse to age at first birth. This paper shows that the linking of ages at menarche, intercourse, marriage, and first birth is a pattern which occurs in very diverse cultures. We present confirmatory data from the United States, Belgium, and Pakistan, and from Malay and Chinese women in Malaysia. We interpret our findings as indicating a biological process leading to (a) social interpretations of readiness for reproduction, and (b) persisting biological differences between early and late maturing women. [ABSTRACT FROM AUTHOR]

While births may be dichotomous, fertility intentions are not inherently so. Intentions are predictions about the future and, as such, are couched in considerable uncertainty. Ignoring this uncertainty hides much of what could be learned from data on fertility intentions. This paper presents a model which allows analysis of the full range of intentions. This paper presents a model which allows analysis of the full range of intentions. After selecting a sample of women in the later stage of childbearing (e.g., those who intend fewer than two additional children) from the 1965 and 1970 National Fertility Studies, it is shown that: (1) substantial portions of women at this stage of the reproductive life cycle were indeed uncertain of their parity-specific intention; (2) this certainty, like more firm intentions, varies by age and parity as the model predicts; and (3) there were significant shifts in the level of certainty between 1965 and 1970. Specifically, while intentions for third, fourth, and fifth births declined, more women "didn't know" if they intended to have another child or not. Among those not intending another child, more seemed uncertain of this intention in 1970 than did comparable women in 1965. In contrast, those intending another child seemed more certain. These changes in intention and uncertainty indicate that the observed decline in intended parity was tentative. Post-1970 evidence suggests that this tentative decline has become an equivocal one. [ABSTRACT FROM AUTHOR]

Background: Engaging patients and community members in healthcare implementation, research and evaluation has become more popular over the past two decades. Despite the growing interest in patient engagement, there is scant evidence of its impact and importance. Boot Camp Translation (BCT) is one evidence-based method of engaging communities in research. The purpose of this report is to describe the uptake by primary care practices of cardiovascular disease prevention materials produced through four different local community engagement efforts using BCT. Methods: EvidenceNOW Southwest (ENSW) was a randomized trial to increase cardiovascular disease (CVD) prevention in primary care practices. Because of its study design, Four BCTs were conducted, and the materials created were made available to participating practices in the "enhanced" study arm. As a result, ENSW offered one of the first opportunities to explore the impact of the BCT method by describing the uptake by primary care practices of health messages and materials created locally using the BCT process. Analysis compared uptake of locally translated BCT products vs. all other products among practices based on geography, type of practice, and local BCT. Results: Within the enhanced arm of the study that included BCT, 69 urban and 13 rural practices participated with 9 being federally qualified community health centers, 14 hospital owned and 59 clinician owned. Sixty-three practices had 5 or fewer clinicians. Two hundred and ten separate orders for materials were placed by 43 of the 82 practices. While practices ordered a wide variety of BCT products, they were more likely to order materials developed by their local BCT. Conclusions: In this study, patients and community members generated common and unique messages and materials for cardiovascular disease prevention relevant to their regional and community culture. Primary care practices preferred the materials created in their region. The greater uptake of locally created materials over non-local materials supports the use of patient engagement methods such as BCT to increase the implementation and delivery of guideline-based care. Yes, patient and community engagement matters. Trial registration and IRB: Trial registration was prospectively registered on July 31, 2015 at ClinicalTrials.gov (NCT02515578, protocol identifier 15–0403). The project was approved by the Colorado Multiple Institutional Review Board and the University of New Mexico Human Research Protections Office. [ABSTRACT FROM AUTHOR]

Evidence suggests an association between exposure to electronic cigarette (e-cigarette) marketing and e-cigarette use (vaping) among adolescents. However, there is limited evidence on exposure to e-cigarette marketing and susceptibility to future vaping, especially among Black and Latino adolescents. This study aimed to examine associations between exposure to e-cigarette marketing and susceptibility to future vaping among Black and Latino adolescents in the United States (US). Participants (N = 362; equal representation between Black and Latino adolescents) completed a baseline assessment (available in English and Spanish) including sociodemographic characteristics (e.g., racial/ethnic group, age, gender, sexual orientation, etc.), exposure to e-cigarette marketing, and susceptibility to future vaping. Exposure to e-cigarette marketing was recoded and organized into two categories (high exposure = 2 to 3; low exposure = 0 to 1). Cochran–Mantel–Haenszel tests were used to evaluate the association between exposure to e-cigarette marketing and susceptibility to future vaping, stratified by racial/ethnic group. Multiple logistic regressions assessed the association between exposure to e-cigarette marketing and susceptibility to future vaping, controlling for gender, sexual orientation, grade, and academic performance within each racial/ethnic group. Black adolescents reported significantly higher frequencies of exposure to e-cigarette marketing (p = 0.005). A significant interaction was found between exposure to e-cigarette marketing and racial/ethnic group (X2 (1) = 6.294, p = 0.012). Among Black adolescents, high exposure to e-cigarette marketing (vs. low exposure) was associated with a higher probability of susceptibility to future vaping (OR: 2.399, 95% CI 1.147–5.021, p = 0.020). For Latino adolescents, exposure to e-cigarette marketing was not associated with susceptibility to future vaping (OR: 0.503, 95% CI 0.245–1.03, p = 0.062). Future studies should evaluate how and where adolescents are exposed to e-cigarette marketing. Prevention efforts must include the implementation of effective counter-marketing campaigns and the reduction of exposure to e-cigarette marketing among Black and Latino adolescents. [ABSTRACT FROM AUTHOR]

Background: The Planetary Health Diet Index (PHDI) measures adherence to the dietary pattern presented by the EAT-Lancet Commission, which aligns health and sustainability targets. There is a need to understand how PHDI scores correlate with dietary greenhouse gas emissions (GHGE) and how this differs from the carbon footprints of scores on established dietary recommendations. The objectives of this study were to compare how the PHDI, Healthy Eating Index-2015 (HEI-2015) and Dietary Approaches to Stop Hypertension (DASH) relate to (a) dietary GHGE and (b) to examine the influence of PHDI food components on dietary GHGE. Methods: We used life cycle assessment data from the Database of Food Recall Impacts on the Environment for Nutrition and Dietary Studies to calculate the mean dietary GHGE of 8,128 adult participants in the 2015–2016 and 2017–2018 cycles of the National Health and Nutrition Examination Survey (NHANES). Poisson regression was used to estimate the association of (a) quintiles of diet score and (b) standardized dietary index Z-scores with dietary GHGE for PHDI, HEI-2015, and DASH scores. In secondary analyses, we used Poisson regression to assess the influence of individual PHDI component scores on dietary GHGE. Results: We found that higher dietary quality on all three indices was correlated with lower dietary GHGE. The magnitude of the dietary quality-dietary GHGE relationship was larger for PHDI [-0.4, 95% CI (-0.5, -0.3) kg CO2 equivalents per one standard deviation change] and for DASH [-0.5, (-0.4, -0.6) kg CO2-equivalents] than for HEI-2015 [-0.2, (-0.2, -0.3) kg CO2-equivalents]. When examining PHDI component scores, we found that diet-related GHGE were driven largely by red and processed meat intake. Conclusions: Improved dietary quality has the potential to lower the emissions impacts of US diets. Future efforts to promote healthy, sustainable diets could apply the recommendations of the established DASH guidelines as well as the new guidance provided by the PHDI to increase their environmental benefits. [ABSTRACT FROM AUTHOR]

Preparing patients for posthospital care may improve readmission risk. Alternative payment models (APMs) incent hospitals to reduce readmissions by tying payment to outcomes. The impact of APMs on preparation for discharge is not well understood. We assessed whether patient-reported preparation for posthospital care was associated with reduced readmissions, and whether APM participation was associated with improved preparation for posthospital care. We used mixed-effects regression on retrospective (2013–2017) observational data for 2685 U.S. hospitals. We measured patient-reported preparation for posthospital care using the 3-Item Care Transition Measure and readmission using 30-day all-cause risk-adjusted readmissions from Hospital Compare. Participation in accountable care organizations (ACOs), Medical Homes, and Medicare's Bundled Payments for Care Improvement program was obtained from Medicare, the American Hospital Association's Annual Survey, and Leavitt Partner's ACO database. We found that APMs are not associated with improved preparation for posthospital care, even though it was associated with reduced readmissions (Marginal Effect: −0.012 percentage points). This may be because hospitals are not investing in patient engagement. This study has limited insight into causality and reduced generalizability among smaller, rural, and non-teaching hospitals. [ABSTRACT FROM AUTHOR]

Introduction: Missed visits have been estimated to cost the U.S. healthcare system $50 billion annually and have been linked to healthcare inefficiency, higher rates of emergency department visits, and worse outcomes. COVID-19 disrupted existing outpatient healthcare utilization patterns. In our study, we sought to examine the frequency of missed outpatient visits over the course of the COVID-19 pandemic and to examine patient-level characteristics associated with non-attendance. Methods: This study utilized data from a longitudinal cohort study (the Chicago COVID-19 Comorbidities (C3) study). C3 participants were enrollees in 1 of 4 active, "parent" studies; they were rapidly enrolled in C3 at the onset of the pandemic. Multiple waves of telephone-based interviews were conducted to collect experiences with the pandemic, as well as socio-demographic and health characteristics, health literacy, patient activation, and depressive and anxiety symptoms. For the current analysis, data from waves 3 to 8 (05/01/20-05/19/22) were analyzed. Participants included 845 English or Spanish-speaking adults with 1 or more chronic conditions. Results: The percentage of participants reporting missed visits due to COVID-19 across study waves ranged from 3.1 to 22.4%. Overall, there was a decline in missed visits over time. No participant sociodemographic or health characteristic was consistently associated with missed visits across the study waves. In bivariate and multivariate analysis, only patient-reported anxiety was significantly associated with missed visits across all study waves. Conclusion: Findings reveal that anxiety was consistently associated with missed visits during the COVID-19 pandemic, but not sociodemographic or health characteristics. Results can inform future public health initiatives to reduce absenteeism by considering patients' emotional state during times of uncertainty. [ABSTRACT FROM AUTHOR]

Background: Prevalence of multiple health risk behaviors is growing, and obesity and smoking are costly. Weight gain associated with quitting smoking is common and can interfere with quit success. Efficacy of adding weight management to tobacco cessation treatment has been tested with women in group sessions over an extended period of time, but has never been tested in real-world settings with men and women seeking help to quit. This paper describes the Best Quit study which tests the effectiveness of delivering tobacco and weight control interventions via existing quitline infrastructures.Methods: Eligible and consenting smokers (n = 2550) who call a telephone quitline will be randomized to one of three groups; the standard quitline or standard quitline plus a weight management program added either simultaneously or sequentially to the tobacco program. The study aims to test: 1) the effectiveness of the combined intervention on smoking cessation and weight, 2) the cost-effectiveness of the combined intervention on cessation and weight and 3) theoretically pre-specified mediators of treatment effects on cessation: reduced weight concerns, increased outcome expectancies about quitting and improved self-efficacy about quitting without weight gain. Baseline, 6 month and 12 month data will be analyzed using multivariate statistical analyses and groups will be compared on treatment adherence, quit rates and change in weight among abstinent participants. To determine if the association between group assignment and primary outcomes (30-day abstinence and change in weight at 6 months) is moderated by pre-determined baseline and process measures, interaction terms will be included in the regression models and their significance assessed.Discussion: This study will generate information to inform whether adding weight management to a tobacco cessation intervention delivered by phone, mail and web for smokers seeking help to quit will help or harm quit rates and whether a simultaneous or sequential approach is better at increasing abstinence and reducing weight gain post quit. If proven effective, the combined intervention could be disseminated across the U.S. through quitlines and could encourage additional smokers who have not sought cessation treatment for fear of gaining weight to make quit attempts.Trial Registration: Clinicaltrials.gov NCT01867983 . Registered: May 30, 2013. [ABSTRACT FROM AUTHOR]

Background: A common method of pain assessment is the numerical rating scale, where patients are asked to rate their pain on a scale from 0 to 10, where 0 is "no pain" and 10 is "pain as bad as you can imagine". We hypothesize such language is suboptimal as it involves a test of a cognitive skill, imagination, in the assessment of symptom severity. Methods: We used a large-scale online research registry, ResearchMatch, to conduct a randomized controlled trial to compare the distributions of pain scores of two different pain scale anchors. We recruited adults located in the United States who reported a chronic pain problem (> 3 months) and were currently in pain. Participants were randomized in a 1:1 ratio to receive pain assessment based on a modified Brief Pain Inventory (BPI), where the anchor for a score of 10 was either "extremely severe pain", or the original BPI, with the anchor "pain as bad as you can imagine". Participants in both groups also answered additional questions about pain, other symptomatology and creativity. Results: Data were obtained from 405 participants for the modified and 424 for the original BPI. Distribution of responses to pain questions were similar between groups (all p-values ≥ 0.12). We did not see evidence that the relationship between pain score and the anchor text differed based on self-perceived creativity (all interaction p-values ≥ 0.2). However, in the key analysis, correlations between current pain assessments and known correlates (fatigue, anxiety, depression, current pain compared to a typical day, pain compared to other people) were stronger for "extreme" vs. "imaginable" anchor text (p = 0.005). Conclusion: Pain rating scales should utilize the modified anchor text "extremely severe pain" instead of "pain as bad as you can imagine". Further research should explore the effects of anchors for other symptoms. [ABSTRACT FROM AUTHOR]

Introduction: In the aging process of the body, in addition to changes in fat and muscle content, there is also bone loss, implying the possibility of a strong muscle–bone–lipid link. In this study, we initially investigated the relationship between lumbar BMD and low muscle mass and the relationship between "muscle–bone–lipid." Methods: The datasets from the National Health and Nutrition Examination Survey (NHANES) 2011–2018 were used in a cross-sectional investigation. BMD and appendicular skeletal muscle (ASM) were measured by dual-energy X-ray absorptiometry (DXA), and appendicular skeletal muscle was adjusted by body mass index (BMI) as a marker of sarcopenia. Weighted multivariate regression and logistic regression analysis were used to explore the independent relationship between lumbar BMD and sarcopenia. Fitted smoothing curves and threshold effect analysis were used to describe the nonlinear relationship. Result: In 8386 participants with ages 20–59 years, there was a negative association between lumbar BMD and sarcopenia. In the fully adjusted model, the risk of developing sarcopenia decreased by 93% for each 1-unit increase in lumbar BMD (OR = 0.07, 95%CI 0.03–0.20). The risk of sarcopenia was 58% lower in participants in the highest quartile of lumbar BMD than in those in the lowest quartile (OR = 0.42, 95%CI 0.27–0.64). This negative association was more pronounced in the population of women with BMI ≥ 25. Conclusion: Our findings suggest that lumbar BMD is negatively associated with sarcopenia in US adults. The dynamic balance between "muscle–bone–lipid" is likely to be related to the pathogenesis of bone loss. [ABSTRACT FROM AUTHOR]

The After Breast Cancer Pooling Project was established to examine the role of physical activity, adiposity, dietary factors, supplement use, and quality of life (QOL) in breast cancer prognosis. This paper presents pooled and harmonized data on post-diagnosis lifestyle factors, clinical prognostic factors, and breast cancer outcomes from four prospective cohorts of breast cancer survivors (three US-based and one from Shanghai, China) for 18,314 invasive breast cancer cases diagnosed between 1976 and 2006. Most participants were diagnosed with stage I-II breast cancer (84.7%). About 60% of breast tumors were estrogen receptor (ER)+/progesterone receptor (PR)+; 21% were ER-/PR-. Among 8,118 participants with information on HER-2 tumor status, 74.8% were HER-2- and 18.5% were HER-2+. At 1-2 years post-diagnosis (on average), 17.9% of participants were obese (BMI ≥ 30 kg/m2), 32.6% were overweight (BMI 25-29 kg/m2), and 59.9% met the 2008 Physical Activity Guidelines for Americans (≥ 2.5 h per week of moderate activity). During follow-up (mean = 8.4 years), 3,736 deaths (2,614 from breast cancer) and 3,564 recurrences have been documented. After accounting for differences in year of diagnosis and timing of post-diagnosis enrollment, five-year overall survival estimates were similar across cohorts. This pooling project of 18,000 breast cancer survivors enables the evaluation of associations of post-diagnosis lifestyle factors, QOL, and breast cancer outcomes with an adequate sample size for investigation of heterogeneity by hormone receptor status and other clinical predictors. The project sets the stage for international collaborations for the investigation of modifiable predictors for breast cancer outcomes. [ABSTRACT FROM AUTHOR]

Objectives: To determine dementia prevalence and costs attributable to dementia using Veterans Health Administration (VHA) data with and without Medicare data.Data Sources: VHA inpatient, outpatient, purchased care and other data and Medicare enrollment, claims, and assessments in fiscal year (FY) 2013.Study Design: Analyses were conducted with VHA data alone and with combined VHA and Medicare data. Dementia was identified from a VHA sanctioned list of ICD-9 diagnoses. Attributable cost of dementia was estimated using recycled predictions.Data Collection: Veterans age 65 and older who used VHA and were enrolled in Traditional Medicare in FY 2013 (1.9 million).Principal Findings: VHA records indicated the prevalence of dementia in FY 2013 was 4.8 percent while combined VHA and Medicare data indicated the prevalence was 7.4 percent. Attributable cost of dementia to VHA was, on average, $10,950 per veteran per year (pvpy) using VHA alone and $6,662 pvpy using combined VHA and Medicare data. Combined VHA and Medicare attributable cost of dementia was $11,285 pvpy. Utilization attributed to dementia using VHA data alone was lower for long-term institutionalization and higher for supportive care services than indicated in combined VHA and Medicare data.Conclusions: Better planning for clinical and cost-efficient care requires VHA and Medicare to share data for veterans with dementia and likely more generally. [ABSTRACT FROM AUTHOR]

While great strides have been made recently in improving end-of-life care in the United States, people with dementia often die with inadequate pain control, with feeding tubes in place, and without the benefits of hospice care. In this paper, we discuss the most important and persistent challenges to providing excellent end-of-life care for patients with dementia, including dementia not being viewed as a terminal illness; the nature of the course and treatment decisions in advanced dementia; assessment and management of symptoms; the caregiver experience and bereavement; and health systems issues. We suggest approaches for overcoming these barriers in the domains of education, clinical practice, and public policy. As the population ages, general internists increasingly will be called upon to provide primary care for a growing number of patients dying with dementia. There are great opportunities to improve end-of-life care for this vulnerable and underserved population. [ABSTRACT FROM AUTHOR]

Background: Suboptimal rest-activity patterns in adolescence are associated with worse health outcomes in adulthood. Understanding sociodemographic factors associated with rest-activity rhythms may help identify subgroups who may benefit from interventions. This study aimed to investigate the association of rest-activity rhythm with demographic and socioeconomic characteristics in adolescents. Methods: Using cross-sectional data from the nationally representative National Health and Nutrition Examination Survey (NHANES) 2011–2014 adolescents (N = 1814), this study derived rest-activity profiles from 7-day 24-hour accelerometer data using functional principal component analysis. Multiple linear regression was used to assess the association between participant characteristics and rest-activity profiles. Weekday and weekend specific analyses were performed in addition to the overall analysis. Results: Four rest-activity rhythm profiles were identified, which explained a total of 82.7% of variance in the study sample, including (1) High amplitude profile; (2) Early activity window profile; (3) Early activity peak profile; and (4) Prolonged activity/reduced rest window profile. The rest-activity profiles were associated with subgroups of age, sex, race/ethnicity, and household income. On average, older age was associated with a lower value for the high amplitude and early activity window profiles, but a higher value for the early activity peak and prolonged activity/reduced rest window profiles. Compared to boys, girls had a higher value for the prolonged activity/reduced rest window profiles. When compared to Non-Hispanic White adolescents, Asian showed a lower value for the high amplitude profile, Mexican American group showed a higher value for the early activity window profile, and the Non-Hispanic Black group showed a higher value for the prolonged activity/reduced rest window profiles. Adolescents reported the lowest household income had the lowest average value for the early activity window profile. Conclusions: This study characterized main rest-activity profiles among the US adolescents, and demonstrated that demographic and socioeconomic status factors may shape rest-activity behaviors in this population. [ABSTRACT FROM AUTHOR]

Some studies have concluded that sign language hinders spoken language development for deaf and hard-of-hearing (DHH) children even though sign language exposure could protect DHH children from experiencing language deprivation. Furthermore, this research has rarely considered the bilingualism of children learning a signed and a spoken language. Here we compare spoken English development in 2–6-year-old deaf and hearing American Sign Language–English bilingual children to each other and to monolingual English speakers in a comparison database. Age predicted bilinguals' language scores on all measures, whereas hearing status was only significant for one measure. Both bilingual groups tended to score below monolinguals. Deaf bilinguals' scores differed more from monolinguals, potentially because of later age of and less total exposure to English, and/or to hearing through a cochlear implant. Overall, these results are consistent with typical early bilingual language development. Research and practice must treat signing-speaking children as bilinguals and consider the bilingual language development literature. [ABSTRACT FROM AUTHOR]

Background: Acupuncture and yoga have both been shown to be effective in chronic pain. Underrepresented populations have poorer pain outcomes with less access to effective pain care. Objective: To assess the feasibility of bundling group acupuncture with yoga therapy for chronic neck, back or osteoarthritis pain in safety net settings. Methods: This was a feasibility pilot in Bronx and Harlem primary care community health centers. Participants with chronic neck, back or osteoarthritis pain received acupuncture and yoga therapy over a 10-week period. Participants received 10 weekly acupuncture treatments in group setting; with Yoga therapy sessions beginning immediately following the 3rd session. Primary outcome was pain interference and pain intensity on the Brief Pain Inventory (BPI); Outcomes were measured at baseline, 10-week close of intervention, and 24-week follow-up. Results: 93 patients were determined to be eligible and completed the baseline interview. The majority of participants were non-White and Medicaid recipients. 78 (84%) completed the intervention and 10-week survey, and 58 (62%) completed the 24-week post intervention survey. Participants received an average number of 6.5 acupuncture sessions (out of a possible 10), and 4 yoga sessions (out of a possible 8) over the 10-week intervention. Patients showed statistically significant improvements in pain at the close of the intervention and at a somewhat lesser rate, at 24-weeks post intervention. Challenges included telephone outreach and site coordination integrating acupuncture with yoga therapy. The trial also had to be stopped early due to the COVID-19 pandemic. Conclusions: Bundling acupuncture therapy and yoga therapy is feasible for an underrepresented population with chronic pain in urban community health centers with preliminary indications of acceptability and benefit to participants. [ABSTRACT FROM AUTHOR]

Objective: To investigate the relationship between infant feeding practices and autism spectrum disorder (ASD) among children aged 2–5 years in the United States (US). Methods: Data from the 2016–2020 National Survey of Children's Health, a nationally representative cross-sectional survey, were utilized for this study. Questionnaires were administered to parents of children aged 2–5 years to gather information on ASD diagnosis, infant feeding practices, and demographic factors (e.g., child sex, ethnic group, and maternal age at birth). Logistic regression with sample weights was employed to assess the association between infant feeding practices and ASD, while controlling for demographic variables. Polynomial regression models were used to examine trends in exclusive breastfeeding and ever breastfeeding rates among children with and without ASD. Results: A total of 35,050 children aged 2–5 years were analyzed, including 616 diagnosed with ASD, after excluding participants with missing information on breastfeeding and ASD diagnosis. Of these children with ASD, 76.6% (n = 472) had a breastfeeding history, with 67.5% (n = 416) engaged in partial breastfeeding and 9.1% (n = 56) exclusively breastfed. Adjusted odds ratios for each additional month of breastfeeding compared to never being breastfed were 0.98 (95% CI, 0.96–1.01). The adjusted odds ratios for breastfeeding durations of > 0–6 months, > 6–12 months, > 12–24 months, and > 24 months were 0.81 (95% CI, 0.50–1.31), 0.65 (95% CI, 0.36–1.18), 0.81 (95% CI, 0.44–1.49), and 0.48 (95% CI, 0.23–1.01), respectively. Compared to children who were never breastfed, the adjusted odds ratio for children who were ever breastfed was 0.74 (95% CI, 0.47–1.18). Among children with ASD, the proportion of ever breastfeeding declined from 82.0% in 2017 to 64.3% in 2020, while exclusive breastfeeding decreased from 12.0% in 2016 to 4.2% in 2020. Conclusions and relevance: Although no significant association was found between infant feeding practices and ASD among US children aged 2–5 years, the rates of breastfeeding, particularly exclusive breastfeeding, were suboptimal among children with ASD. This highlights the need for specific policies and practices to promote and support breastfeeding among parents of children with ASD or those at high risk of having a child with ASD. [ABSTRACT FROM AUTHOR]

Social capital has been conceptualized as features of social organization, such as networks, and norms that facilitate coordination and cooperation for mutual benefit. Because of long-standing anti-Black structural oppression in the United States, social capital may be associated with health differently for Black people than for other racial/ethnic groups. Our aim was to examine the psychometric properties of social capital indicators, comparing responses from Black and White people to identify whether there is differential item functioning (DIF) in social capital according to race. DIF examines how items are related to a latent construct and whether this relationship differs across groups such as different racial groups. We used data from respondents to the Southeastern Pennsylvania Household Health Survey in 2004, who lived in Philadelphia (n  = 2,048), a city with a large Black population. We used item response theory analysis to test for racial DIF. We found DIF across the items, indicating measurement error, which could be related to the way these items were developed (i.e. based on cultural assumptions tested in mainstream White America). Hence, our findings underscore the need to interrogate the assumptions that underly existing social capital items through an equity-based lens, and to take corrective action when developing new items to ensure that they are racially and culturally congruent. [ABSTRACT FROM AUTHOR]

Although clozapine has demonstrated unique efficacy for the treatment of seriously ill patients with refractory psychosis, its real-world use presents challenges to clinicians in a variety of settings, leading to its underutilization in the United States. The barriers include a lack of prescriber knowledge and confidence, negative prescriber attitudes, special monitoring requirements, administrative burden, unprepared health systems, and inadequate appreciation of clozapine's unique nature by policy makers and payers. In 2016, the National Association of State Mental Health Program Directors (NASMHPD) gathered a national team of expert clinicians and researchers to identify and address barriers to clozapine use. NASMHPD has since expanded the work group, which convenes monthly to continue addressing specific recommendations. This Open Forum describes the deliberations of the work group and urges practitioners, administrators, local and state governments, researchers, families, and patients to join similar efforts to promote better access to clozapine and improve the treatment management for patients receiving clozapine. [ABSTRACT FROM AUTHOR]

This paper examines the ways in which the behavior of twentieth century cohorts of American women changed simultaneously in the three components of fertility that determine age at last birth--age at first birth, spacing between subsequent births, and parity progression ratios of subsequent births--to produce changes in the timing of the completion of childbearing. It decomposes changes in the mean age at last birth among cohorts and between whites and nonwhites to changes in these three components. To perform these analyses, we developed and applied a method to estimate the distributions and means of ages and last births, birth intervals, and parity progression ratios from age- and parity-specific fertility rates available from vital statistics data. Results show that the cohorts increased and decreased their age at first birth, birth intervals, and parity progression ratios of lower and higher birth orders in almost every possible combination so as to achieve a relatively young age at final birth. [ABSTRACT FROM AUTHOR]