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In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Fatigue is a dominant feature of both acute and convalescent coronavirus disease 2019 (COVID-19) (sometimes termed "long-COVID"), with up to 46% of patients reporting fatigue that lasts from weeks to months. The investigators of the international Collaborative on Fatigue Following Infection (COFFI) conducted a systematic review of post-COVID fatigue and a narrative review on fatigue after other infections, and made recommendations for clinical and research approaches to assessing fatigue after COVID-19. In the majority of COVID-19 cohort studies, persistent fatigue was reported by a significant minority of patients, ranging from 13% to 33% at 16-20 weeks post-symptom onset. Data from the prospective cohort studies in COFFI and others indicate that fatigue is also a prevalent outcome from many acute systemic infections, notably infectious mononucleosis, with a case rate for clinically significant Post-infective fatigue after exclusion of recognized medical and psychiatric causes, ranging from 10%-35% at 6 months. To better characterize post-COVID fatigue, the COFFI investigators recommend the following: application of validated screening questionnaires for case detection; standardized interviews encompassing fatigue, mood, and other symptoms; and investigative approaches to identify end-organ damage and mental health conditions., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Prior to the pandemic, our research team implemented a randomized controlled trial of an intervention to reduce risk for alcohol-exposed pregnancy (AEP) in American Indian women. When active recruitment for the in-person trial was paused due to COVID, the research team moved to conducting follow-up surveys with participants who had completed the intervention to better understand changes to their alcohol use during the pandemic. We collected surveys from 62 American Indian women who had completed the Native CHOICES intervention. Baseline data collected pre-COVID included demographics and scores on the Alcohol Use Disorders Identification Test (AUDIT). Follow-up surveys conducted during the active pandemic period included a self-reported questionnaire about changes in drinking patterns. At pre-COVID baseline, all participants were engaged in heavy or binge drinking. At follow-up during COVID, 24.2% reported drinking more, and over half had at least one binge drinking episode. Approximately half reported reduced drinking. We found that risky drinking remained an issue during the pandemic for many American Indian women who had engaged in this behavior pre-COVID, while others reported reducing their alcohol consumption. As the pandemic abates, concerted efforts must be made to reach those with identified alcohol use disorders to offer resources and intervention as needed.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Competing Interests: None declared.

Evidence suggests that perceived stress and psychological resilience are related to the presence and severity of cardiometabolic disease. Despite increased stress and cardiometabolic disease burden among American Indian and Alaska Native (AI/AN) people, the relationships between these factors are not well established in these populations. The objective of this study was to evaluate the relationships of stress with five cardiometabolic health indicators and to assess whether psychological resilience mediates these relationships in AI/AN adults. Four hundred and ninety-six AI/AN attendees were surveyed at three powwows. The questionnaire included sociodemographic items, questions on self-reported obesity, prediabetes, diabetes, high blood pressure, and high cholesterol, the Perceived Stress Scale, and the Brief Resilience Scale. Multivariable logistic regression models were used to measure associations of health indicators with Perceived Stress Scale and Brief Resilience Scale scores while controlling for sociodemographic characteristics. Among respondents, obesity was the most common cardiometabolic health indicator reported (48%), followed by high blood pressure, prediabetes, diabetes, and high cholesterol. Mean Perceived Stress Scale and Brief Resilience Scale scores were 16.1 (6.4 SD) and 3.5 (0.7 SD), respectively. Higher Perceived Stress Scale scores were associated with greater odds of self-reported prediabetes and diabetes. Brief Resilience Scale scores did not serve as a mediator. These results suggest that perceived stress is associated with some self-reported indicators of cardiometabolic health among AI/AN adults, but findings are limited by the convenience sample, reliance on self-report, and cross-sectional design. Future work should capitalize on nationally representative data, longitudinal designs, and objective measures of cardiometabolic health., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors. Published by Elsevier Inc.)

To examine risk factors for elevated blood pressure and hypertension in American Indians and Alaska Natives (AI/ANs), compared to three other ethnic groups in the US. Weighted relative risk regression models, stratified by race/ethnicity, were used to measure the associations between risk factors and elevated blood pressure and hypertension in AI/ANs, compared to non-Hispanic Whites, non-Hispanic Blacks and Hispanics, with data from the National Longitudinal Study of Adolescent to Adult Health. In all groups, females had a lower risk of both elevated blood pressure and hypertension than males. Increasing body mass index raised hypertension risk in all groups. In AI/ANs, financial instability increased the risk of hypertension by 88% (95% CI: 1.27-2.77), but not in other groups. No other statistically significant associations were found. Future interventions should include socio-economic factors in efforts to prevent hypertension in AI/ANs.

Movements are defining characteristics of all behaviors. Animals walk around, move their eyes to explore the world or touch structures to learn more about them. So far we only have some basic understanding of how the brain generates movements, especially when we want to understand how different areas of the brain interact with each other. In this study we investigated the influence of sensory object information on grasp planning in four different brain areas involved in vision, touch, movement planning, and movement generation in the parietal, somatosensory, premotor and motor cortex. We trained one monkey to grasp objects that he either saw or touched beforehand while continuously recording neural spiking activity with chronically implanted floating multi-electrode arrays. The animal was instructed to sit in the dark and either look at a shortly illuminated object or reach out and explore the object with his hand in the dark before lifting it up. In a first analysis we confirmed that the animal not only memorizes the object in both tasks, but also applies an object-specific grip type, independent of the sensory modality. In the neuronal population, we found a significant difference in the number of tuned units for sensory modalities during grasp planning that persisted into grasp execution. These differences were sufficient to enable a classifier to decode the object and sensory modality in a single trial exclusively from neural population activity. These results give valuable insights in how different brain areas contribute to the preparation of grasp movement and how different sensory streams can lead to distinct neural activity while still resulting in the same action execution., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Buchwald and Scherberger.)

Objectives: Disparities in access to medication-assisted treatment are a major problem. This study estimated and compared drive time to the nearest opioid treatment program (OTP) and office-based buprenorphine treatment (OBBT) across the urban-rural continuum in the U.S., Methods: Drive time was calculated between the longitude and latitude of population weighted block group centroids and the longitude and latitude of the nearest OTP and OBBT. Rural-Urban Commuting Area (RUCA) codes were used for defining rurality. The Integrated Nested Laplace Approximation approach was used for statistical analysis., Results: The mean travel time to the nearest OBBT compared to OTP decreased by 7.18 min (95 % CI = 7.23-7.14) in metropolitan cores, 36.63 min (95 % CI = 37.12-36.15) in micropolitan cores, 38.84 min (95 % CI = 39.57-38.10) in small town cores, and 40.16 min (95 % CI = 40.81-39.50) in rural areas. Additionally, travel burden to the nearest OTP would be more than 60 min for 13,526,605 people and more than 90 min for 5,371,852 people. The travel burden to the nearest OBBT would be more than 60 min for 845,991 people and more than 90 min for 149,297 people., Conclusions: The mean drive time to the closest OBBT was significantly smaller than the mean drive time to the closest OTP. Analysis of barriers to access is necessary to devising creative initiatives to improve access to critical opioid use disorder treatment services., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Aims: To test if contingency management (CM) interventions for alcohol and drug abstinence were associated with increased alcohol and drug abstinence among American Indian adults with alcohol dependence who also use drugs., Design: In this 2 × 2 factorial randomized controlled trial, American Indian adults with alcohol dependence who also used drugs were randomized to four conditions: (1) incentives for submission of urine samples only (control condition), (2) CM incentives for alcohol abstinence, (3) CM incentives for drug abstinence or (4) CM incentives for abstinence from both alcohol and drugs., Setting: A Northern Plains Reservation in the United States., Participants: A total of 114 American Indian adults aged 35.8 years (standard deviation = 10.4); 49.1% were male., Intervention and Comparator: Participants received incentives if they demonstrated abstinence from alcohol (CM for alcohol, n = 30), abstinence from their most frequently used drug (CM for drugs, n = 27) or abstinence from both alcohol and their most frequently used drug (CM for alcohol and drugs, n = 32) as assessed by urine tests. Controls (n = 25) received incentives for submitting urine samples only., Measurements: Primary outcomes were urine ethyl glucuronide (alcohol) and drug tests conducted three times per week during the 12-week intervention period. Data analyses included listwise deletion and multiple imputation to account for missing data., Findings: The three CM groups were significantly (P < 0.05) more likely to submit alcohol-abstinent urine samples compared with the control condition, with odds ratios ranging from 2.4 to 4.8. The CM for drugs (OR = 3.2) and CM for alcohol and drugs (OR = 2.5) were significantly more likely to submit urine samples that indicated drug abstinence, relative to the control condition (P < 0.05). However, these differences were not significant in multiple imputation analyses (P > 0.05)., Conclusions: Contingency management (CM) incentives for abstinence were associated with increased alcohol abstinence in American Indian adults diagnosed with alcohol dependence who also used drugs, living on a rural reservation. The effect of CM incentives on drug abstinence was inconclusive., (© 2020 Society for the Study of Addiction.)

The validation of the assessment of depression across ethnic groups is critical yet deficient for American Indian (AI) adults. Therefore, we assessed the psychometric properties of the Center for Epidemiological Studies-Depression (CES-D) in AI elders and tested differences in depression constructs between gender. Participants were 817 AI adults (68% women), mean age 73.2 years ( SD = 6.1, range: 64-95) for women and 72.6 years ( SD = 5.3, range: 65-90) for men., in the Cerebrovascular Disease and Its Consequences in AIs Study. We evaluated the factor structure of the 20-item and 12-item CES-D and tested measurement invariance between gender. Results demonstrated a poor fit for the 20-item CES-D and partial gender measurement invariance of the 12-item CES-D. AI female elders had significantly higher depression levels than AI male elders on the Depressed Affect subscale, the Somatic Symptoms subscale, and the Well-Being (reverse-coded) subscale. Further replication is needed, and we recommend future psychometric work with the 12-item CES-D with AI elders. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Importance: Many American Indian and Alaska Native communities are disproportionately affected by problems with alcohol use and seek culturally appropriate and effective interventions for individuals with alcohol use disorders., Objective: To determine whether a culturally tailored contingency management intervention, in which incentives were offered for biologically verified alcohol abstinence, resulted in increased abstinence among American Indian and Alaska Native adults. This study hypothesized that adults assigned to receive a contingency management intervention would have higher levels of alcohol abstinence than those assigned to the control condition., Design, Setting, and Participants: This multisite randomized clinical trial, the Helping Our Native Ongoing Recovery (HONOR) study, included a 1-month observation period before randomization and a 3-month intervention period. The study was conducted at 3 American Indian and Alaska Native health care organizations located in Alaska, the Pacific Northwest, and the Northern Plains from October 10, 2014, to September 2, 2019. Recruitment occurred between October 10, 2014, and February 20, 2019. Eligible participants were American Indian or Alaska Native adults who had 1 or more days of high alcohol-use episodes within the last 30 days and a current diagnosis of alcohol dependence. Data were analyzed from February 1 to April 29, 2020., Interventions: Participants received treatment as usual and were randomized to either the contingency management group, in which individuals received 12 weeks of incentives for submitting a urine sample indicating alcohol abstinence, or the control group, in which individuals received 12 weeks of incentives for submitting a urine sample without the requirement of alcohol abstinence. Regression models fit with generalized estimating equations were used to assess differences in abstinence during the intervention period., Main Outcomes and Measures: Alcohol-negative ethyl glucuronide (EtG) urine test result (defined as EtG<150 ng/mL)., Results: Among 1003 adults screened for eligibility, 400 individuals met the initial criteria. Of those, 158 individuals (39.5%; mean [SD] age, 42.1 [11.4] years; 83 men [52.5%]) met the criteria for randomization, which required submission of 4 or more urine samples and 1 alcohol-positive urine test result during the observation period before randomization. A total of 75 participants (47.5%) were randomized to the contingency management group, and 83 participants (52.5%) were randomized to the control group. At 16 weeks, the number who submitted an alcohol-negative urine sample was 19 (59.4%) in the intervention group vs 18 (38.3%) in the control group. Participants randomized to the contingency management group had a higher likelihood of submitting an alcohol-negative urine sample (averaged over time) compared with those randomized to the control group (odds ratio, 1.70; 95% CI, 1.05-2.76; P = .03)., Conclusions and Relevance: The study's findings indicate that contingency management may be an effective strategy for increasing alcohol abstinence and a tool that can be used by American Indian and Alaska Native communities for the treatment of individuals with alcohol use disorders., Trial Registration: ClinicalTrials.gov Identifier: NCT02174315.

Grasping movements are some of the most common movements primates do every day. They are important for social interactions as well as picking up objects or food. Usually, these grasping movements are guided by vision but proprioceptive and haptic inputs contribute greatly. Since grasping behaviors are common and easy to motivate, they represent an ideal task for understanding the role of different brain areas during planning and execution of complex voluntary movements in primates. For experimental purposes, a stable and repeatable presentation of the same object as well as the variation of objects is important in order to understand the neural control of movement generation. This is even more the case when investigating the role of different senses for movement planning, where objects need to be presented in specific sensory modalities. We developed a turntable setup for non-human primates (macaque monkeys) to investigate visually and tactually guided grasping movements with an option to easily exchange objects. The setup consists of a turntable that can fit six different objects and can be exchanged easily during the experiment to increase the number of presented objects. The object turntable is connected to a stepper motor through a belt system to automate rotation and hence object presentation. By increasing the distance between the turntable and the stepper motor, metallic components of the stepper motor are kept at a distance to the actual recording setup, which allows using a magnetic-based data glove to track hand kinematics. During task execution, the animal sits in the dark and is instructed to grasp the object in front of it. Options to turn on a light above the object allow for visual presentation of the objects, while the object can also remain in the dark for exclusive tactile exploration. A red LED is projected onto the object by a one-way mirror that serves as a grasp cue instruction for the animal to start grasping the object. By comparing kinematic data from the magnetic-based data glove with simultaneously recorded neural signals, this setup enables the systematic investigation of neural population activity involved in the neural control of hand grasping movements., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Buchwald, Schaffelhofer, Dörge, Dann and Scherberger.)

Introduction: Prenatal exposure to alcohol can cause lifelong physical and cognitive challenges in the form of fetal alcohol syndrome and other fetal alcohol spectrum disorders (FASDs). The prevention of prenatal alcohol exposure is thus a public health priority - and one that should account for the particular needs of subpopulations, including in American Indian/Alaska Native (AI/AN) communities. Prior to conception, alcohol-exposed pregnancy prevention is accomplished by encouraging the reduction or elimination of risky alcohol use and/or promoting effective contraceptive use among risky drinkers who could become pregnant. The current study builds on promising findings about the impact of the Centers for Disease Control and Prevention CHOICES intervention with AI/AN communities by implementing a randomized control trial of Native CHOICES, a cultural adaptation of CHOICES, with AI/AN women in a rural reservation community., Methods: AI/AN women aged 18-44 who are at-risk for an alcohol-exposed pregnancy are being recruited. Participants are randomized in 1:1 proportion to the intervention and a services-as-usual, waitlist control condition. The Native CHOICES intervention consists of 2 motivational interviewing (MI) sessions, an elective contraception counseling session, and electronic messaging to boost the effects of MI. Data are collected at baseline and at 6 weeks, 3 months, and 6 months post-baseline. Those assigned to the control group are eligible to enroll in Native CHOICES following the completion of the 6 months post-baseline data collection. In addition to testing intervention effectiveness, the study is designed to yield a comprehensive economic evaluation, which will provide important information regarding the financial feasibility and sustainability of Native CHOICES for healthcare systems serving AI/ANs., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background and Aims: Despite known Indigenous health and socioeconomic disadvantage in countries with a Very High Human Development Index, data on the incidence of stroke in these populations are sparse. With oversight from an Indigenous Advisory Board, we will undertake a systematic review of the incidence of stroke in Indigenous populations of developed countries or regions, with comparisons between Indigenous and non-Indigenous populations of the same region, though not between different Indigenous populations. Methods: Using PubMed, OVID-EMBASE, and Global Health databases, we will examine population-based incidence studies of stroke in Indigenous adult populations of developed countries published 1990-current, without language restriction. Non-peer-reviewed sources, studies including <10 Indigenous People, or with insufficient data to determine incidence, will be excluded. Two reviewers will independently validate the search strategies, screen titles and abstracts, and record reasons for rejection. Relevant articles will undergo full-text screening, with standard data extracted for all studies included. Quality assessment will include Sudlow and Warlow's criteria for population-based stroke incidence studies, the Newcastle-Ottawa Scale for risk of bias, and the CONSIDER checklist for Indigenous research. Results: Primary outcomes include crude, age-specific and/or age-standardized incidence of stroke. Secondary outcomes include overall stroke rates, incidence rate ratio and case-fatality. Results will be synthesized in figures and tables, describing data sources, populations, methodology, and findings. Within-population meta-analysis will be performed if, and where, methodologically sound and comparable studies allow this. Conclusion: We will undertake the first systematic review assessing disparities in stroke incidence in Indigenous populations of developed countries. Data outputs will be disseminated to relevant Indigenous stakeholders to inform public health and policy research., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The Handling Editor declared a past co-authorship with two of the authors, AD and MP., (Copyright © 2021 Balabanski, Dos Santos, Woods, Thrift, Kleinig, Suchy-Dicey, Siri, Boden-Albala, Krishnamurthi, Feigin, Buchwald, Ranta, Mienna, Zavaleta, Churilov, Burchill, Zion, Longstreth, Tirschwell, Anand, Parsons, Brown, Warne, Harwood and Katzenellenbogen.)

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sweeping across our country has reawakened the fear, pain, stigma, and loss of past outbreaks of infectious diseases among American Indians and Alaska Natives. Attention to the pandemic has emphasized the challenges it poses for Native peoples: their vulnerability, the heartbreaking battle to constrain contagion, the lack of resources to care for those afflicted by the virus, and the mounting consequences for individuals, families, and community. We highlight the factors that contribute to them but conclude by underscoring the intrinsic strengths and resilience, which, in combination with modern public health tools, promise to resolve them., Competing Interests: No competing financial interests exist., (© Spero M. Manson and Dedra Buchwald 2021; Published by Mary Ann Liebert, Inc.)

Objective: Posttraumatic stress disorder (PTSD) is highly comorbid with chronic pain conditions that often co-occur such as migraine headaches, temporomandibular disorder, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, chronic prostatitis/chronic pelvic pain syndrome, and tension headaches. Using a genetically informative sample, the current study evaluated the genetic and environmental factors contributing to the co-occurrence of PTSD and chronic pain conditions., Methods: Data from 4680 male twins in the Vietnam Era Twin Registry were examined. Biometric modeling was used to estimate genetic and environmental variance components and genetic and environmental correlations between PTSD and multiple chronic pain conditions., Results: Heritabilities were estimated at 43% (95% confidence interval [CI] = 15%-63%) for PTSD and 34% (95% CI = 27%-41%) for the combined history of any one or more pain condition. Specific pain condition heritabilities ranged from 15% (95% CI = 0%-48%) for tension headaches to 41% (95% CI = 27%-54%) for migraine headaches. Environmental influences accounted for the remaining variance in pain conditions. The genetic correlation between PTSD and combined history of any one or more pain condition was rg= 0.61 (95% CI = 0.46-0.89) and ranged for individual pain conditions from rg= 0.44 (95% CI = 0.24-0.77) for migraine headache to rg= 0.75 (95% CI = 0.52-1.00) for tension headaches., Conclusions: PTSD and chronic pain conditions are highly comorbid, and this relationship can be explained by both genetic and environmental overlap. The precise mechanisms underlying these relationships are likely diverse and multifactorial., (Copyright © 2020 by the American Psychosomatic Society.)

Objectives: To measure access to opioid treatment programs (OTPs) and office-based buprenorphine treatment (OBBTs) at the smallest geographic unit for which the Census Bureau publishes demographic and socioeconomic data (ie, block group) and to explore disparities in access to treatment across the rural-urban and area deprivation continua across the United States., Methods: Access to OTPs and OBBTs at the block group in 2019 was quantified using an innovative 2-step floating catchment area technique that accounts for the supply of treatment facilities relative to the population size, proximity of facilities relative to the location of population in block groups, and time as a barrier within catchments. Block groups were stratified into tertiles based on the rural-urban continuum codes (metropolitan, micropolitan, small town, or rural) and area deprivation index (least-deprived, middle-deprived, most-deprived). The Integrated Nested Laplace Approximation approach was used for statistical analysis., Results: Across the United States, 3329 block groups corresponding to 2 915 949 adults lacked access to OTPs within a 2-hour drive of their community and 130 block groups corresponding to 86 605 adults did not have access to OBBTs. Disparities in access to treatment were observed across the urban-rural and area deprivation continua including (1) lowest mean access score to OBBTs were found among most-deprived small towns, and (2) lower mean access score to OTPs were found among micropolitan and small towns., Conclusions: The results of this study revealed disparities in access to medication-assisted treatment. The findings call for creative initiatives and local and regional policies to develop to mitigate access problems., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Background: The vascular endothelial glycocalyx is susceptible to ischemia and hypoxia. Released soluble components of the endothelial glycocalyx (EG) have been identified as potential damage associated molecular patterns (DAMPs) able to enhance an ongoing inflammatory response. Shedding of the EG has been associated with released atrial-natriuretic peptide (ANP) during cardiac surgery procedures. A novel hemoadsorption technique (CytoSorb ® ) has been shown to effectively remove molecules up to 55 kDa unspecifically from circulation. It is not known whether ANP or glycocalyx components can be removed successfully by this technique., Methods: In 15 patients undergoing on-pump cardiac surgery, the hemoadsorption device was integrated in the cardiopulmonary bypass (CPB) circuit. Pre- and post-adsorber concentrations of ANP, heparan sulphate (HEP), syndecan-1 (SYN) and hyaluronan (HYA) were measured at 10 (T1), 30 (T2), and 60 (T3) minutes after aortic cross-clamping and complete CPB., Results: Hemoadsorption significantly reduced mean HEP concentrations (-157.5 [333.4] ng/mL; P<0.001) post adsorber. For ANP and SYN no statistically significant changes were detected whereas mean [SD] HYA concentrations even increased significantly (+21.6 [43.0] ng/mL; P<0.001) post adsorber., Conclusions: In this study representing a real-life scenario, we could demonstrate that the novel hemoadsorption device (CytoSorb ® ) was able to effectively adsorb HEP from the circulation if integrated in a CPB circuit. However, blood concentrations of HYA, SYN, and ANP could not be reduced during CPB in our investigation.

Background: Research on sustaining community-based interventions is limited. This is particularly true for suicide prevention programs and in American Indian and Alaska Native (AIAN) settings. Aiming to inform research in this area, this paper sought to identify factors and strategies that are key to sustain suicide prevention efforts in AIAN communities., Methods: We used a modified Nominal Group Technique with a purposeful sample of N = 35 suicide prevention research experts, program implementors and AIAN community leaders to develop a list of prioritized factors and sustainability strategies. We then compared this list with the Public Health Program Capacity for Sustainability Framework (PHPCSF) to examine the extent the factors identified aligned with the existing literature., Results: Major factors identified included cultural fit of intervention approaches, buy in from local communities, importance of leadership and policy making, and demonstrated program success. Strategies to promote these factors included partnership building, continuous growth of leadership, policy development, and ongoing strategic planning and advocacy. All domains of the PHPCF were representative, but additional factors and strategies were identified that emerged as important in AIAN settings., Conclusions: Sustaining effective and culturally informed suicide prevention efforts is of paramount importance to prevent suicide and save lives. Future research will focus on generating empirical evidence of these strategies and their effectiveness at promoting program sustainability in AIAN communities., Competing Interests: Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Epidemiologic studies often use self-report as proxy for clinical history. However, whether self-report correctly identifies prevalence in minority populations with health disparities and poor health-care access is unknown. Furthermore, overlap of clinical vascular events with covert vascular brain injury (VBI), detected by imaging, is largely unexamined., Methods: The Strong Heart Study recruited American Indians from 3 regions, with surveillance and adjudication of stroke events from 1989 to 2013. In 2010-2013, all 817 survivors, aged 65-95 years, underwent brain imaging, neurological history interview, and cognitive testing. VBI was defined as imaged infarct or hemorrhage., Results: Adjudicated stroke was prevalent in 4% of participants and separately collected, self-reported stroke in 8%. Imaging-defined VBI was detected in 51% and not associated with any stroke event in 47%. Compared with adjudication, self-report had 76% sensitivity and 95% specificity. Participants with adjudicated or self-reported stroke had the poorest performance on cognitive testing; those with imaging-only (covert) VBI had intermediate performance., Conclusion: In this community-based cohort, self-report for prior stroke had good performance metrics. A majority of participants with VBI did not have overt, clinically recognized events but did have neurological or cognitive symptoms. Data collection methodology for studies in a resource-limited setting must balance practical limitations in costs, accuracy, feasibility, and research goals., (© 2021 S. Karger AG, Basel.)

Introduction: Cardiovascular disease (CVD) is the leading cause of death among American Indians and Alaska Natives. Reducing CVD risk requires effective communication about risk factors and preventive behaviors. Messages should be designed with an understanding of where people seek health information, their perceptions of a hazard, and their perception of information sufficiency. We examined these components of message design to inform strategies to effectively communicate information about CVD to American Indians and Alaska Natives., Methods: We surveyed 220 adults who self-identified as American Indians or Alaska Natives at 2 Native-focused events in urban areas. Our survey included items on demographic characteristics, place of residence, sources of information used to learn about CVD, perceived information sufficiency, and perceptions about the importance of CVD as a health problem., Results: Respondents used the internet (67%), their doctors (66%), friends and relatives (63%), brochures (62%), and television (61%) to learn about CVD. Participants aged 60 or older and those living on a reservation were more likely to use their doctor to learn about CVD than their younger (≤30 y) or urban peers. CVD was viewed as a major problem for American Indians and Alaska Natives (84%) and for Americans in general (86%). Most respondents felt moderately (54%) or well informed (37%) about CVD., Conclusion: Various information sources should be used to increase awareness about CVD. Special attention may be needed to optimize communication to American Indians and Alaska Natives aged 60 or older and people living on reservations. Further study is needed to determine how our findings can best inform effective interventions to reduce CVD morbidity and mortality among these populations.

Introduction: The population of American Indians and Alaska Natives (AI/ANs) aged 65 and older is growing rapidly, raising concerns about Alzheimer's disease (AD) in their communities., Methods: We distributed a survey incorporating the Alzheimer's Disease Knowledge Scale to 341 AI/AN community members attending cultural events. We computed average adjusted predictions and 95% confidence intervals from a linear regression model, used joint F tests to examine differences in scores according to demographic variables, calculated the percentage of correct items for each participant, and computed domain-specific averages across the sample., Results: The average score was 19.0 (maximum 30); the average percentage of correct responses was 63%. Higher scores were associated with education but not with age, sex, or rural versus urban residence. Low scores were observed for items on caregiving and disease risk., Discussion: Participants were moderately well informed about AD, but specific knowledge domains call for community outreach and education., (© 2020 The Authors. Alzheimer's & Dementia: Translational Research & Clinical Interventions published by Wiley Periodicals, Inc. on behalf of Alzheimer's Association.)

Background: Arsenic and cadmium are known cardiovascular toxicants that pose disproportionate risk to rural communities where environmental exposures are high. American Indians have high vascular risk, which may be attributable in part to these exposures., Objective: We examined urine metal concentrations in association with magnetic resonance imaging findings of vascular brain injury or cerebral atrophy in adult American Indians., Methods: We measured arsenic and cadmium in American Indian participants from the Strong Heart Study (1989-1991) and evaluated these associations with later (2010-2013) measures of infarct, hemorrhage, white matter hyperintensity (WMH) grade, brain and hippocampal volume, and sulcal and ventricle atrophy using nested multivariate regression analyses., Results: Among participants with available data ( N = 687 ), the median urine arsenic:creatinine ratio was 7.54 μ g / g [interquartile range (IQR): 4.90-11.93] and the cadmium:creatinine ratio was 0.96 μ g / g (IQR: 0.61-1.51). Median time between metal measurement and brain imaging was 21 y (range: 18-25 y). Statistical models detected significant associations between arsenic and higher burden of WMH [ grade increase = 0.014 (95% CI: 0.000, 0.028) per 10% increase in arsenic]; and between cadmium and presence of lacunar infarcts [ relative risk  ( RR ) = 1.024 (95% CI: 1.004, 1.045) per 10% increase in cadmium]., Discussion: This population-based cohort of American Indian elders had measured values of urine arsenic and cadmium several times higher than previous population- and clinic-based studies in the United States and Mexico, and comparable values with European industrial workers. Our findings of associations for arsenic and cadmium exposures with vascular brain injury are consistent with established literature. Environmental toxicant accumulation is modifiable; public health policy may benefit from focusing on reductions in environmental metals. https://doi.org/10.1289/EHP6930.

Background: A diverse research workforce is essential for catalyzing biomedical advancements, but this workforce goal is hindered by persistent sex and racial/ethnic disparities among investigators receiving research grants from the National Institutes of Health (NIH). In response, the NIH-funded National Research Mentoring Network implemented a Grant Writing Coaching Program (GCP) to provide diverse cohorts of early-career investigators across the United States with intensive coaching throughout the proposal development process. We evaluated the GCP's national reach and short-term impact on participants' proposal submissions and funding outcomes., Methods: The GCP was delivered as six similar but distinct models. All models began with an in-person group session, followed by a series of coaching sessions over 4 to 12 months. Participants were surveyed at 6-, 12- and 18-months after program completion to assess proposal outcomes (submissions, awards). Self-reported data were verified and supplemented by searches of public repositories of awarded grants when available. Submission and award rates were derived from counts of participants who submitted or were awarded at least one grant proposal in a category (NIH, other federal, non-federal)., Results: From June 2015 through March 2019, 545 investigators (67% female, 61% under-represented racial/ethnic minority, URM) from 187 different institutions participated in the GCP. Among them, 324 (59% of participants) submitted at least one grant application and 134 (41% of submitters) received funding. A total of 164 grants were awarded, the majority being from the NIH (93, 56%). Of the 74 R01 (or similar) NIH research proposals submitted by GCP participants, 16 have been funded thus far (56% to URM, 75% to women). This 22% award rate exceeded the 2016-2018 NIH success rates for new R01s., Conclusion: Inter- and intra-institutional grant writing coaching groups are a feasible and effective approach to supporting the grant acquisition efforts of early-career biomedical investigators, including women and those from URM groups., Competing Interests: The authors have declared that no competing interests exist.

Introduction: We examined health insurance benefits, workplace policies, and health promotion programs in small to midsize businesses in Alaska whose workforces were at least 20% Alaska Native. Participating businesses were enrolled in a randomized trial to improve health promotion efforts., Methods: Twenty-six Alaska businesses completed from January 2009 through October 2010 a 30-item survey on health benefits, policies, and programs in the workplace. We generated frequency statistics to describe overall insurance coverage, and to detail insurance coverage, company policies, and workplace programs in 3 domains: tobacco use, physical activity and nutrition, and disease screening and management., Results: Businesses varied in the number of employees (mean, 250; median, 121; range, 41-1,200). Most businesses offered at least partial health insurance for full-time employees and their dependents. Businesses completely banned tobacco in the workplace, and insurance coverage for tobacco cessation was limited. Eighteen had onsite food vendors, yet fewer than 6 businesses offered healthy food options, and even fewer offered them at competitive prices. Cancer screening and treatment were the health benefits most commonly covered by insurance., Conclusion: Although insurance coverage and workplace policies for chronic disease screening and management were widely available, significant opportunities remain for Alaska businesses to collaborate with federal, state, and community organizations on health promotion efforts to reduce the risk of chronic illness among their employees.

The burden of Alzheimer's disease and related dementias (ADRD) has increased substantially in the United States, particularly in health disparity populations. Little is known about the epidemiology of ADRD in American Indian (AI) adults, although they have a high prevalence of ADRD risk factors including hypertension, diabetes, obesity, and smoking. Using electronic health records from a large health care organization during 2016-18, we describe characteristics of AI patients aged ≥55 years with and without an ADRD diagnosis, assess ADRD risk factors and contrast findings with results from age- and sex-matched non-Hispanic White (NHW) patients. To identify factors associated with ADRD diagnoses, we estimated population-averaged prevalence rate ratios to approximate relative risk (RR) using generalized estimating equations models adjusted for age, sex, and marital and rural residency status. The age-adjusted prevalence of ADRD diagnosis was 6.6% of AI patients, compared with 4.4% in NHW patients. Patient age and diagnosis of hypertension, depression, hyperlipidemia, or diabetes were significantly associated with higher risk of ADRD diagnosis in AIs (RR range: 1.1-2.8) whereas female sex or being married/having a partner were associated with lower risk of ADRD diagnosis (each RR=.7). ADRD risk factors were generally similar between AI and NHW patients, except for sex and marital status. However, the adjusted risk of ADRD was approximately 49% higher in AI patients. To our knowledge, our study is the first to examine ADRD diagnoses and comorbidities in AIs across a large geographical region in southwest United States. Future efforts to confirm our findings in diverse AI communities are warranted., Competing Interests: Competing Interests: ER and DS are employees of Banner Health; we have no other conflicts of interest., (Copyright © 2020, Ethnicity & Disease, Inc.)

Objectives: The objective of this study was to examine the predictive validity of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) among Alaska Native and American Indian (ANAI) people with an alcohol use disorder., Methods: The sample was 170 ANAI adults with an alcohol use disorder living in Anchorage, Alaska who were part of a larger alcohol intervention study. The primary outcome of this study was alcohol use as measured by mean urinary ethyl glucuronide (EtG). EtG urine tests were collected at baseline and then up to twice a week for four weeks. We conducted bivariate linear regression analyses to evaluate associations between mean EtG value and each of the three SOCRATES subscales (Recognition, Ambivalence, and Taking Steps) and other covariates such as demographic characteristics, alcohol use history, and chemical dependency service utilization. We then performed multivariable linear regression modeling to examine these associations after adjusting for covariates., Results: After adjusting for covariates, mean EtG values were negatively associated with the Taking Steps (P = 0.017) and Recognition (P = 0.005) subscales of the SOCRATES among ANAI people living in Alaska. We did not find an association between mean EtG values and the Ambivalence subscale (P = 0.129) of the SOCRATES after adjusting for covariates., Conclusions: Higher scores on the Taking Steps and Recognition subscales of the SOCRATES at baseline among ANAI people predicted lower mean EtG values. This study has important implications for communities and clinicians who need tools to assist ANAI clients in initiating behavior changes related to alcohol use.

Background: There is an increasing focus among cancer patients on the use of cannabis-based medicine (CBM) as a supplement to conventional palliative care. However, physicians are reluctant to engage in dialog with the patients as clinical evidence is lacking. As a result, the patients are often left alone to rely on their own judgment in purchasing CBM products on the illegal market. Objective: Our study aimed to collect information from CBM treatment-experienced cancer patients receiving palliative care regarding treatment decision rationale and outcome. Design: A qualitative interview study using thematic analysis was performed. Setting/Participants: A total of 20 informants took part in individual interviews. Results: To the question addressing the main rationale for starting CBM treatment, all 20 patients responded that they carried a hope that cannabis would have a curative effect on the cancer disease. Most patients reported relief of symptoms, such as insomnia, anxiety, nausea, and pain, after initiation of CBM treatment, but this outcome was perceived as less of a focus in comparison to hope of a cure. Conclusion: This study contributes with knowledge from the perspective of the cancer patient in palliative care regarding the decision behind the use of CBM. There seems to be striving for surviving cancer based on the rationale that cannabis may constitute curative properties. Relief of symptoms is perceived as a secondary reason for treatment. This knowledge is essential in the dialog between the health professional and the cancer patient about the use of CBM products for treatment.

Aims: The Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network initiated a second observational cohort study-the Symptom Patterns Study (SPS)-to further investigate the underlying pathophysiology of Urologic Chronic Pelvic Pain Syndrome (UCPPS) and to discover factors associated with longitudinal symptom changes and responses to treatments., Methods: This multisite cohort study of males and females with UCPPS features a run-in period of four weekly web-based symptom assessments before a baseline visit, followed by quarterly assessments up to 36 months. Controls were also recruited and assessed at baseline and 6 months. Extensive clinical data assessing urological symptoms, nonurological pain, chronic overlapping pain syndromes, and psychosocial factors were collected. Diverse biospecimens for biomarker and microbiome studies, quantitative sensory testing (QST) data under multiple stimuli, and structural and functional neuroimaging scans were obtained under a standardized protocol., Results: Recruitment was initiated (July 2015) and completed (February 2019) at six discovery sites. A total of 620 males and females with UCPPS and 73 Controls were enrolled, including 83 UCPPS participants who re-enrolled from the first MAPP Network cohort study (2009-2012). Baseline neuroimaging scans, QST measures, and biospecimens were obtained on 578 UCPPS participants. The longitudinal follow-up of the cohort is ongoing., Conclusions: This comprehensive characterization of a large UCPPS cohort with extended follow-up greatly expands upon earlier MAPP Network studies and provides unprecedented opportunities to increase our understanding of UCPPS pathophysiology, factors associated with symptom change, clinically relevant patient phenotypes, and novel targets for future interventions., (© 2020 Wiley Periodicals LLC.)

We investigated the heritability of educational attainment and how it differed between birth cohorts and cultural-geographic regions. A classical twin design was applied to pooled data from 28 cohorts representing 16 countries and including 193,518 twins with information on educational attainment at 25 years of age or older. Genetic factors explained the major part of individual differences in educational attainment (heritability: a 2  = 0.43; 0.41-0.44), but also environmental variation shared by co-twins was substantial (c 2  = 0.31; 0.30-0.33). The proportions of educational variation explained by genetic and shared environmental factors did not differ between Europe, North America and Australia, and East Asia. When restricted to twins 30 years or older to confirm finalized education, the heritability was higher in the older cohorts born in 1900-1949 (a 2  = 0.44; 0.41-0.46) than in the later cohorts born in 1950-1989 (a 2  = 0.38; 0.36-0.40), with a corresponding lower influence of common environmental factors (c 2  = 0.31; 0.29-0.33 and c 2  = 0.34; 0.32-0.36, respectively). In conclusion, both genetic and environmental factors shared by co-twins have an important influence on individual differences in educational attainment. The effect of genetic factors on educational attainment has decreased from the cohorts born before to those born after the 1950s.

Type 2 diabetes is a serious global epidemic that disproportionately affects disadvantaged populations. American Indians and Alaska Natives (AIs/ANs) have the highest rates of diabetes in the nation with a prevalence of 14.7% in 2018, more than twice that of non-Hispanic Whites. AI/AN men have the highest prevalence of diagnosed type 2 diabetes (14.5%) compared to non-Hispanic Black (11.4%), non-Hispanic Asian (10.0%), and non-Hispanic White (8.6%) men. Several landmark clinical trials have shown that lifestyle interventions can effectively prevent or delay the onset of diabetes among those at risk, including in AIs/ANs. Despite positive outcomes for AIs/ANs in these studies, very few were men. To date, there have been no concerted efforts to recruit and retain AI/AN men in interventions that promote weight loss and healthy lifestyles to prevent diabetes, and they remain underrepresented in these types of studies. This article describes the design and methods of the first randomized controlled trial of a diabetes prevention program with a study sample comprised entirely of AI/AN men. Research to date has demonstrated suboptimal patterns of recruitment and retention of AI/AN men, resulting in their virtual absence in health and intervention research. Effective methods to recruit and retain AI/AN men, and potential benefit gained from participation in diabetes prevention research, are unknown for this population who experience a high prevalence of type 2 diabetes. The study design presented in this article offers promising insights to help remedy these important shortcomings in the science of recruitment and retention of AI/AN men in research.

Context: The vast, rugged geography and dispersed population of Alaska pose challenges for managing chronic disease risk. Creative, population-based approaches are essential to address the region's health needs. The American Cancer Society developed Workplace Solutions, a series of evidence-based interventions, to improve health promotion and reduce chronic disease risk in workplace settings., Issues: To adapt Workplace Solutions for implementation in eligible Alaskan businesses, research teams with the University of Washington and the Alaska Native Tribal Health Consortium collaborated to address various geographic, intervention, and workplace barriers. Terrain, weather, and hunting seasons were frequent geographic challenges faced over the entire course of the pilot study. Coordinating several research review boards at the university, workplace, and regional tribal health organizations; study staff turnover during the entire course of the study; and difficulties obtaining cost-effective intervention options were common intervention barriers. Few workplaces meeting initial study eligibility criteria, turnover of business contacts, and a downturn in the state economy were all significant workplace barriers., Lessons Learned: Flexibility, organization, responsiveness, communication, and collaboration between research staff and businesses were routinely required to problem-solve these geographic, intervention, and workplace barriers.

Background: Few, if any, home visiting programs for children under the age of three have been culturally adapted for American Indian reservation settings. We recently adapted one such program: Promoting First Relationships®., Objectives: To culturally adapt Promoting First Relationships® while maintaining program fidelity, we used a community-based participatory approach to elicit input from two American Indian partners., Methods: University-based researchers, reservation-based Native project staff, and Native tribal liaisons conducted collaborative meetings, conference calls, and focus groups to adapt Promoting First Relationships® to reflect local community needs and values., Lessons Learned: Working closely with onsite Native project staff, being flexible and open to suggestions, and attending to the logistical needs of the community are imperative to developing and implementing adaptations., Conclusions: Several adaptations were made based on the collaboration between researchers and Native project staff. Collaboration is critical for adapting programs so they can be tested in ways that respect both American Indian culture and research needs.

Objective: This study examined the association of several social and environmental factors on the likelihood of reaching centenarian age for older adults in Washington State. Methods: A survival analysis of reaching centenarian age for older adults aged 75 years and above was performed using Washington State mortality data from 2011-2015. Models were adjusted for sex, race, education, marital status, and neighborhood level social and environmental variables at the block group level. Geographic clusters of increased chance of becoming a centenarian were also mapped. Results: In the adjusted model, increased neighborhood walkability, lower education level, higher socioeconomic status, and a higher percent of working age population were positively associated with reaching centenarian age. Being widowed, divorced/separated, or never married were also positively correlated compared to being married. Additionally, being white or female were positively correlated with reaching centenarian status. Discussion: Several social and environmental factors are correlated with becoming a centenarian in Washington State. In this study, we explore findings that are consistent with previous research, as well as some that have not been previously explained. More research is needed to expand upon these findings in this rapidly growing field.

The US government recently updated the Common Rule, a set of federal regulations to ensure the ethical conduct of human subjects research. The new regulations require that consent documents provide information that is clear and concise enough to enable truly informed consent. This study explores potential American Indian research participants' understanding and perceptions of an example consent document, focusing on possible improvements to better serve the requirements of the revised Common Rule. Participants completed a survey that collected demographic data and measured health literacy, numeracy, and comprehension of the example document. Next, they participated in focus groups to answer open-ended questions regarding their views on the example document. We calculated mean scores and frequencies of response to analyze quantitative survey data and performed a qualitative thematic analysis of focus group transcripts. Results demonstrated that American Indian participants with relatively strong health literacy skills clearly understood key elements of the consent document, including the purpose of signing it, confidentiality, compensation, and whom to contact for questions. However, they were overwhelmed by details on research procedures and were concerned about the document's layout. To make consent documents more readily comprehensible, participants recommended the addition of headings, bullets, graphics, and relevant pictures. They also recommended a two-step consent process, comprising a short introduction to the research project followed by a longer explanation of procedures. These results illustrate the potential advantages of community engagement in drafting consent materials. Health researchers would likely benefit from community recommendations like the ones we elicited as they design consent documents adherent to the revised Common Rule.

Objective: American Indians experience substantial health disparities relative to the US population, including vascular brain aging. Poorer cognitive test performance has been associated with cranial magnetic resonance imaging findings in aging community populations, but no study has investigated these associations in elderly American Indians., Methods: We examined 786 American Indians aged 64 years and older from the Cerebrovascular Disease and its Consequences in American Indians study (2010-2013). Cranial magnetic resonance images were scored for cortical and subcortical infarcts, hemorrhages, severity of white matter disease, sulcal widening, ventricle enlargement, and volumetric estimates for white matter hyperintensities (WMHs), hippocampus, and brain. Participants completed demographic, medical history, and neuropsychological assessments including testing for general cognitive functioning, verbal learning and memory, processing speed, phonemic fluency, and executive function., Results: Processing speed was independently associated with the presence of any infarcts, white matter disease, and hippocampal and brain volumes, independent of socioeconomic, language, education, and clinical factors. Other significant associations included general cognitive functioning with hippocampal volume. Nonsignificant, marginal associations included general cognition with WMH and brain volume; verbal memory with hippocampal volume; verbal fluency and executive function with brain volume; and processing speed with ventricle enlargement., Conclusions: Brain-cognition associations found in this study of elderly American Indians are similar to those found in other racial/ethnic populations, with processing speed comprising an especially strong correlate of cerebrovascular disease. These findings may assist future efforts to define opportunities for disease prevention, to conduct research on diagnostic and normative standards, and to guide clinical evaluation of this underserved and overburdened population.

In 1984, Hrubec and Robinette published what was arguably the first review of the role of twins in medical research. The authors acknowledged a growing distinction between two categories of twin studies: those aimed at assessing genetic contributions to disease and those aimed at assessing environmental contributions while controlling for genetic variation. They concluded with a brief section on recently founded twin registries that had begun to provide unprecedented access to twins for medical research. Here we offer an overview of the twin research that, in our estimation, best represents the field has progress since 1984. We start by summarizing what we know about twinning. We then focus on the value of twin study designs to differentiate between genetic and environmental influences on health and on emerging applications of twins in multiple areas of medical research. We finish by describing how twin registries and networks are accelerating twin research worldwide.

Objectives: Limited research suggests commonalities between urological chronic pelvic pain syndromes (UCPPS) and other nonurological chronic overlapping pain conditions (COPCs) including fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome. The goal of this case-control study was to examine similarities and differences between UCPPS and these other COPCs., Materials and Methods: As part of the Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research (MAPP) Network, we examined 1039 individuals with UCPPS (n=424), nonurological COPCs (n=200), and healthy controls (HCs; n=415). Validated standardized measures were used to assess urological symptoms, nonurological pain symptoms, and psychosocial symptoms and traits., Results: Participants with UCPPS had more urological symptoms than nonurological COPCs or HCs (P<0.001); nonurological COPC group also had significantly worse urological symptoms than HCs (P<0.001). Participants with nonurological COPCs reported more widespread pain than those with UCPPS (P<0.001), yet both groups had similarly increased symptoms of anxiety, depression, negative affect, perceived stress, neuroticism, and lower levels of extraversion than HCs (P<0.001). Participants with UCPPS with and without COPCs reported more catastrophizing than those with nonurological COPCs (P<0.001)., Discussion: Findings are consistent with the hypothesis of common underlying biopsychosocial mechanisms and can guide the comprehensive assessment and treatment of these conditions regardless of the primary site of pain or diagnosis. Heightened catastrophizing in UCPPS should be examined to inform psychosocial interventions and improve patient care.

Multilevel and community-level interventions that target the social determinants of health and ultimately health disparities are seldom conducted in Native American communities. To contextualize the importance of multilevel and community-level interventions, major contributors to and causes of health disparities in Native communities are highlighted. Among the many documented socioeconomic factors influencing health are poverty, low educational attainment, and lack of insurance. Well-recognized health disparities include obesity, diabetes, and hypertension. Selected challenges of implementing community-level and multilevel interventions in Native communities are summarized such as the shortage of high-quality population health data and validated measurement tools. To address the lack of multilevel and community-level interventions, the National Institutes of Health created the Intervention Research to Improve Native American Health (IRINAH) program which solicits proposals that develop, adapt, and test strategies to address these challenges and create interventions appropriate for Native populations. A discussion of the strategies that four of the IRINAH grantees are implementing underscores the importance of community-based participatory policy work, the development of new partnerships, and reconnection with cultural traditions. Based on the work of the nearly 20 IRINAH grantees, ameliorating the complex social determinants of health disparities among Native people will require (1) support for community-level and multilevel interventions that examine contemporary and historical factors that shape current conditions; (2) sustainability plans; (3) forefronting the most challenging issues; (4) financial resources and time to collaborate with tribal leaders; and (5) a solid evidence base.

This study used a parallel convergent mixed methods design with TribalCrit theory and intersectionality as analytical frameworks to identify how American Indian men's identities intersect with broader structures and systems to shape their eating and physical activity choices and behaviors, and to elicit recommendations for a men's lifestyle intervention. AI men were recruited in Minneapolis, Minnesota and Portland, Oregon between March and December 2017 and in Phoenix, Arizona in December 2019 to participate in a survey and focus groups. The survey included demographic questions and questions about physical and cultural activities men engage in, perceived social support for lifestyle behaviors, masculine characteristics, and values important to American Indian men. The 6-item Kessler Psychological Distress Scale was used to assess psychological distress. Focus groups were audio recorded and transcribed for a phenomenological analysis. Descriptive statistics and correlations were computed for survey data. We conducted 15 focus groups with 151 adult American Indian men in three urban sites. The mean age of participants ranged from 36-51 across the sites; 7%-32% were college graduates; 13%-22% were currently married and 28%-41% were working full time. The most important values reported by participants were being: strong mentally and emotionally, a good parent, responsible, spiritual, and a good spouse or partner. On the K6 psychological distress scale, 63%-70% scored ≥5 but <13 (moderate mental distress), and 8%-15% scored ≥13 indicating severe mental distress. Younger age was significantly correlated with higher mean K6 score (p < .0001). Colonizers and missionaries that settled in the U.S. imposed cultural and gender hegemony which enforced a patriarchal capitalist system that have had long-lasting and deleterious effects on American Indians, particularly American Indian men.

The COllaborative project of Development of Anthropometrical measures in Twins (CODATwins) project is a large international collaborative effort to analyze individual-level phenotype data from twins in multiple cohorts from different environments. The main objective is to study factors that modify genetic and environmental variation of height, body mass index (BMI, kg/m2) and size at birth, and additionally to address other research questions such as long-term consequences of birth size. The project started in 2013 and is open to all twin projects in the world having height and weight measures on twins with information on zygosity. Thus far, 54 twin projects from 24 countries have provided individual-level data. The CODATwins database includes 489,981 twin individuals (228,635 complete twin pairs). Since many twin cohorts have collected longitudinal data, there is a total of 1,049,785 height and weight observations. For many cohorts, we also have information on birth weight and length, own smoking behavior and own or parental education. We found that the heritability estimates of height and BMI systematically changed from infancy to old age. Remarkably, only minor differences in the heritability estimates were found across cultural-geographic regions, measurement time and birth cohort for height and BMI. In addition to genetic epidemiological studies, we looked at associations of height and BMI with education, birth weight and smoking status. Within-family analyses examined differences within same-sex and opposite-sex dizygotic twins in birth size and later development. The CODATwins project demonstrates the feasibility and value of international collaboration to address gene-by-exposure interactions that require large sample sizes and address the effects of different exposures across time, geographical regions and socioeconomic status.

Objective: Valid neuropsychological assessment is critical to the accurate diagnosis and effective treatment of diverse populations. American Indians and Alaska Natives experience substantial health disparities relative to the general U.S., Population: Given the dearth of studies on neuropsychological health in this population, we aimed to characterize neuropsychological performance among older American Indians with respect to age, sex, education, income, and language use., Method: From 2010 to 2014, we recruited 818 American Indians aged 60 and older from the Cerebrovascular Disease and Its Consequences in American Indians Study, who comprised all of the surviving members of a cardiovascular study (Strong Heart Study). This cohort from 11 tribes resided on or near their home reservations in three geographic regions (Northern Plains, Southern Plains, and Southwest). Using a cross-sectional design investigating potential vascular brain injury, we administered a brief, targeted neuropsychological and motor function assessments., Results: Higher scores on neuropsychological tests were associated with younger age, female sex, more education, higher income, and less Native American language use. Similar associations were found for the motor tests, although men had higher scores on both motor function tests. After accounting for other sociocultural and health factors, age, sex, education, income, and Native American language use all had significant associations to the test scores., Conclusions: Our findings may be used to guide research and inform clinical practice. The development of future normative studies for older American Indians will be more culturally appropriate when sociocultural factors are included. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background: Acute respiratory distress syndrome (ARDS) has a reported incidence of 34-43% in ventilated burn patients and is associated with a mortality of 59% in the severe form. The use and experience with extracorporeal membrane oxygenation (ECMO) in burn patients developing ARDS are still limited. We present our results and discuss the significance of ECMO in treating burn patients., Methods: A retrospective analysis of burn patients treated with ECMO for ARDS between January 2017 and January 2019 was performed. Demographic, clinical, and outcome data were collected and analyzed., Results: Eight burn patients were treated at our institution with ECMO in the designated time period. Of these, all but one patient had inhalation injury, burn percentage of TBSA was 37 ± 23%, ABSI score was 8.4 ± 2, and R-Baux-score was 98 ± 21. Seven patients developed severe ARDS and one patient moderate ARDS according to the Berlin classification with a PaO 2 /FiO 2 ratio upon initiation of ECMO therapy of 62 ± 22 mmHg. ECMO duration was 388 ± 283 h. Three patients died from severe sepsis while five patients survived to hospital discharge., Conclusions: ECMO is a viable therapy option in burn patients developing severe ARDS and can contribute to survival rates similar to ECMO therapy in non-burn-associated severe ARDS. Consequently, patients with severe respiratory insufficiency with unsuccessful conventional treatment and suspected worsening should be transferred to burn units with the possibility of ECMO treatment to improve outcome., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2019.)

Objectives: Veno-arterial extracorporeal membrane oxygenation represents the last therapy option in refractory cardiogenic shock. Successful weaning becomes difficult if the myocardial function recovers but pulmonary impairment persists. We present our experience with a new weaning strategy, using a stepwise mode-switch from veno-arterial to veno-veno-arterial and veno-venous extracorporeal membrane oxygenation setting for patients with primary cardiogenic shock and subsequent respiratory failure., Methods: From 81 patients treated with veno-arterial extracorporeal membrane oxygenation following acute cardiogenic shock between January 2014 and April 2018, eight patients with cardiac and pulmonary failure were identified to be treated using the following protocol: patients were put on veno-arterial extracorporeal membrane oxygenation, a second inflow cannula was inserted via the right jugular vein and cardiac weaning was performed via veno-veno-arterial support. Finally, patients were pulmonary weaned via veno-venous extracorporeal membrane oxygenation mode., Results: In the mode-switch group, etiologies of cardiogenic shock were cardiac arrest (12.5%), myocardial infarction (12.5%) and post-cardiotomic heart failure (75%). Mean time between onset of cardiogenic shock and start of veno-arterial extracorporeal membrane oxygenation was 76 ± 117 min. At implantation, lactate and pH values were 9.5 ± 5.0 mmol/L and 7.2 ± 0.2. Total extracorporeal membrane oxygenation-time was 9.3 ± 4.7 days, with a mode-switch from veno-arterial to veno-veno-arterial after 3.9 ± 2.7 days. The weaning rate in the mode-switch group was 75% (vs. 41% in the entire cohort) and the 30-day survival was 50% (vs 32% in the cohort). 38% of the patients presented a favorable neurological outcome., Conclusion: Mode-switch from veno-arterial to veno-veno-arterial and weaning via veno-venous extracorporeal membrane oxygenation mode is feasible for combined cardiac and pulmonary failure, with promising results due to an optimized pre-pulmonary oxygenation.

Objectives: Insulin resistance is a substantial health issue for American Indians, with type 2 diabetes overrepresented in this population as compared with non-Hispanic whites. Insulin resistance and its related conditions in turn increase risk for dementia and cognitive impairment. The aim of the current study was to determine whether type 2 diabetes and insulin resistance at midlife was associated with later-life cognitive testing in a large sample of older American Indians, aged 65 and older., Methods: American Indian participants who underwent both fasting blood draw as part of the Strong Heart Study and had subsequent cognitive testing as part of the later adjunct Cerebrovascular Disease and its Consequences in American Indians study were included (n = 790). Regression models examined type 2 diabetes and impaired fasting glucose and subsequent cognitive test performance as part of a longitudinal study design. The relationship between a continuous measure of insulin resistance and later cognitive test performance was assessed using generalized estimating equations., Results: Controlling for demographic and clinical factors, verbal fluency and processing speed/working memory were significantly negatively associated with having type 2 diabetes and with insulin resistance, but not with impaired fasting glucose., Conclusion: In this sample of American Indians, type 2 diabetes at midlife was associated with subsequent lower performance on measures of executive function. These results may have important implications for future implementation of diagnostic and intervention services in this population., (© 2019 John Wiley & Sons, Ltd.)

Objective: To evaluate the genetic and environmental relationship among prostatitis and other urological conditions, including benign prostatic hyperplasia (BPH) and prostate cancer (CaP), a classical twin design and biometric modeling was used. While prostatitis-characterized by pain and voiding symptoms, no clear etiology, and functional and quality of life impairments-co-occurs with other urinary conditions, the degree of shared overlapping etiologic processes among them remains unclear. We examined the contribution of genetic and environmental factors to these conditions and the etiology of their associations at the level of genetic and environmental influences., Methods: 4380 monozygotic and dizygotic male twin pairs from the Vietnam Era Twin Registry reported lifetime physician-diagnosed prostatitis (combined acute and chronic), bladder problems, enlarged prostate/BPH, and CaP. Multivariate biometrical modeling estimated the magnitude of genetic and environmental influences for each condition, as well as their genetic and environmental covariance. The common pathway model tested the assumption that covariation among these urinary conditions is determined by a single latent factor., Results: Overall prevalence of prostatitis was 2.7%. Heritability estimates ranged from 19% for bladder problems to 42% for CaP. Significant shared environmental influences were present for CaP (12%), enlarged prostate/BPH (10%) but were smaller than genetic influences. A reduced one factor common pathway model provided the best fit, suggesting that covariation among the conditions is determined by a shared latent factor., Conclusion: We identified a common, genetically-influenced factor that accounts for much of the comorbidity among these 4 disease conditions. Nonshared environmental factors also make a significant contribution., (Published by Elsevier Inc.)

Objectives: To estimate the prevalence of lifetime traumatic experiences, describe related symptoms of traumatic stress, and examine their association with perceived social support and physical and mental health among older American Indians., Method: Analyses of existing interview data from the Native Elder Care Study, a random age-stratified sample of 505 tribal members ≥55 years of age conducted in partnership with a large Southeastern tribe. Interviews assessed trauma exposure, traumatic stress, measures of social support, and physical and mental health status., Results: Overall, 31% of participants had experienced a traumatic event; of these, 43% reported traumatic stress at the time of the interview. Higher perceived social support was associated with a reduced prevalence of traumatic stress. Compared to their counterparts without traumatic stress, women participants reporting traumatic stress reported more symptoms of depression, and both symptomatic men and women had a higher prevalence of cardiovascular disease and chronic pain., Discussion: Traumatic stress was associated with less perceived social support and poorer health. Social support was not found to moderate the relationship between traumatic stress and physical and mental health., (© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

A hallmark of success for early career biomedical researchers is the acquisition of research funding. There are marked disparities among principal investigators who submit grants and the likelihood of receiving national funding. The National Research Mentoring Network was funded by the National Institutes of Health to diversify the biomedical research workforce and included grantsmanship training for early career researchers. Self-efficacy in developing research grant applications is significantly improved over time with training and experience. We created a 19-item self-efficacy assessment inventory. Our aims were to confirm the internal consistency of a three-factor solution for grantsmanship confidence and to test the likelihood that self-efficacy influences grant proposal submission timing. We gathered data from 190 diverse biomedical trainees who completed NRMN grantsmanship training between August 2015 and June 2017. Findings revealed high internal consistency for items in each of three factors. There was a statistically significant association between self-efficacy mean scores and grant submission timing predicting that, for every one-point increase in the mean score, the odds of submitting a grant 6 months post-training increased by 69%. An abbreviated inventory of grantsmanship skills self-efficacy is a promising tool for monitoring changes over time in early career researchers and for promoting tailored grantsmanship interventions., (© 2018 New York Academy of Sciences.)