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Nagy A Mekhail,1 Shrif J Costandi,1 Sherif Armanyous,1 Ricardo Vallejo,2 Lawrence R Poree,3 Lora L Brown,4 Stanley Golovac,5 Timothy R Deer6 1Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA; 2Millennium Pain Center, Bloomington, IL, USA; 3Pain Management Center, UCSF Health, San Francisco, CA, USA; 4TruWell Health, St. Petersburg, FL, USA; 5Florida Pain Institute, Merritt Island, FL, USA; 6Center for Pain Relief, Charleston, WV, USACorrespondence: Nagy A Mekhail Email mekhain@ccf.orgBackground and Purpose: Minimally invasive lumbar decompression (mild®) is an effective long-term therapy for patients with symptomatic lumbar spinal stenosis (LSS) resulting primarily from hypertrophic ligamentum flavum (HLF). Most subjects in clinical studies of the mild procedure have been older adults (age≥ 65). While the incidence of LSS increases with age, a substantial number of adults (age< 65) also suffer from neurogenic claudication secondary to HLF. In this report, outcomes of mild were compared between adults and older adults.Patients and Methods: All prospective studies of the mild procedure with a 1-year follow-up completed since the beginning of 2012 that allowed the inclusion of adult patients of all ages were reviewed. Outcomes of visual analog scale (VAS), Oswestry Disability Index (ODI), Pain Disability Index (PDI), Roland Morris Low Back Pain and Disability Questionnaire (RMQ), standing time and walking distance were compared for adults and older adults.Results: Four studies met the inclusion criteria, resulting in an analysis of 49 adults and 160 older adults. Patients in both age groups experienced significant mean improvements in all but one outcome measure at 6- and 12-month follow-up. Differences between the two age groups in all scores at 6 and 12 months were not statistically significant.Conclusion: Analysis of the four studies indicated that symptom improvements for adults and older adults were significant from baseline, and no statistically significant difference was observed between the two age groups. These results illustrate that mild can be an effective treatment for LSS due primarily to HLF, regardless of the adult patient age.Keywords: mild, neurogenic claudication, ligamentum flavum, LSS

Michael J Mello,1,2 Julie R Bromberg,1,2 Steven Rougas,1 Thomas H Chun,1 Linda L Brown,1 Christina S Parnagian,2 Janette Baird1,2 1Department of Emergency Medicine, The Warren Alpert Medical School, Brown University, Providence, RI, USA; 2Injury Prevention Center, Rhode Island Hospital, Providence, RI, USA Introduction: Emergency medicine (EM) providers are in an opportunistic position to identify and intervene with patients at risk for alcohol misuse and related problems. However, alcohol screening, brief intervention, and referral to treatment (SBIRT) services are underutilized within the emergency department. Providing SBIRT training to trainees may help to increase ­utilization of these valuable services in the future. An SBIRT training program for EM faculty and ­trainees was developed and delivered to increase trainees’ skills and practice of SBIRT services. Methods: The SBIRT training program included unique tracks for medical students, physician assistant (PA) students, EM residents and faculty preceptors. Faculty and trainees completed ­performance measures at the end of each training session, 30 days post-training and 12 months later. Results: SBIRT training was provided to 238 trainees and 65 faculty members. At all follow-up time points, satisfaction of training and usefulness varied by trainee type with PA students rating constructs higher than both medical students and EM residents. At the 12-month follow-up survey, there was no significant difference in ratings of sharing the information (χ2 (2)=0.38, P=0.33) between these trainees, with the majority of all trainees (96% of PA students, 83% of residents and 68% of medical students) responding that they had applied what they learned in the training to their work. Conclusion: An SBIRT training curriculum for EM trainees was delivered successfully and utilized 12 months after implementation. Keywords: SBIRT, substance misuse, emergency medicine trainees

Objectives: Children make up 5-10% of emergency medical services (EMS) transports and are at risk for under-recognition and under-treatment of pain. Prior studies have identified enablers to pediatric analgesia including EMS pediatric analgesia education, agency leadership support, the availability of assistive guides and having positive relationships with online medical control. Prior barriers identified were intravenous (IV) line insertion pain, caregiver concerns, difficulty assessing pain, pain medication safety concerns, unfamiliarity with pediatrics, unwanted attention from authority figures and perceived superiority of hospital care. This study's objective was to evaluate enablers and barriers to prehospital analgesia for children presenting with traumatic pain after the introduction of intranasal (IN) fentanyl into EMS protocols., Methods: Focus groups with EMS clinicians were used to elicit perspectives on pediatric analgesia. EMS clinicians discussed transports of children in pain, decision-making regarding analgesic administration, available resources to treat pain including EMS protocols, patient and family reactions, and ways to improve pediatric oligoanalgesia. Themes were explored until thematic saturation was reached using a deductive approach with open-ended yet structured questions., Results: Enablers for pediatric analgesia included longer transports, desire to stabilize the patient, vital signs or injuries suggestive of severe pain, and clinician comfort with and availability of IN pain medication. Barriers to analgesia included concerns that the child was not stable enough for pain medication, avoiding masking symptoms prior to hospital arrival, lack of pediatric experience, lack of access to opiates in some ambulances, poor suspension in ambulances causing difficulty with IV access, patient refusal for an IV, caregivers' discomfort with opiates and caregivers' lack of knowledge of available prehospital medications. Focus group themes identified were that there was a lack of experience with pediatric patients, medical control was a helpful resource and training that approximated real-world situations was important., Conclusions: New enablers for pediatric analgesia identified were longer transports and EMS clinician comfort with IN pain medications. While many barriers to pediatric analgesia persist, new barriers identified were poor suspension in ambulances causing difficulty with IV access and caregivers' lack of knowledge of available prehospital medications. Additional EMS pediatric training and experience may improve pediatric oligoanalgesia.

Objective: To assess whether initial epinephrine administration by endotracheal tube (ET) in newly born infants receiving chest compressions and epinephrine in the delivery room (DR) is associated with lower rates of return of spontaneous circulation (ROSC) than newborns receiving initial intravenous (IV) epinephrine., Study Design: We conducted a retrospective review of neonates receiving chest compressions and epinephrine in the DR from the AHA Get With The Guidelines-Resuscitation registry from October 2013 through July 2020. Neonates were classified according to initial route of epinephrine (ET vs IV). The primary outcome of interest was ROSC in the DR., Results: In total, 408 infants met inclusion criteria; of these, 281 (68.9%) received initial ET epinephrine and 127 (31.1%) received initial IV epinephrine. The initial ET epinephrine group included those infants who also received subsequent IV epinephrine when ET epinephrine failed to achieve ROSC. Comparing initial ET with initial IV epinephrine, ROSC was achieved in 70.1% vs 58.3% (adjusted risk difference 10.02; 95% CI 0.05-19.99). ROSC was achieved in 58.3% with IV epinephrine alone, and 47.0% with ET epinephrine alone, with 40.0% receiving subsequent IV epinephrine., Conclusions: This study suggests that initial use of ET epinephrine is reasonable during DR resuscitation, as there were greater rates of ROSC compared with initial IV epinephrine administration. However, administration of IV epinephrine should not be delayed in those infants not responding to initial ET epinephrine, as almost one-half of infants who received initial ET epinephrine subsequently received IV epinephrine before achieving ROSC., Competing Interests: Declaration of Competing Interest This research was supported by the Ohio Perinatal Research Network (OPRN) at Nationwide Children's Hospital. OPRN is supported by the Center for Perinatal Research at Nationwide Children's hospital. Funding is provided by the Abigail Wexner Research Institute at Nationwide Children’s Hospital. The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: To examine lifetime experiences of employment discrimination and their association with Black older adults' employment status and well-being., Methods: We use data from the Health and Retirement Study's leave-behind questionnaire to characterize lifetime experiences of being unfairly fired, not hired, or not promoted among Black older adults ( N = 2948) and test associations with labor force status at age 62, job satisfaction among those working, and depressive symptoms., Results: Employment discrimination was commonly reported by Black older adults, especially among men and those with college educations. Employment discrimination was not associated with employment status at age 62 but was associated with job dissatisfaction (OR = 2.00, p = .001) and depressive symptoms (Beta = 0.34, p < .001)., Discussion: Findings suggest a negative association between employment discrimination at any point in the life course and Black older adults' well-being. Employment discrimination is an obstacle to healthy aging, yet improved discrimination survey items are needed to fully capture its impact on Black Americans., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

On July 19th, 2023, the National Institute of Allergy and Infectious Diseases co-organized a workshop with the Society of Mathematical Biology, with the authors of this paper as the organizing committee. The workshop, "Bridging multiscale modeling and practical clinical applications in infectious diseases" sought to create an environment for mathematical modelers, statisticians, and infectious disease researchers and clinicians to exchange ideas and perspectives., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

In this observational study, we assessed the extent to which a community-created pilot intervention, providing trauma-informed care for persons with HIV (PWH), affected HIV care retention and viral suppression among PWH attending an HIV Services Organization in the Southern US. PWH with trauma exposure and/or trauma symptoms (N = 166) were offered a screening and referral to treatment (SBIRT) session. Per self-selection, 30 opted-out, 29 received SBIRT-Only, 25 received SBIRT-only but reported receiving other behavioral health care elsewhere, and 82 participated in the Safety and Stabilization (S&S) Intervention. Estimates from multivariable logistic regression analyses indicated S&S Intervention participants had increased retention in HIV care (adjusted odds ratio [aOR] 5.46, 95% CI 1.70-17.50) and viral suppression (aOR 17.74, 95% CI 1.83-172), compared to opt-out participants. Some evidence suggested that PTSD symptoms decreased for intervention participants. A randomized controlled trial is needed to confirm findings., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Medical schools considering longitudinal integrated clerkships (LICs) have access to literature that provides recommendations for planning, implementation, and sustainability. However, LIC development and implementation remain notoriously challenging. University of Utah's LIC development process was informed by the documented experiences of long-established LIC programs. A literature gap was identified pertaining to more recently implemented LICs. The aim of this study was to explore the experiences of faculty in the early stages of LIC development., Methods: Thirteen representatives from eight LICs implemented after 2015 participated in 2 Zoom focus groups (5 participated in the first and the other 8 participated in the second). Participants were asked questions to assess key supports, barriers, and recommendations. Following the focus groups, participants were asked to rank the responses based on their level of importance., Results: Highest ranked supports included stakeholder and partner involvement; a dedicated coordinator or team; and strong, committed leadership. Highest ranked barriers included difficulty recruiting preceptors and clinical sites; underestimation of the amount of work required to coordinate the LIC; and challenges in providing the needed faculty development. Top recommendations for new LICs included investing in the needs of clinical partners; staffing or assigning a dedicated coordinator early in the development and implementation process; and frequent communication with all stakeholders., Conclusion: Despite variation among the types of new LICs represented, there was consensus among participants on the importance of key supports, barriers, and recommendations. Knowledge of these factors can help new schools plan and allocate resources during their LIC development process. Participants found the focus group process and follow-up discussions useful and have formed an ongoing workgroup which meets quarterly., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Objectives: Midlife stressors may be particularly consequential for cognitive performance and disparities in cognitive decline. This study examined Black-White differences in trajectories of cognition among middle-aged adults and the effects of acute and chronic stressors on these trajectories., Methods: Data come from 4,011 cognitively healthy individuals aged 51-64 (620 Black and 3,391 White) who participated in the 2006-2018 waves of the Health and Retirement Study. Stressors included a count of recent life events and measures of financial strain and everyday discrimination. Global cognition was assessed using a modified version of the Telephone Interview for Cognitive Status. Linear mixed models with random slopes and intercepts assessed change in cognition over time. Race-by-time, race-by-stressor, time-by-stressor, and race-by-stressor-by-time interactions were assessed as were quadratic terms for time and each stressor., Results: After adjusting for sociodemographic, health behaviors, and health-related factors, Black respondents had lower initial cognitive performance scores (b = -1.75, p < .001) but experienced earlier but slower decline in cognitive performance over time (Black × Time2 interaction: b = 0.02, p < .01). Financial strain, discrimination, and recent life events each had distinct associations with cognitive performance but did not influence racial differences in levels of or change in cognition over time., Discussion: Middle-aged Black adults have lower initial cognition levels and experience earlier but less accelerated cognitive decline compared to White middle-aged adults. Midlife acute and chronic stressors influence baseline cognition but do so in different ways. Future research should examine the influence of other stressors on racial differences in cognitive decline at other points in the life course., (© The Author(s) 2023. 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.)

Introduction: Lifetime exposure to interpersonal violence or abuse has been associated with several chronic diseases, including adult-onset diabetes, yet this pattern has not been confirmed by sex and race within a large cohort., Methods: Data from the Southern Community Cohort Study collected between 2002-2009 and 2012-2015 were used to explore the relationship between lifetime interpersonal violence or abuse and diabetes (N=25,251). Prospective analyses of lower-income people living in the southeastern U.S. were conducted in 2022 to examine the risk of adult-onset diabetes associated with lifetime interpersonal violence or abuse by sex and race. Lifetime interpersonal violence or abuse was defined as (1) physical or psychological violence, threats, or abuse in adulthood (adult interpersonal violence or abuse) and (2) childhood abuse or neglect., Results: After adjustment for potentially confounding factors, adult interpersonal violence or abuse was associated with a 23% increased risk of diabetes (adjusted hazard ratio=1.23; 95% CI=1.16, 1.30). Diabetes risks associated with childhood abuse or neglect were 15% (95% CI=1.02, 1.30) for neglect and 26% (95% CI=1.19, 1.35) for abuse. When combining adult interpersonal violence or abuse and childhood abuse or neglect, the risk of diabetes was 35% higher (adjusted hazard ratio=1.35; 95% CI=1.26, 1.45) than those experiencing no violence, abuse, or neglect. This pattern held among Black and White participants, and among women and men., Conclusions: Both adult interpersonal violence or abuse and childhood abuse or neglect increased the risk of adult-onset diabetes in a dose-dependent pattern for men and women, and by race. Intervention and prevention efforts to reduce adult interpersonal violence or abuse and childhood abuse or neglect could not only reduce the risk of lifetime interpersonal violence or abuse but may also reduce one of the most prevalent chronic diseases, adult-onset diabetes., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: We simulated an on-site, multi-hospital mass casualty incident (MCI) to educate emergency medicine providers in the principles of trauma resuscitation and collaboration with administration and staff during an MCI., Methods: We implemented high-fidelity manikins, inflatable manikins, and actors to simulate a sarin gas bombing. Learners triaged patients at a decontamination tent using the simple triage and rapid treatment (START) tool, or they participated in a simulation in a resuscitation bay., Results: Forty participants anonymously rated the learning impact of the exercise, the clinical relevance to emergency medicine, and the effectiveness of the faculty facilitation and debriefing on a 1-5 Likert scale. The average responses to all questions were 4.45 or greater, and 98% of respondents recommended adding the scenario to the standard curriculum., Discussion: We successfully executed a novel, multi- hospital, MCI drill that was rated to be a better alternative to sequential simulation in a simulation center.

Objective: Despite many strengths of trauma-informed care (TIC), critics argue TIC is necessary but alone insufficient, can be deficit focused, lacks construct operationalization, and requires greater inclusion of resilience theory. We sought to address these critiques by creating an assessment tool through an iterative and community-engaged process., Method: We collected cross-sectional data between May and June 2019 with a convenience sample from 12 sites across the United States ( N = 861). Data were analyzed through application of classical test theory and item response theory, using principal components analysis., Results: The final 40-item Organizational Trauma Resilience Assessment (OTRA) is sufficiently unidimensional and has a five-factor solution with strong validity and reliability., Conclusion: We believe this instrument marks the first of its kind to synthesize tenets of organizational resilience with TIC principles. Creation of the OTRA progresses the TIC knowledge base and is a cost-effective and valid method for evaluating organizational culture of trauma resilience. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Achieving optimal health is an aspirational goal for the population, yet the definition of health remains unclear. The role of nutrition in health has evolved beyond correcting malnutrition and specific deficiencies and has begun to focus more on achieving and maintaining 'optimal' health through nutrition. As such, the Council for Responsible Nutrition held its October 2022 Science in Session conference to advance this concept. Here, we summarize and discuss the findings of their Optimizing Health through Nutrition - Opportunities and Challenges workshop, including several gaps that need to be addressed to advance progress in the field. Defining and evaluating various indices of optimal health will require overcoming these key gaps. For example, there is a strong need to develop better biomarkers of nutrient status, including more accurate markers of food intake, as well as biomarkers of optimal health that account for maintaining resilience-the ability to recover from or respond to stressors without loss to physical and cognitive performance. In addition, there is a need to identify factors that drive individualized responses to nutrition, including genotype, metabotypes, and the gut microbiome, and to realize the opportunity of precision nutrition for optimal health. This review outlines hallmarks of resilience, provides current examples of nutritional factors to optimize cognitive and performance resilience, and gives an overview of various genetic, metabolic, and microbiome determinants of individualized responses., (Published by Elsevier Inc.)

Background: The effect of years of education on the maintenance of healthy cognitive functioning may differ by race and ethnicity given historical and ongoing inequities in educational quality., Methods: We examined 20,311 Black, Latinx, and White adults aged 51-100 from the Health and Retirement Study (2008-2016). Telephone Interview for Cognitive Status-27 data was used to measure cognitive functioning. Generalized additive mixed models were stratified by race and ethnicity and educational attainment (≥12 vs. <12 years). Selected social determinants of health, all-cause mortality, time-varying health and healthcare utilization characteristics, and study wave were included as covariates., Results: On average, Black and Latinx adults scored lower at baseline compared to White adults regardless of educational attainment (p < 0.001), with a significant overlap in the distributions of scores. The rate of cognitive decline was non-linear for Black, Latinx, and White adults (p < 0.001), and a period of stability was witnessed for those with higher educational attainment irrespective of race and ethnicity. Compared to Black, Latinx, and White adults with lower educational attainment, higher-educated White adults received the greatest protection from cognitive decline (13 years; 64 vs. 51), followed by Latinx (12 years; 67 vs. 55), and Black adults (10 years; 61 vs. 51). Latinx adults experienced cognitive decline beginning at a later age., Conclusions: The extent to which higher educational attainment protects adults from cognitive decline differs by race and ethnicity, such that higher-educated White adults received a greater benefit than higher-educated Black or Latinx adults., (© 2023 The American Geriatrics Society.)

Objectives: To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality., Methods: Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored., Results: A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores., Conclusions: A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores., (Copyright © 2023 by the American Academy of Pediatrics.)

Objective: The authors sought to determine the impact of selected social determinants of health (SDoH) on psychological health and well-being (defined as depression, cognition, and self-rated health) among Black and Hispanic/Latinx adults relative to White adults 51-89 years of age., Methods: Disparities in depressive symptomatology, cognition, and self-rated health were measured among 2,306 non-Hispanic/Latinx Black, 1,593 Hispanic/Latinx, and 7,244 non-Hispanic/Latinx White adults who participated in the Health and Retirement Study (N=11,143). Blinder-Oaxaca decomposition was used to examine whether differences in selected SDoH explained a larger share of the disparities than age, sex, measures of health, health behaviors, and health care utilization. Selected SDoH included education, parental education, number of years worked, marital status, veteran status, geographic residence, nativity status, income, and insurance coverage., Results: Black and Hispanic/Latinx adults reported worse depressive symptomatology, cognition, and self-rated health than White adults. Selected SDoH were associated with a larger proportion of the Black-White disparities in depressive symptomatology (51%), cognition (39%), and self-rated health (37%) than were age, sex, measures of health, health behaviors, and health care utilization. SDoH were associated with a larger proportion of the Hispanic/Latinx-White disparity in cognition (76%) and self-rated health (75%), but age and physical health correlated with the disparity in depressive symptomatology (28%). Education, parental education, years worked, income, and insurance parity were SDoH associated with these disparities., Conclusions: Differences in SDoH underlie racial/ethnic disparities in depression, cognition, and self-rated health among older adults. Education, income, number of years worked, and insurance parity are key SDoH., Competing Interests: The authors report no financial relationships with commercial interests.

Background: Current breastfeeding guidelines promote initiating breastfeeding ≤1 h after birth to establish long-term breastfeeding. Previous studies dichotomized initiation to ≤1 h versus subsequent hours combined. There are limited data evaluating the effect of initiation in each subsequent hour on breastfeeding duration. Our objective was to evaluate the association between breastfeeding initiated at ≤1 h versus the subsequent 23 hours after birth and outpatient breastfeeding duration., Methods: In this retrospective cohort study, we analyzed real-time, discretely documented electronic health record (EHR) breastfeeding data for 3315 infants born at a university center and followed to age ≥12 mo at 27 university primary care clinics. The primary outcome was breastfeeding duration. The exposure variable was hour of breastfeeding initiation within 24 h postnatally. Data were analyzed by univariable and multivariable linear regression separately for infants born by vaginal versus cesarean delivery., Results: In adjusted models, initiating breastfeeding during each hour from age >1 to ≤6 h and during ages >6 to ≤24 h was not associated with decreased breastfeeding duration versus initiating breastfeeding at ≤1 h after birth for infants born via vaginal or cesarean delivery., Conclusions: Delaying breastfeeding initiation to >1 to ≤24 h after birth is not associated with decreased breastfeeding duration compared with initiating breastfeeding at ≤1 h after birth. Integration of breastfeeding measures into inpatient and outpatient EHR discrete data fields may clarify best practices that support long-term breastfeeding as a public health imperative., Competing Interests: Financial Disclosure The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objectives: Chronic stressors, experienced disproportionately by Black older adults, are a risk factor for memory impairment. Racially patterned stress exposure may contribute to higher rates of Alzheimer's disease and related dementias (ADRD) among Black older adults compared with Whites, but less is known about the role of stress appraisal. This study examined whether chronic stress exposure mediates racial disparities in memory and whether stress appraisal moderates these associations., Methods: Participants included 16,924 older adults (Mage = 67.39, 21% Black) from the 2010 and 2012 waves of the Health and Retirement Study who completed measures of chronic stress exposure (health, financial, housing, relationships, and caregiving) and appraisal. Latent growth curves modeled longitudinal performance on a word list memory task over 6 years., Results: Black older adults reported greater stress exposure than Whites, and greater stress exposure partially mediated Black-White disparities in initial memory (standardized indirect effect = -0.002, p = .009). However, Black older adults appraised stressors as less upsetting than Whites. While stress appraisal did not moderate links between stress exposure and memory, appraising stressors as less upsetting was independently associated with better initial memory. Thus, Black-White disparities in initial memory was partially offset by Black participants' appraisal of stressors as less upsetting (standardized indirect effect = 0.002, p = .016)., Discussion: Reducing chronic stress exposure may reduce racial disparities in ADRD risk. The counteractive effect of stress appraisal on Black-White disparities in episodic memory highlights resilience factors among Black older adults that should be characterized in future research to move beyond deficit models of ADRD inequality., (© The Author(s) 2021. 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.)

Immune health products represent approximately 10% of all US dietary supplement sales. Claims made on products to support or boost the immune system are attractive to the otherwise healthy consumer who may or may not be experiencing certain life stressors. The purpose of this systematic review is to critically evaluate the purported benefits and/or potential harms of select dietary supplement ingredients frequently listed on the labels of products having immune health or related market claims. With a focus on resilience, research questions were related to whether dietary supplement ingredients are efficacious in preserving and protecting immune health in healthy individuals; and when faced with a stressor, whether taking a supplement prophylactically can assist in maintaining health and resisting or bouncing back more quickly. Thirty-nine randomized controlled studies involving populations including children, adults and seniors exposed to stressors, such as air travel, intense exercise, academic stress, and/or exposure to winter weather, met eligibility criteria. The studies included eight of the 27 supplement ingredients identified through a market-driven scoping review. Those ingredients used in single ingredient products were echinacea, elderberry, garlic, vitamin A, vitamin C, vitamin D, vitamin E, and zinc. Whereas some studies may point to evidence for benefit, specific gaps preclude the authors from making firm statements with regard to the overall evidence-base for these products and ingredients and in answering the research questions. As we move toward a vision of health promotion and resilience rather than a sole focus on disease prevention and treatment, further work in this area of dietary supplements is of utmost importance.

Previous research using functional MRI identified brain regions associated with sensory processing sensitivity (SPS), a proposed normal phenotype trait. To further validate SPS, to characterize it anatomically, and to test the usefulness in psychology of methodologies that assess axonal properties, the present study correlated SPS proxy questionnaire scores (adjusted for neuroticism) with diffusion tensor imaging (DTI) measures. Participants (n = 408) from the Human Connectome Project were studied. Voxelwise analysis showed that mean- and radial diffusivity correlated positively with SPS scores in the right and left subcallosal and anterior-ventral cingulum bundle, and the right forceps minor of the corpus callosum, all frontal cortex areas generally underlying emotion, motivation, and cognition. Further analyses showed correlations throughout medial frontal cortical regions in the right and left ventromedial prefrontal cortex, including the superior longitudinal fasciculus, inferior fronto-occipital fasciculus, uncinate, and arcuate fasciculus. Fractional anisotropy was negatively correlated with SPS scores in white matter (WM) of the right premotor/motor/somatosensory/supramarginal gyrus regions. Region of interest (ROI) analysis showed small effect sizes (- 0.165 to 0.148) in WM of the precuneus and inferior frontal gyrus. Other ROI effects were found in the dorsal-, ventral visual pathways and primary auditory cortex. The results reveal that in a large group of participants, axonal microarchitectural differences can be identified with SPS traits that are subtle and in the range of typical behavior. The results suggest that the heightened sensory processing in people who show that SPS may be influenced by the microstructure of WM in specific cortical regions. Although previous fMRI studies had identified most of these areas, the DTI results put a new focus on brain areas related to attention and cognitive flexibility, empathy, emotion, and first levels of sensory processing, as in primary auditory cortex. Psychological trait characterization may benefit from DTI methodology by identifying influential brain systems for traits., (© 2022. The Author(s).)

Background and Purpose: Health care professionals are required to interact with increasingly diverse cultural groups and complexity of culture. The purpose of this study was to design and disseminate an online cultural communication module for use by pharmacy students across three countries., Educational Activity and Setting: Three pharmacy schools from Australia, the United States, and the United Kingdom developed 18 role-play videos demonstrating interactions between pharmacists and patients from diverse cultural groups. Videos were incorporated into an online module and implemented within each school's existing skills laboratory and/or communication curricula in 2019. Students completed a survey and a reflection at the module's end. Open-ended responses were analyzed qualitatively using an inductive approach., Findings: Ninety-five percent of students (n = 500) across the three schools attempted the module. A total of 89% agreed the videos were useful in helping them understand the language and terms relating to cultural awareness in pharmacy, and 90% agreed the module helped them learn approaches to communicate with culturally diverse people in pharmacy. However, some students found the module lengthy and experienced technical issues with the platform. The majority of students identified awareness of cultural differences, respect for patient, and a person-centered approach as important when communicating with patients., Summary: There is a growing need for appropriate training models to enhance cross-cultural skills and cultural awareness in health care professional training such as pharmacy. Collaborating internationally to develop a teaching innovation focused on widening understanding of culture and added to the depth of learning., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: While evidence highlights the detrimental mental health consequences of chronic stress exposure, the impact of this stress exposure on older Black Americans' mental health varies by exposure to other types of stressors like discrimination as well as subjective evaluations of stress like chronic stress appraisal. Methods: Using data from the 2010/2012 Health and Retirement Study, we use latent profile analysis (LPA) to describe 2,415 Black older adults experience with chronic stress exposure, appraisal, and discrimination and examine which stress contexts are associated with depressive symptomology. Results: Analyses revealed five stress clusters-demonstrating the diversity in the stress experience for older Black adults. Black older adults with stress profiles that include lower stress appraisal report fewer depressive symptoms regardless of number of stress exposures. Discussion: LPA is as an alternative approach to examining the stress-mental health link that can define stress profiles by both exposure and appraisal-based measures.

Objective: We assessed the effects of hope, purpose in life, and religiosity on trajectories of depressive symptoms among middle-aged and older Blacks, with a focus on age differences in these associations. Methods: Data come from 1906 respondents from the 2006-2016 Health and Retirement Study. Linear mixed models were estimated and included interactions between age and time and between age and each psychosocial resource. Results: Depressive symptoms decreased for Blacks ages 51-64, did not change for those 65-74, and increased among Blacks age 75+. Hope and purpose in life were inversely associated with symptom levels but were not associated with change over time in symptomology. Associations were stronger among the youngest age group and weakest among the oldest. Religiosity was unrelated to depressive symptoms. Discussion: Psychosocial resources protect against depressive symptoms in age-dependent ways among middle-aged and older Blacks. Differences in these effects may be related to aging, cohort, and selection effects.

Intimate partner violence (IPV) and HIV are correlated and endemic in South Africa. However, safety strategy use to prevent IPV among HIV-positive women is understudied. This study assesses correlates of specific safety strategy use among 166 Black South African women recently experiencing IPV and testing positive for HIV. Associations were observed between consultation with formal (i.e., counselors, clergy, IPV specialists) and informal networks (i.e., friends/family) and participant language ( isi Zulu, isi Xhosa, Sesotho, and English), past year IPV, and engaging in HIV care. Future HIV-IPV programs should consider how characteristics of different IPV safety strategies may influence strategy uptake and ultimately HIV care.

Although HIV and substance use disorders (SUDs) constitute a health syndemic, no research to date has examined the perceived negative impacts of different SUDs for people with HIV (PWH). In May 2019, 643 stakeholders in the U.S., representing clients of AIDS service organizations (ASOs), ASO staff, and HIV/AIDS Planning Council members, participated in an innovative Stakeholder-Engaged Real-Time Delphi (SE-RTD) survey focused on the prevalence and individual-level negative impact of five SUDs for PWH. The SE-RTD method has advantages over conventional survey methods by efficiently sharing information, thereby reducing the likelihood that between-group differences are simply due to lack of information, knowledge, and/or understanding. The population-level negative impacts were calculated by weighting each SUD's individual-level negative impact on indicators of the HIV Care Continuum and other important areas of life by the perceived prevalence of each SUD. Overall, we found these SUDs to have the greatest population-level negative impact scores (possible range 0-24): alcohol use disorder (population-level negative impact = 6.9; perceived prevalence = 41.9%), methamphetamine use disorder (population-level negative impact = 6.5; perceived prevalence = 3.2%), and opioid use disorder (population-level negative impact = 6.4; perceived prevalence = 34.6%). Beyond further demonstration of the need to better integrate SUD services within HIV settings, our findings may help inform how finite funding is allocated for addressing the HIV-SUD syndemic within the U.S. Based on our findings, such future efforts should prioritize the integration of evidence-based treatments that help address use disorders for alcohol, methamphetamine, and opioids., (© 2021. The Author(s).)

Background: Postgraduate training programmes rely on faculty to meet core educational needs, including simulation. Time is arguably the most valuable resource for academic physicians, which presents a challenge for recruiting faculty to provide extra-clinical teaching. To increase faculty engagement in simulation-based education (SBE), we first identified barriers to participation. Next, we sought to overcome barriers using a self-determination theory (SDT) framework to increase motivation using strategies that addressed faculty autonomy, competence and relatedness., Methods: Faculty from a single department of emergency medicine were surveyed about factors influencing participation in SBE. Responses were grouped into themes and used to develop the intervention-a faculty support bundle-to overcome common barriers and promote participation. Supports focused on course materials, organisational consistency and peer recognition. Faculty participation in SBE pre- and post-implementation of the support bundle was analysed via chi-squared analysis. Faculty who delivered SBE were resurveyed after the implementation phase to explore how the support bundle affected their experience., Results: Initial survey response was 41%. Reported barriers to participation in SBE included scheduling issues, preparation time, competing responsibilities, lack of confidence with simulation and lack of interest. Twenty-four faculty participated in SBE during the pre-implementation phase, compared to 39 post implementation (p = 0.03)., Discussion: The faculty support bundle increases faculty participation in SBE. Strategies focused on internal motivators identified using an SDT framework. In contrast to traditional external motivators, these were no cost interventions. Those seeking to increase faculty participation in SBE should consider implementing similar strategies., (© 2022 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Objectives: Despite known health benefits of breastfeeding, the Navajo have low reported frequency of breastfeeding initiation and support. We evaluated breastfeeding frequencies and practices in the predominately Navajo community of rural San Juan County, Utah, to identify factors that affect breastfeeding decisions and duration., Methods: We performed retrospective chart review for 135 infants aged 0 to 12 months, and surveys of 85 mothers of infants aged 0 to 2 years, and eight primary care providers. We characterized demographic factors using counts/percentages and medians/inter-quartile ranges, and compared mothers who breastfed for 6 months or less versus greater than 6 months., Results: In 96 infants with complete feeding documentation, 86 infants (90%) received some breast milk and 36 infants (38%) were exclusively breastfed at age 2 months. In 67 infants with complete feeding documentation at ≥ 6 months, 22 infants (33%) were exclusively breastfed 6 months. Most mothers knew about breastfeeding benefits. In 56 mothers whose infants were aged ≥ 6 months at the time of the survey, breastfeeding for more than 6 months had been planned by 44 mothers (79%) but performed by only 29 mothers (52%). Mothers who breastfed for > 6 months were more likely to have been influenced by WIC and less likely to have introduced formula at an early age. Barriers to breastfeeding included maternal pain, latch difficulties, and concerns about inadequate milk supply. Primary care providers reported limited confidence in providing breastfeeding support but would support telehealth-driven interventions., Conclusions for Practice: Practical, culturally sensitive interventions, including telehealth and improved provider education, may improve breastfeeding outcomes and community health in this underserved population., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aims: This study aimed to: 1) investigate sex differences in heat-induced mitochondrial dysfunction, ROS production, and skeletal muscle injury in mice; 2) evaluate whether curcumin and astaxanthin, alone or together, would prevent those heat-induced changes., Main Methods: Male and female C57BL/6J mice were treated with curcumin and astaxanthin for 10 days, then exposed to 39.5 °C heat for up to 3 h. Heat-induced hyperthermia, changes in mitochondrial morphology and function, and oxidative damage to skeletal muscle were evaluated., Key Findings: Although female mice had a slightly higher basal core body temperature (Tc) than male mice, peak Tc during heat exposure was significantly lower in females than in males. Heat increased ROS levels in skeletal muscle in both sexes; interestingly, the increases in ROS were greater in females than in males. Despite the above-mentioned differences, heat induced similar levels of mitochondrial fragmentation and membrane potential depolarization, caspase 3/7 activation, and injury in male and female skeletal muscle. Individual treatment of curcumin or astaxanthin did not affect basal and peak Tc but prevented heat-induced mitochondrial dysfunction, ROS increases, and apoptosis in a dose-dependent manner. Moreover, a low-dose combination of curcumin and astaxanthin, which individually showed no effect, reduced the heat-induced oxidative damage to skeletal muscle., Significance: Both male and female mice can develop mitochondrial dysfunction and oxidative stress in skeletal muscle when exposed to heat stress. High doses of either curcumin or astaxanthin limit heat-induced skeletal muscle injury, but a low-dose combination of these ingredients may increase their efficacy., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The current study assesses the relationship between continuing education (CE) with a focus on pediatrics and children with special heath care needs and how CE influences the knowledge and comfort levels of prehospital providers who treat these cases. Data are survey responses provided by paramedic and emergency medical technician (EMT) level providers (N = 575) in Los Angeles County. Regression models assessed the relationship between pediatric-focused continuing education and EMTs' knowledge of and comfort with pediatric cases, adjusting for relevant covariates. EMTs' participation in continuing education focusing on pediatrics and special health care needs was significantly associated with an increase in perceived comfort and knowledge. Among EMTs who did not receive continuing education focused on either pediatrics or special health care needs, the most frequently reported barrier to education was a perceived lack of availability. The impact of continuing education on perceived comfort and knowledge was more pronounced than the effect of prior experience, especially considering the limited prevalence of provider exposure to pediatric and childhood special health care needs cases compared to adult cases. Expanding educational opportunities is a promising approach to increasing the comfort and knowledge of EMTs who transport and care for pediatric cases.

Objectives: Pediatric emergencies can occur in pediatric primary care offices. However, few studies have measured emergency preparedness, or the processes of emergency care, provided in the pediatric office setting. In this study, we aimed to measure emergency preparedness and care in a national cohort of pediatric offices., Methods: This was a multicenter study conducted over 15 months. Emergency preparedness scores were calculated as a percentage adherence to 2 checklists on the basis of the American Academy of Pediatrics guidelines (essential equipment and supplies and policies and protocols checklists). To measure the quality of emergency care, we recruited office teams for simulation sessions consisting of 2 patients: a child with respiratory distress and a child with a seizure. An unweighted percentage of adherence to checklists for each case was calculated., Results: Forty-eight teams from 42 offices across 9 states participated. The mean emergency preparedness score was 74.7% (SD: 12.9). The mean essential equipment and supplies subscore was 82.2% (SD: 15.1), and the mean policies and protocols subscore was 57.1% (SD: 25.6). Multivariable analyses revealed that independent practices and smaller total staff size were associated with lower preparedness. The median asthma case performance score was 63.6% (interquartile range: 43.2-81.2), whereas the median seizure case score was 69.2% (interquartile range: 46.2-80.8). Offices that had a standardized process of contacting emergency medical services (EMS) had a higher rate of activating EMS during the simulations., Conclusions: Pediatric office preparedness remains suboptimal in a multicenter cohort, especially in smaller, independent practices. Academic and community partnerships using simulation can help address gaps and implement important processes like contacting EMS., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Whitfill is a board observer of a medical device company, 410 Medical, Inc (Durham, NC), which commercializes a device for fluid resuscitation; and the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

The COVID-19 pandemic has adversely affected people with HIV due to disruptions in prevention and care services, economic impacts, and social isolation. These stressors have contributed to worse physical health, HIV treatment outcomes, and psychological wellness. Psychological sequelae associated with COVID-19 threaten the overall well-being of people with HIV and efforts to end the HIV epidemic. Resilience is a known mediator of health disparities and can improve psychological wellness and behavioral health outcomes along the HIV Continuum of Care. Though resilience is often organically developed in individuals as a result of overcoming adversity, it may be fostered through multi-level internal and external resourcing (at psychological, interpersonal, spiritual, and community/neighborhood levels). In this Perspective , resilience-focused HIV care is defined as a model of care in which providers promote optimum health for people with HIV by facilitating multi-level resourcing to buffer the effects of adversity and foster well-being. Adoption of resilience-focused HIV care may help providers better promote well-being among people living with HIV during this time of increased psychological stress and help prepare systems of care for future catastrophes. Informed by the literature, we constructed a set of core principles and considerations for successful adoption and sustainability of resilience-focused HIV care. Our definition of resilience-focused HIV care marks a novel contribution to the knowledge base and responds to the call for a multidimensional definition of resilience as part of HIV 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., (Copyright © 2021 Brown, Martin, Knudsen, Gotham and Garner.)