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BackgroundPhysician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.ObjectiveTo examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.DesignPatient self-report surveys at treatment initiation linked to medical records.SettingVeterans Health Administration (VA) clinics nationally, 2018-2020.ParticipantsA total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) MAIN MEASURES: Patient self-reported preferences for medication and psychotherapy on 0-10 self-anchoring visual analog scales (0="completely unwilling"; 10="completely willing"). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.Key resultsMore patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ21=175.3, p

Many organizations persist in working with others that engage in known, remediable structural discrimination. We name this practice interorganizational structural discrimination (ISD) and argue it is a pivotal contributor to inequities in science and medicine. We urge organizations to leverage their relationships and demand progress from collaborators.

BackgroundPhysician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.ObjectiveTo examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.DesignPatient self-report surveys at treatment initiation linked to medical records.SettingVeterans Health Administration (VA) clinics nationally, 2018-2020.ParticipantsA total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) MAIN MEASURES: Patient self-reported preferences for medication and psychotherapy on 0-10 self-anchoring visual analog scales (0="completely unwilling"; 10="completely willing"). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.Key resultsMore patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ21=175.3, p

BackgroundPsychiatric comorbidities may complicate depression treatment by being associated with increased role impairments. However, depression symptom severity might account for these associations. Understanding the independent associations of depression severity and comorbidity with impairments could help in treatment planning. This is especially true for depressed Veterans, who have high psychiatric comorbidity rates.Methods2,610 Veterans beginning major depression treatment at the Veterans Health Administration (VHA) were administered a baseline self-report survey that screened for diverse psychiatric comorbidities and assessed depression severity and role impairments. Logistic and generalized linear regression models estimated univariable and multivariable associations of depression severity and comorbidities with impairments. Population attributable risk proportions (PARPs) estimated the relative importance of depression severity and comorbidities in accounting for role impairments.ResultsNearly all patients (97.8%) screened positive for at least one comorbidity and half (49.8%) for 4+ comorbidities. The most common positive screens were for generalized anxiety disorder (80.2%), posttraumatic stress disorder (77.9%), and panic/phobia (77.4%). Depression severity and comorbidities were significantly and additively associated with impairments in multivariable models. Associations were attenuated much less for depression severity than for comorbidities in multivariable versus univariable models. PARPs indicated that 15-60% of role impairments were attributable to depression severity and 5-32% to comorbidities.LimitationsThe screening scales could have over-estimated comorbidity prevalence. The cross-sectional observational design cannot determine either temporal or causal priorities.ConclusionsAlthough positive screens for psychiatric comorbidity are pervasive among depressed VHA patients, depression severity accounts for most of the associations of these comorbidities with role impairments.

IntroductionThe Veterans Health Administration (VHA) supports the nation's largest primary care-mental health integration (PC-MHI) collaborative care model to increase treatment of mild to moderate common mental disorders in primary care (PC) and refer more severe-complex cases to specialty mental health (SMH) settings. It is unclear how this treatment assignment works in practice.MethodsPatients (n = 2610) who sought incident episode VHA treatment for depression completed a baseline self-report questionnaire about depression severity-complexity. Administrative data were used to determine settings and types of treatment during the next 30 days.ResultsThirty-four percent (34.2%) of depressed patients received treatment in PC settings, 65.8% in SMH settings. PC patients had less severe and fewer comorbid depressive episodes. Patients with lowest severity and/or complexity were most likely to receive PC antidepressant medication treatment; those with highest severity and/or complexity were most likely to receive combined treatment in SMH settings. Assignment of patients across settings and types of treatment was stronger than found in previous civilian studies but less pronounced than expected (cross-validated AUC = 0.50-0.68).DiscussionBy expanding access to evidence-based treatments, VHA's PC-MHI increases consistency of treatment assignment. Reasons for assignment being less pronounced than expected and implications for treatment response will require continued study.

Radiation therapy (RT) consensus contouring guidelines in the postoperative setting for complex cutaneous squamous cell carcinoma of the head and neck have been developed by expert clinicians in the field of head and neck and dermato-oncology and members of the Head and Neck Cancer International Group to assist radiation oncologists involved in the management of this disease. These guidelines present a set of principles used to define postoperative RT volumes and corresponding minimum doses after resection of all macroscopic tumor with or without microscopic residual disease. It is anticipated they will promote the harmonization of postoperative RT globally and contribute to a reduction in treatment variation among clinicians, allowing for RT quality and outcomes assessment across institutions.

Background: Programmed cell death ligand 1 (PD-L1) inhibitors have limited efficacy as monotherapy in patients with recurrent/metastatic (R/M) Human Papilloma Virus (HPV) oropharyngeal squamous cell carcinoma (OPSCC). A phase I study of the therapeutic HPV-16 DNA vaccine AMV002 in curatively treated patients with OPSCC demonstrated a measurable immune response against HPV while being associated with high safety and tolerability. This prospective phase Ib single centre pilot study aims to test the safety and tolerability of combined PD-L1 inhibitor, Durvalumab, with AMV002 in 12 patients with recurrent OPSCC. Methods: Participants had evidence of R/M HPV-associated OPSCC. They received three intradermal administrations of AMV002 with Durvalumab followed by Durvalumab maintenance. Safety and tolerability data was the primary endpoint. The study was conducted with ethical approval (HREC/2018/QMS/47293) in Brisbane, Australia. Findings: The most common adverse event (AE) related to vaccine administration was erythema at the injection site. There were no grade 3 or 4 vaccine related AEs. There was one presumed immune-related grade 3 elevation in lipase secondary to Durvalumab with no intervention required. No patient ceased study due to treatment-related AEs. At week 16, objective response rate was 8% (N=1) and disease control rate was 17% (N=2). At a median follow up of 25.6 (20.0-26.6) months there was one long term complete response while all other participants developed progressive disease. Of the 11 evaluated patients, 9, (82%) had E6 and/or E7-specific T cell responses to the vaccine. Conclusion: The combination of AMV002 therapeutic HPV-16 vaccine and Durvalumab was found to be safe and well tolerated with no increased safety signals generated. T cell responses to vaccine were observed but further work will be required to improve efficacy. [ABSTRACT FROM AUTHOR]

Hard and soft structural composites found in biology provide inspiration for the design of advanced synthetic materials. Many examples of bio-inspired hard materials can be found in the literature; far less attention has been devoted to soft systems. Here we introduce deterministic routes to low-modulus thin film materials with stress/strain responses that can be tailored precisely to match the non-linear properties of biological tissues, with application opportunities that range from soft biomedical devices to constructs for tissue engineering. The approach combines a low-modulus matrix with an open, stretchable network as a structural reinforcement that can yield classes of composites with a wide range of desired mechanical responses, including anisotropic, spatially heterogeneous, hierarchical and self-similar designs. Demonstrative application examples in thin, skin-mounted electrophysiological sensors with mechanics precisely matched to the human epidermis and in soft, hydrogel-based vehicles for triggered drug release suggest their broad potential uses in biomedical devices.

IntroductionSmoking both cigarettes and marijuana is increasingly common among young adults, yet little is known about use patterns, motivations, or thoughts about abstinence. In a U.S. sample, this study explored young adults' severity of cigarette and marijuana co-use, quit attempts, and thoughts about use.MethodsYoung adults age 18-to-25 who had smoked at least one cigarette in the past 30 days completed an anonymous online survey.ResultsOf 1987 completed surveys, 972 participants reported both past-month cigarette and marijuana use (68% male, 71% Caucasian, mean age 20.4 years [SD=2.0]). Frequency of use, temptations to use, measures of dependence, decisional balance, and past-year quit attempts were associated across the two substances (all p

This document provides guidelines for the safe practice of stereotactic body radiation therapy (SBRT) or stereotactic ablative radiation therapy (SABR). The guidelines aim to ensure appropriate care for patients receiving these treatments, which involve high-precision, image-guided dose delivery to well-defined targets with steep dose gradients. The document outlines recommendations for departmental staffing, equipment, planning, treatment, and quality assurance measures. It also emphasizes the importance of multidisciplinary expertise and ongoing training for the safe and accurate delivery of SBRT/SABR. The guidelines do not replace clinical judgment or decisions made by the treating team and are not meant to be used for litigious purposes. [Extracted from the article]

Key Points: Question: Can development of an individualized treatment rule identify patients presenting to emergency departments/urgent care with suicidal ideation or suicide attempts who are likely to benefit from psychiatric hospitalization? Findings: A decision analytic model found that hospitalization was associated with reduced suicide attempt risk among patients who attempted suicide in the past day but not among others with suicidality. Accounting for heterogeneity, suicide attempt risk was found to increase with hospitalization in 24% of patients and decrease in 28%. Meaning: Results of this study suggest that implementing an individualized treatment rule could identify many additional patients who may benefit from or be harmed by hospitalization. Importance: Psychiatric hospitalization is the standard of care for patients presenting to an emergency department (ED) or urgent care (UC) with high suicide risk. However, the effect of hospitalization in reducing subsequent suicidal behaviors is poorly understood and likely heterogeneous. Objectives: To estimate the association of psychiatric hospitalization with subsequent suicidal behaviors using observational data and develop a preliminary predictive analytics individualized treatment rule accounting for heterogeneity in this association across patients. Design, Setting, and Participants: A machine learning analysis of retrospective data was conducted. All veterans presenting with suicidal ideation (SI) or suicide attempt (SA) from January 1, 2010, to December 31, 2015, were included. Data were analyzed from September 1, 2022, to March 10, 2023. Subgroups were defined by primary psychiatric diagnosis (nonaffective psychosis, bipolar disorder, major depressive disorder, and other) and suicidality (SI only, SA in past 2-7 days, and SA in past day). Models were trained in 70.0% of the training samples and tested in the remaining 30.0%. Exposures: Psychiatric hospitalization vs nonhospitalization. Main Outcomes and Measures: Fatal and nonfatal SAs within 12 months of ED/UC visits were identified in administrative records and the National Death Index. Baseline covariates were drawn from electronic health records and geospatial databases. Results: Of 196 610 visits (90.3% men; median [IQR] age, 53 [41-59] years), 71.5% resulted in hospitalization. The 12-month SA risk was 11.9% with hospitalization and 12.0% with nonhospitalization (difference, −0.1%; 95% CI, −0.4% to 0.2%). In patients with SI only or SA in the past 2 to 7 days, most hospitalization was not associated with subsequent SAs. For patients with SA in the past day, hospitalization was associated with risk reductions ranging from −6.9% to −9.6% across diagnoses. Accounting for heterogeneity, hospitalization was associated with reduced risk of subsequent SAs in 28.1% of the patients and increased risk in 24.0%. An individualized treatment rule based on these associations may reduce SAs by 16.0% and hospitalizations by 13.0% compared with current rates. Conclusions and Relevance: The findings of this study suggest that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath of an SA but not after other recent SAs or SI only. Substantial heterogeneity exists in these associations across patients. An individualized treatment rule accounting for this heterogeneity could both reduce SAs and avert hospitalizations. This predictive analytics model develops a preliminary individualized treatment rule to estimate the association between psychiatric hospitalization and subsequent suicidal behaviors in patients at risk for suicide. [ABSTRACT FROM AUTHOR]

Subjective social status (SSS), an individual's subjective view of standing in society, has been shown to better predict health outcomes compared to objective measures of socioeconomic status (SES), including educational attainment and income. This study examines the relationship between SSS and severity of tobacco, alcohol, and marijuana use after controlling for objective measures of SES. Young adults (N = 1,987) aged 18-25 who reported smoking at least one cigarette in the past 30 days were recruited and surveyed anonymously online. Three separate structural equation models examined whether SSS was associated with severity of tobacco, alcohol, and marijuana use, controlling for personal and household income, years of education, employment status, and parental education. Household income (b = .31), employment status (b = .07), years of education (b = .09), and parental education (b = .16) were positively associated with SSS (all p values < .001); personal income was not significantly associated with SSS (p = .11). All three models adequately fit the data. SSS was negatively associated with severity of tobacco (b = -.13, p < .001) and marijuana use (b = -36, p = .02), but not alcohol use severity (b = .01, p = .56). Among young adults, higher subjective social status is associated with less severe tobacco and marijuana use, whereas alcohol use severity appears to be similar across socioeconomic class.

BackgroundThe co-occurring use of tobacco and marijuana among young people is a concern, yet little research has examined processes of co-use. Understanding expectancies around use of the two substances will help identify intervention targets. This study examined psychometric properties of the Nicotine and Marijuana Interaction Expectancy (NAMIE) questionnaire based on three modified scales of the Nicotine and Other Substance Interaction Expectancy (NOSIE) questionnaire.MethodAn anonymous online survey recruited participants (N=1152) age 18-25 (mean age 20 years, 67% male, 72% Caucasian) who reported use of cigarettes and marijuana in the past 30 days. Analyses examined reliability and validity of the NAMIE.ResultsA confirmatory factor analysis indicated good model fit for a 3-factor model. Scales were marijuana increases tobacco use and urges, tobacco increases marijuana use and urges, and smoking to cope with marijuana urges. Subscales correlated significantly with measures of cigarette smoking (r=.08 to .27, p

ObjectiveWe examined the frequency and intensity of tobacco use and thoughts about abstinence among young adults in the United States as a function of their use of marijuana. We hypothesized that heavier marijuana use would be associated with heavier tobacco use and fewer attempts to quit smoking, and we explored relationships between marijuana use and ratings of intentions and thoughts related to quitting tobacco.MethodThis was a cross-sectional survey consisting of online recruitment and anonymous self-report. Participants were English literate, were between the ages of 18 and 25 years, and reported past-month tobacco use. More than half (53%) had smoked marijuana in the past 30 days. Tobacco use (quantity/frequency, Heavy Smoking Index, past-year quit attempt), thoughts about tobacco use (outcome expectancies, desire, self-efficacy, difficulty of quitting, abstinence goal, pros and cons, stage of change), alcohol use, and other drug use were assessed.ResultsCompared with those who smoked only tobacco, cousers were younger and had smoked for fewer years; had higher household income; were more likely to be male, multiethnic, and nondaily smokers; and reported greater alcohol and other drug use. The variable of days using marijuana in the past 30 days was associated with multiple measures of tobacco use intensity/frequency. Only one association was significant between marijuana use and tobacco-related cognitions: Cousers had a lower likelihood of planning to quit tobacco for good (odds ratio = 0.75, 95% CI [0.58, 0.98]).ConclusionsFindings support the association between tobacco and marijuana use among young people but speak to the importance of addressing tobacco cognitions in young adult smokers regardless of level of marijuana use.

Background: Only a limited number of patients with major depressive disorder (MDD) respond to a first course of antidepressant medication (ADM). We investigated the feasibility of creating a baseline model to determine which of these would be among patients beginning ADM treatment in the US Veterans Health Administration (VHA). Methods: A 2018–2020 national sample of n = 660 VHA patients receiving ADM treatment for MDD completed an extensive baseline self-report assessment near the beginning of treatment and a 3-month self-report follow-up assessment. Using baseline self-report data along with administrative and geospatial data, an ensemble machine learning method was used to develop a model for 3-month treatment response defined by the Quick Inventory of Depression Symptomatology Self-Report and a modified Sheehan Disability Scale. The model was developed in a 70% training sample and tested in the remaining 30% test sample. Results: In total, 35.7% of patients responded to treatment. The prediction model had an area under the ROC curve (s.e.) of 0.66 (0.04) in the test sample. A strong gradient in probability (s.e.) of treatment response was found across three subsamples of the test sample using training sample thresholds for high [45.6% (5.5)], intermediate [34.5% (7.6)], and low [11.1% (4.9)] probabilities of response. Baseline symptom severity, comorbidity, treatment characteristics (expectations, history, and aspects of current treatment), and protective/resilience factors were the most important predictors. Conclusions: Although these results are promising, parallel models to predict response to alternative treatments based on data collected before initiating treatment would be needed for such models to help guide treatment selection. [ABSTRACT FROM AUTHOR]

Introduction: Head and neck lymphedema can occur in the internal or external structures of the head and neck region. Little is known about the development of this condition over the course of treatment for head and neck cancer. This study aimed to observe the development of internal and external lymphedema from diagnosis to 12 weeks postacute treatment. Methods: A single center, prospective observational cohort study assessed participants for external lymphedema, internal lymphedema, quality of life, and symptom burden. Assessments were conducted prior to starting radiotherapy (RT), at the end of RT, 6 and 12 weeks after RT. Results: Forty‐six participants were recruited. External lymphedema as measured by percentage water content, increased from 41.9 at baseline (95% CI: 39.3–44.4) to 50.4 (95% CI: 46.0–54.8) at 12 weeks following RT (p‐value <.001). After adjusting for changes in weight and participant age at baseline, a general increase in tape measurements was observed over time with significant increases from baseline to 12 weeks post‐RT for all measurement points. By 12 weeks post‐RT, all participants had lymphedema present in eight of 13 internal sites assessed. Conclusions: Internal and external head and neck lymphedema was observed to increase from baseline to 12 weeks after completion of RT without abatement. People with head and neck cancer should be educated about the potentially extended duration of this treatment side effect. Further research is required to determine the point at which swelling symptoms recede. [ABSTRACT FROM AUTHOR]