Phenotyping Depression After Mild Traumatic Brain Injury: Evaluating the Impact of Multiple Injury, Gender, and Injury Context

The chronic mental health consequences of mild traumatic brain injury (TBI) are a leading cause of disability. This is surprising given the expectation of significant recovery after mild TBI, which suggests that other injury-related factors may contribute to long-term adverse outcomes. The objective of this study was to determine how number of prior injuries, gender, and environment/context of injury may contribute to depressive symptoms after mild TBI among deployed United States service members and veterans (SMVs). Data from the Long-term Impact of Military-Relevant Brain Injury Consortium Prospective Longitudinal Study was used to assess TBI injury characteristics and depression scores previously measured on the Patient Health Questionnaire-9 (PHQ-9) among a sample of 1456 deployed SMVs. Clinical diagnosis of mild TBI was defined via a multi-step process centered on a structured face-to-face interview. Logistical and linear regressions stratified by gender and environment of injury were used to model depressive symptoms controlling for sociodemographic and combat deployment covariates. Relative to controls with no history of mild TBI (n = 280), the odds ratios (OR) for moderate/severe depression (PHQ-9 ≥ 10) were higher for SMVs with one mild TBI (n = 358) OR: 1.62 (95% confidence interval [CI] 1.09-2.40, p = 0.016) and two or more mild TBIs (n = 818) OR: 1.84 (95% CI 1.31-2.59, p < 0.001). Risk differences across groups were assessed in stratified linear models, which found that depression symptoms were elevated in those with a history of multiple mild TBIs compared with those who had a single mild TBI (p < 0.001). Combat deployment-related injuries were also associated with higher depression scores than injuries occurring in non-combat or civilian settings (p < 0.001). Increased rates of depression after mild TBI persisted in the absence of post-traumatic stress disorder. Both men and women SMVs separately exhibited significantly increased depressive symptom scores if they had had combat-related mild TBI. These results suggest that contextual information, gender, and prior injury history may influence long-term mental health outcomes among SMVs with mild TBI exposure.

Identifying clinical phenotypes of frontotemporal dementia in post-9/11 era veterans using natural language processing

Introduction

Frontotemporal dementia (FTD) encompasses a clinically and pathologically diverse group of neurodegenerative disorders, yet little work has quantified the unique phenotypic clinical presentations of FTD among post-9/11 era veterans. To identify phenotypes of FTD using natural language processing (NLP) aided medical chart reviews of post-9/11 era U.S. military Veterans diagnosed with FTD in Veterans Health Administration care.

Methods

A medical record chart review of clinician/provider notes was conducted using a Natural Language Processing (NLP) tool, which extracted features related to cognitive dysfunction. NLP features were further organized into seven Research Domain Criteria Initiative (RDoC) domains, which were clustered to identify distinct phenotypes.

Results

Veterans with FTD were more likely to have notes that reflected the RDoC domains, with cognitive and positive valence domains showing the greatest difference across groups. Clustering of domains identified three symptom phenotypes agnostic to time of an individual having FTD, categorized as Low (16.4%), Moderate (69.2%), and High (14.5%) distress. Comparison across distress groups showed significant differences in physical and psychological characteristics, particularly prior history of head injury, insomnia, cardiac issues, anxiety, and alcohol misuse. The clustering result within the FTD group demonstrated a phenotype variant that exhibited a combination of language and behavioral symptoms. This phenotype presented with manifestations indicative of both language-related impairments and behavioral changes, showcasing the coexistence of features from both domains within the same individual.

Discussion

This study suggests FTD also presents across a continuum of severity and symptom distress, both within and across variants. The intensity of distress evident in clinical notes tends to cluster with more co-occurring conditions. This examination of phenotypic heterogeneity in clinical notes indicates that sensitivity to FTD diagnosis may be correlated to overall symptom distress, and future work incorporating NLP and phenotyping may help promote strategies for early detection of FTD.

Role of Deployment History on the Association Between Epilepsy and Traumatic Brain Injury in Post-9/11 Era US Veterans

BACKGROUND AND OBJECTIVES

Traumatic brain injury (TBI) is a well-established epilepsy risk factor and is common among service members. Deployment-related TBI, where combat/blast may be more common, may have different outcomes than nondeployment-related TBI. This work examined associations of all TBI exposures (not just combat), and epilepsy, while adjusting for comorbidities associated with epilepsy, among veterans by deployment status.

METHODS

The cohort included post-9/11 veterans with ≥2 years of care in both Veterans Health Administration and Defense Health Agency systems. We identified epilepsy using ICD-9/10-CM codes, antiseizure medication, and service-connected disability for epilepsy. We conducted a logistic regression model with interaction terms for conditions by deployment history that adjusted for demographics and military characteristics.

RESULTS

The cohort (n = 938,890) included post-9/11 veterans of whom 27,436 (2.92%) had epilepsy. Most veterans had a history of deployment (70.64%), referred to as "deployed." Epilepsy was more common among veterans who were never deployed ("nondeployed") (3.85% vs 2.54%). Deployed veterans were more likely to have had TBI, compared with the nondeployed veterans (33.94% vs 14.24%), but nondeployed veterans with moderate/severe TBI had higher odds of epilepsy compared with deployed veterans (adjusted odds ratio [aOR] 2.92, 95% CI 2.68-3.17 vs aOR 2.01, 95% CI 1.91-2.11). Penetrating TBI had higher odds of epilepsy among the deployed veterans (aOR 5.33, 95% CI 4.89-5.81), whereas the odds of epilepsy for mild TBI did not significantly differ by deployment status. Although most neurologic conditions were more prevalent among the nondeployed veterans, they were often associated with higher odds of epilepsy in the deployed veterans.

DISCUSSION

Deployment history had a significant differential impact on epilepsy predictors. As expected, penetrating TBI had a greater epilepsy impact among deployed veterans perhaps due to combat/blast. Some epilepsy predictors (moderate/severe TBI, multiple sclerosis, and Parkinson disease) had a stronger association in the nondeployed veterans suggesting a potential healthy warrior effect in which such conditions preclude deployment. Other neurologic conditions (e.g., brain tumor, Alzheimer disease/frontotemporal dementia) had a greater epilepsy impact in the deployed veterans. This may be attributable to deployment-related exposures (combat injury, occupational exposures). A better understanding of deployment effects is critical to provide targeted epilepsy prevention in veterans and military service members.

Prescribing Trends of Antiseizure Drugs in Women Veterans With Epilepsy

OBJECTIVE

Antiseizure medications (ASMs) are frequently used for other indications, such as migraine, pain syndromes, and psychiatric disorders. Possible teratogenic effects are therefore of wide concern and the risks imposed by the medications must be weighed against the risk with the disorder treated. It is our objective to update family practitioners on the implications of starting ASM for women with epilepsy during childbearing age. We hypothesized that clinicians would prescribe ASM based on avoiding teratogenesis and treating associated comorbidities simultaneously.

METHODS

The study cohort was derived from women veterans with epilepsy (WVWE) prescribed ASM who received Veterans Health Administration care for at least 3 years in Veterans Health Administration between fiscal years (FY)01 and FY19. Regimens were classified as monotherapy or polytherapy. Multivariant logistic regression examined the association between demographics, military characteristics, physical/psychiatric comorbidities, neurological care, and use of each ASM.

RESULTS

Among 2,283 WVWE, in ages between 17 and 45, the majority (61%) received monotherapy in FY19. Commonly prescribed ASM included 29% gabapentin, 27% topiramate, 20% lamotrigine, 16% levetiracetam, and 8% valproate (VPA). Comorbid diagnosis of headache predicted use of topiramate and VPA, bipolar disease predicted use of LMT and VPA, pain predicted gabapentin, and schizophrenia was associated with VPAs use. Women receiving levetiracetam and lamotrigine were significantly more likely to receive neurology care previously.

CONCLUSION

The presence of medical comorbidities influences the selection of ASM. VPAs use in WVWE during childbearing age continues, despite the high teratogenic risk, especially in women with bipolar disorder and headaches. Multidisciplinary care integrating family practice doctors, mental health, and neurology can prevent the enduring problem of teratogenesis in women taking ASM.

The Impact of Patient Autonomy Among Uninsured Free Clinic Patients

Uninsured primary care patients tend to experience barriers to autonomy in clinical decision-making due to limited choices of healthcare facilities and low health literacy. This study examined whether certain factors, including the component of patient-centeredness, are associated with patient autonomy among these populations and contribute to reducing disparities in healthcare. This was a cross-sectional study using a convenience sample of free clinic patients aged 18 years and older who spoke English and/or Spanish. Multiple regression analyses were performed to understand factors associated with Ideal Patient's Autonomy. Data were collected from September to December 2019. Findings conclude that Spanish-speaking patients at the free clinic have a stronger belief in a paternalist model of the provider-patient relationship (P < .01). Better communication between patients and providers results in higher levels of autonomy (P < .01). Higher levels of educational attainment and better communication partnership were associated with higher levels of a free clinic patient's understanding of treatment risks (P < .01). This research study found that components of patient-centeredness are important considerations for improving patient autonomy among free clinic patients.

Perceived Stress, Cortisol Responses, and the Effect of Social Networks among Uninsured Free Clinic Patients

OBJECTIVES

Stress among free clinic patients is an important issue to address in health care. Evaluating the differences between perceived stress and physiological stress will help healthcare professionals to better understand the stress and coping management skills that will improve health outcomes for underserved populations. The aim of this study was to accelerate research to better understand the biological and psychological aspect of stress in health disparities.

METHODS

This was a cross-sectional study using a convenience sample of free clinic patients aged 18 years and older who spoke English and/or Spanish. Multiple modals of data were collected from 178 participants during summer 2019, including a self-administered paper survey and a biomedical saliva sample. Descriptive statistics were used to present the characteristics of the participants, and a correlation heatmap was used to show a graphical representation of the main variables. Two models of multivariable regression were performed to understand factors associated with cortisol and perceived stress.

RESULTS

Higher levels of perceived stress were not significantly more prevalent than higher levels of salivary cortisol among free clinic patients; however, higher levels of social networking were significantly associated with lower levels of perceived stress. Our analysis revealed that having more friends in a social network was slightly more associated with lower levels of perceived stress than having more family members.

CONCLUSIONS

The result of this study provides awareness to healthcare promoters and educators concerning the health of uninsured patients. More specifically, this study provides a foundation to understand the salivary cortisol levels and the relation to perceived stress among this population. Further studies are needed to measure salivary cortisol repeatedly during a period of time among a larger population to better understand the reasons behind normal cortisol level manifesting along with chronic stress.

Veteran perspectives of epilepsy care: Impact of Veteran satisfaction, knowledge, and proactivity

OBJECTIVE

Veterans are at elevated risk of epilepsy due to higher rates of traumatic brain injury (TBI). However, little work has examined the extent to which quality of care is associated with key outcomes for Veterans with epilepsy (VWE). This study aimed to examine the impact of quality of care on three outcomes: patients' knowledge of epilepsy self-care, proactive epilepsy self-management, and satisfaction with care.

METHOD

We conducted a cross-sectional study of Post-9/11 Veterans with validated active epilepsy who received VA care (n = 441). Veterans were surveyed on care processes using American Academy of Neurology epilepsy quality measures, and a patient-generated measure related to the use of emergency care. Outcome measures included epilepsy self-care knowledge, proactive epilepsy self-management, and satisfaction with epilepsy care. Covariates included sociodemographic and health status variables and a measure of patient-provider communication. An ordinary least-squares (OLS) regression model was used to determine if the quality of care was associated with the outcomes adjusting for multiple comparisons.

RESULTS

Self-reported measures of quality of care were broadly associated with satisfaction with care and epilepsy knowledge. OLS modeling indicated that healthcare provider guidance on when to seek emergency care was significantly associated with higher Veteran satisfaction with care (p < 0.01). Veterans who were asked about seizure frequency at every visit by their provider also reported higher satisfaction with care (p < 0.01) and increased epilepsy knowledge (p < 0.01). Veteran-provider communication was positively associated with epilepsy knowledge and proactive epilepsy self-management. Veterans with epilepsy with drug resistance epilepsy were significantly less satisfied with their care and reported lower proactivity compared to epilepsy controlled with medications. Further analysis indicated Black VWEs reported lower scores on epilepsy self-care knowledge compared to Whites (p < 0.001).

CONCLUSIONS

This study found that quality measures were associated with satisfaction and epilepsy knowledge but not associated with proactive self-management in multivariable models. The finding that better communication between providers and Veterans suggests that in addition to technical quality, interpersonal quality is important for patient outcomes. The secondary analysis identified racial disparities in epilepsy knowledge. This work offers opportunities to improve the quality of epilepsy care through the practice of patient-centered care models that reflect Veteran priorities and perceptions.

COVID-19 pandemic experiences among people with epilepsy: Effect on symptoms of co-occurring health conditions and fear of seizure

OBJECTIVE

The Coronavirus disease 2019 (COVID-19) pandemic profoundly affected people worldwide, but little is known about how it impacted people with epilepsy (PWE). We examined the associations between COVID-19 stressors and health outcomes including increases in other health symptoms and fear of seizure among PWE.

METHODS

This cross-sectional study used data from an online survey that asked about demographic characteristics, health conditions, and potential life stressors during COVID-19. Data were collected from October 30 to December 8, 2020. COVID-19 stressors were anger, anxiety, stress, healthcare access, fear of seeking healthcare, social isolation, sense of control over their lives, and alcohol consumption. A binary variable was created for each of these measures to indicate whether PWEs experienced a negative change versus a neutral or positive change. We used multivariable logistic regression to assess the associations of COVID-19 stressors with primary outcomes: exacerbated co-occurring health conditions and increasing fear of seizure during the pandemic.

RESULTS

Of the 260 PWE included in the study, 165 (63.5%) were women; the average age was 38.7 years. During the survey administration period, 79 (30.3%) of the respondents reported exacerbated co-occurring health conditions, and 94 (36.2%) reported an increased fear of seizures. Regression results indicated that the fear of seeking healthcare during COVID-19 was associated with both exacerbated co-occurring health conditions (aOR 1.12; 95%CI 1.01-1.26) and increasing fear of seizure (aOR 2.31; 95%CI 1.14-4.68). Social isolation was associated with exacerbated co-occurring health conditions during COVID-19 (aOR 1.14; 95%CI 1.01-1.29). Reduced access to physical healthcare was associated with increasing fear of seizure (aOR 2.58; 95%CI 1.15-5.78).

CONCLUSION

A considerable number of PWE experienced more symptoms of existing health conditions and fear of seizure during the initial year of the pandemic (2020). Fear of seeking healthcare services was associated with both negative outcomes. Assuring access to health care and reducing social isolation could potentially reduce negative outcomes for PWE. It is necessary to provide adequate support for PWE to reduce risks as COVID-19 continues to be a health concern.

The FACIT-Sp spiritual wellbeing scale: a factor analysis in patients with severe and/or life-limiting medical illnesses

BACKGROUND

The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp) is a widely used measure of spiritual wellbeing. However, consensus on the best factor structure for this measure has not been reached. Both a 2-factor (Meaning/Peace, Faith) and a 3-factor (Meaning, Peace, Faith) structure are reported in the literature. In this study, we examined the factorial structure of the FACIT-Sp in a population of patients with severe and/or life-limiting medical illnesses.

METHODS

The present study is a part of a larger study that validated the National Institute of Health-Healing Experiences of All Life Stressors (NIH-HEALS), a measure of psycho-social-spiritual healing developed by the Pain and Palliative Care Service at the National Institutes of Health Clinical Center (NIH-CC). The sample included 200 subjects who were recruited from the NIH Clinical Center inpatient units and outpatient clinics with severe and/or life limiting illnesses (cancer, non-genetic conditions, genetic conditions, blood dyscrasias). FACIT-Sp is a 12-item questionnaire scored on a 5-point Likert scale (0 = not at all; 4 = very much). Exploratory factor analysis (EFA) and principal component analysis (PCA) were used to analyze results and to identify the number of latent constructs and underlying factor structure.

RESULTS

The results supported the 3-factor (Meaning, Peace, and Faith) model of the FACIT-Sp and accounted for the most variability (74.20%), followed by the 2-factor solution (64.95%). The identified factors related to Faith, Peace, and Meaning and were consistent with previously reported 3-factor model.

CONCLUSIONS

This study confirmed the 3-factor structure of FACIT-Sp. This information can inform interventions aimed at improving quality of life and spiritual wellbeing in clinical and palliative care settings.

Multimodal Quality of Life Assessment in Post-9/11 Veterans With Epilepsy: Impact of Drug Resistance, Traumatic Brain Injury, and Comorbidity

BACKGROUND AND OBJECTIVES

Epilepsy is defined by the occurrence of multiple unprovoked seizures, but quality of life (QOL) in people with epilepsy is determined by multiple factors, in which psychiatric comorbidities play a pivotal role. Therefore, understanding the interplay between comorbidities and QOL across epilepsy phenotypes is an important step towards improved outcomes. Here, we report the impact of QOL across distinct epilepsy phenotypes in a cohort of post-9/11 veterans with high rates of traumatic brain injury (TBI).

METHODS

This observational cohort study from the Veterans Health Administration included post-9/11 Veterans with epilepsy. A process integrating an epilepsy identification algorithm, chart abstraction, and self-reported measures was used to classify patients into one of four groups: 1. Epilepsy controlled with medications, 2. Drug resistant epilepsy (DRE), 3. Post-traumatic epilepsy (PTE), or 4. Drug resistant post-traumatic epilepsy (PT-DRE). Summary scores for six QOL measures were compared across the groups, adjusting for age, sex, and number of comorbidities.

RESULTS

A total of 529 survey respondents with epilepsy were included in the analysis: 249 controls (i.e., epilepsy without DRE or PTE), 124 with DRE, 86 with PTE, and 70 with PT-DRE. Drug resistant epilepsy was more common in those with PTE compared with non-traumatic epilepsy (45% vs. 33%, odds ratio 1.6 (95% CI: [1.1-2.4], p=0.01)). Patients with PTE and PT-DRE had significantly more comorbid conditions in health records than those with nontraumatic epilepsy. Those with both PTE and DRE reported the lowest QOL across all six measures, and this persisted after adjustment for comorbidities, and in further linear analyses.

DISCUSSION

Among those with PTE, DRE prevalence was significantly higher than for non-traumatic epilepsies. PTE was also associated with higher burden of comorbidity, and worse overall QOL compared to those with non-traumatic epilepsies. People with PTE are distinctly vulnerable to the comorbidities associated with TBI and epilepsy. This at-risk group should be the focus of future studies aimed at elucidating the factors associated with adverse health outcomes and developing anti-epileptogenic therapies.

Patient Adherence to Health Care Provider Recommendations and Medication among Free Clinic Patients

Patient adherence is vital for the quality of health care outcomes and treatment efficacy, and reduces the economic burden on the healthcare system. The purpose of this study was to examine factors associated with levels of general adherence among uninsured free clinic patients. This was a cross-sectional study using a convenience sample of free clinic patients aged 18 years and older who spoke English and/or Spanish. Descriptive statistics and multiple regression were performed to understand sociodemographic characteristics and factors associated with higher levels of general adherence. A higher level of general adherence were significantly associated with younger age (P < .01), levels of adherence to lifestyle recommendations (P < .01), and medication (P < .01). Having attended health education classes and having a primary care provider were not associated with levels of general adherence.This study suggested that a lower level of general adherence exists among elderly patients of the free clinic. In this light, providers need to consider unique strategies to enhance the provider-patient relationship by understanding patient's characteristics and providing sufficient information and explanation for treatment and medication.

How Food Insecurity and Financial Difficulty Relate to Emotional Well-Being and Social Functioning

OBJECTIVES

Medically uninsured individuals living in poverty experience poor health and face social barriers that negatively affect their health. The purpose of this study was to examine the association between social barriers, particularly healthy food availability and financial difficulty, and well-being among uninsured free clinic patients in the United States.

METHODS

Data were collected using a self-administered paper survey at a free clinic from adult patients who spoke and read English or Spanish (N = 666) from January to April 2019.

RESULTS

Better neighborhood healthy food availability is associated with better self-reported general health. Food security is related to better emotional well-being and social functioning. Having difficulty paying rent or a mortgage is linked to worse emotional well-being and social functioning.

CONCLUSIONS

Providing health education programs may not be sufficient to promote healthy eating among underserved populations because of the social barriers that they experience, such as food insecurity and financial difficulty. Future research could be performed to determine how these social factors influence those of different social and cultural backgrounds than the participants in this study.

The Awareness of Cancer Risk and Healthy Lifestyle among Non-refugees Compared with Refugees Resettled in the United States

PURPOSE

The purpose of this study is to examine the following questions: 1) Do refugees and non-refugees differ in self-rated health? 2) Do refugees and non-refugees differ in cancer risk awareness? and 3) Are lifestyle factors such as diet, physical activity participation, and weight status risk or protective factors of cancer risk awareness?

METHODS

A self-administered or interviewer-administered survey were collected from adults with a refugee background from spring to fall in 2017 in Salt Lake County, Utah. Free clinic data (a non-refugee comparison group) were collected using a self-administered survey from May to June in 2017 from a free clinic in Salt Lake County, Utah.

RESULTS

Refugees reported better self-rated health and were less likely to be obese/overweight, have family history of cancer, and have healthy diet. Refugees reported lower levels of cancer risk awareness than free clinic non-refugee patients. Having a healthy diet was associated with higher levels of cancer risk awareness.

CONCLUSION

Future studies should examine cultural differences related to cancer risk awareness among refugee populations.

Patient Satisfaction With Telehealth and Experiences During the COVID-19 Pandemic Among Uninsured Free Clinic Patients

The COVID-19 pandemic is a significant public health issue especially for underserved populations. Little is known about patient satisfaction with telehealth among free clinic patients or other underserved populations. The purpose of this study is to examine factors associated with patient satisfaction with in-person services and telehealth during the pandemic and describe the experiences during the pandemic among free clinic patients. Data were collected from 628 uninsured English- and Spanish-speaking patients of a free clinic using an online survey from June to August in 2020. Free clinic patients are satisfied both with in-person services and telehealth. Factors associated with satisfaction were slightly different for in-person services and telehealth. The major experiences during the pandemic were related to food/diet and physical inactivity. This study examined a new trend in patient satisfaction and is important because telehealth may be a stepping-stone on how to handle future doctor visits for underserved populations. Furthermore, as the pandemic rapidly develops and changes daily life experiences, the uninsured population faces imminent impacts in various aspects of their life experiences.

Immigration stress among refugees resettled in the United States

BACKGROUND

Immigration stress includes acculturation stress and the stress related to language barriers, discrimination, occupational challenges, and feelings of isolation from society and a sense of newness or loss.

AIMS

The purpose of this study was to examine immigration stress among refugees resettled in the United States.

METHODS

A self-administered or interviewer-administered survey was collected from individuals with a refugee background in Utah from summer through fall in 2017 (N = 190).

RESULTS

Older age was associated with higher levels of financial stress and homesickness. Poorer levels of self-rated health and fewer somatic symptoms were related to higher levels of homesickness and language barriers. Higher educational attainment was associated with higher levels of financial stress.

CONCLUSION

Refugees are a vulnerable population due to being displaced to a foreign country and having to quickly learn a new language and different culture. It is imperative to gain more knowledge on diverse refugee groups and ways in which they can maintain optimum quality of life through and after the resettlement process.

A nature-based health intervention at a military healthcare center: a randomized, controlled, cross-over study

We describe a mixed qualitative and quantitative research study in a military facility regarding the role of nature in well-being. Study intervention included two 20-minute walks. One walk was in an intentionally designed woodland environment (Green Road) and the other was on a busy campus road in a medical treatment facility (Urban Road). Twelve volunteers from a military facility participated in both walks in a cross-over experimental design. The two walking sessions were randomly ordered and preceded by pre-walk instructions appropriate to each road’s characteristics and incorporated focused attention and present moment orientation. A semi-structured post-walk interview, the primary outcome, was conducted after the conclusion of each walk. Qualitative data analyses consisted of sentiments and themes by using NVivo 12 software. The Green Road was unanimously rated as positive (100%). Responses to Urban Road were evenly distributed among positive (33.3%), negative (33.3%), and neutral/mixed (33.3%) sentiments. The Green Road yielded predominantly positive themes such as enjoyment of nature, relaxation, and feelings of privacy and safety. Urban Road produced significantly more negative themes such as concerns for safety, dislike of noise and other noxious experiences. Quantitative assessment of distress and mindfulness with Distress Thermometer (DT) and Mindful Attention Awareness Scale-state version (MAAS) demonstrated that a walk on the Green Road significantly decreased distress and increased mindfulness compared to a walk on the Urban Road. We also observed that pre-walk instructions could direct attention to both obvious and subtle elements of experience and enhance awareness. Results support the notion that an intentional nature-based environment may produce significantly more positive experiences and result in health-promoting benefits in a military health-care setting compared to an urban environment. Future studies with clinical populations could advance our understanding of the healing value of nature-based interventions. The impact of intentional green environments may be enhanced by well-designed instructions for both recreational and therapeutic use.

The Use of Complementary and Alternative Medicine Strategies, Opioids, and Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) Among Patients Attending a Free Clinic

The purpose of this study was to describe the use of opioids and complementary and alternative medicine (CAM) among uninsured free clinic patients. A self-administered paper survey was collected to describe the use of opioids, complementary, and alternative medicine, and other pain relievers from 877 free clinic patients from January to April 2018. The US born English speakers are more likely to use CAM, nonprescription pain relievers, and prescription opioids, and to be more knowledgeable about opioids compared to non-US born English speakers and Spanish speakers. The main source of opioids for free clinic patients is a health care facility other than a free clinic as well as friends. Although nonprescription pain relievers are commonly used among free clinic patients, CAM is less common to use for pain control. More health education programs are needed to increase the knowledge of opioid risks among free clinic patients as well as other underserved population.

Effect of a Brief Mindfulness-Based Program on Stress in Health Care Professionals at a US Biomedical Research Hospital: A Randomized Clinical Trial

IMPORTANCE

Stress among health care professionals is well documented. The use of mindfulness-based interventions to reduce stress has shown promising results; however, the time commitment of typical programs can be a barrier to successful implementation in health care settings.

OBJECTIVE

To determine the efficacy and feasibility of a brief mindfulness-based program to reduce stress during work hours among health care professionals.

DESIGN, SETTING, AND PARTICIPANTS

This intent-to-treat randomized clinical trial was conducted among full-time health care professionals at the Clinical Center at the National Institutes of Health in Bethesda, Maryland, between September 2017 and May 2018. Participants were randomized to receive mindfulness-based self-care (MBSC) training or life-as-usual control. Data were analyzed from June 2018 to January 2020.

INTERVENTIONS

The MBSC intervention included 5 weekly, 1.5-hour in-class mindfulness practice sessions.

MAIN OUTCOMES AND MEASURES

Stress level was the primary outcome, assessed with the Perceived Stress Scale 10-Item version. Secondary outcomes included anxiety, burnout, positive and negative affect, mindfulness (trait and state), and self-care. Assessments were taken at baseline and at the end of the intervention (week 5) in the intervention and control groups, and at follow-up (week 13) in the intervention group to test for a maintenance effect. A postprogram evaluation was also obtained.

RESULTS

Of 82 randomized participants, 78 who completed the study at week 5 were included in the modified intent-to-treat analysis (median [interquartile range] age, 32 [23-48] years; 65 [83%] women), including 43 participants in the MBSC group and 35 participants in the control group. At the end of the intervention, compared with the control group, the MBSC group had reduced levels of stress (mean [SD] score, 17.29 [5.84] vs 18.54 [6.30]; P = .02) and anxiety (mean [SD] score, 2.58 [1.52] vs 4.23 [1.73]; P < .001), and improved positive affect (mean [SD] score, 35.69 [7.12] vs 31.42 [7.27]; P < .001), state mindfulness (mean [SD] score, 3.74 [1.18] vs 2.78 [1.16]; P < .001), and mindful self-care (mean [SD] score, 7.29 [2.44] vs 5.54 [2.77]; P < .001). Burnout, negative affect, and trait mindfulness levels did not differ between groups. Changes within the MBSC group through follow-up included sustained reductions in stress (change, -6.14; 95% CI, -7.84 to -4.44; P < .001), anxiety (change, -1.46; 95% CI, -1.97 to -0.94; P < .001), trait mindfulness (change, 0.63; 95% CI, 0.36 to 0.90; P < .001), and state mindfulness (change, 1.89; 95% CI, 1.39 to 2.39; P < .001).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that this brief mindfulness-based intervention was an effective and feasible means to reduce stress in health care professionals. Larger studies are needed to assess the effects on clinical care and patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03781336.

Study of the effect individual, occupational and environmental factors on return to work (RTW ) among office workers with Low back pain in one of the oil company in southern part of Iran

Introduction: low back pain is one of the prevalent musculoskeletal disorders among working population including office workers. In this regard, various factors are important for low back pain reduction and return to work. The aim of this study was to investigate factors influencing return to work among employees with low back pain. Methods: About 303 administrative employees participated in this study from an oil company located in southern part of Iran in 1394. The study variables were a 4-part questionnaire including demographic, job related variables and information about low back pain and the interventions implemented for return work. Results: The majority of participants were male 35-47 years old, bachelor degrees. With 9-25 years job tenure. Most of the employees had medium to high mental, physical, and temporal demands. From 303 participants, about 85(28/1) had low back pain. The main cause of low back pain was mostly muscular spasm (52/9) and the physiotherapy was the most treatment method (51/8). About 91% of participants had individual intervention like changing the life style. About 88/2 of them had job interventions as body posture correction. Furthermore, 62/4 had organizational interventions as teamwork development. The age, physical activity, and the type of treatment showed significant relationship with return to work. Also, the individual, occupational, and organizational interventions had a significant relationship with RTW. Conclusion: The ability to return to work was seen mostly among the individuals with less physical activities in their working practices. Also, physiotherapy played better role in a rapid return to work comparing to other treatments. The individual interventions showed high impact on RTW. The issues such as individual interventions including change in lifestyle as well as doing particular exercises, job interventions including change in working stations, change in physical status during work and organizational interventions including special routine examinations, performing teamwork as well as particular training classes had played great impacts on RTW.

Patient-Provider Relationships Among Vulnerable Patients: The Association With Health Literacy, Continuity of Care, and Self-Rated Health

While the patient–provider relationship is one factor that can improve access to primary care for underserved populations, vulnerable patients often experience challenges to have a good relationship with providers. The purpose of this study is to examine factors that affect patient–provider relationship among vulnerable patients; in particular, among uninsured primary care patients. This study focused on health literacy, continuity of care, and self-rated health as predictors of patient–provider relationship. A self-administered survey was collected from uninsured primary care patients utilizing a free clinic in the metropolitan area in the Rocky Mountain Region in the United States from May to July in 2018. Higher levels of health literacy and continuity of care are associated with a better patient–provider relationship. Better self-rated health is associated with better patient–provider relationship. Health literacy may improve by the communication and connection with a specific provider because patients better understand the care and/or medications that are being prescribed. Seeing the same provider helps patients develop a better relationship and make clinical decisions in a way that they prefer. Improving the patient–provider relationship can potentially change health outcomes positively for vulnerable patients. Informing patients that they can request a specific medical provider may allow them to increase continuity of care, and improve communication, partnering, connection, and patient centeredness, leading to an increase in health literacy and better self-rated health.

Gender Differences in Psycho-Social-Spiritual Healing

Background: Many individuals exhibit significant distress in response to serious and/or life-limiting illness. However, there are others who make life-transforming changes, which involve healing experiences in the psychological, social, and spiritual domains of life regardless of illness outcome. The aim of the present study is to determine if there are any differences in psycho-social-spiritual healing between genders.

Materials and Methods: The NIH Healing Experiences in All Life Stressors (NIH-HEALS), a 35-item measure of psycho-social-spiritual healing, is composed of three factors: Connection, Reflection & Introspection, and Trust & Acceptance. NIH-HEALS and a demographic questionnaire were administered to 193 patients with serious and/or life-limiting illness at the National Institutes of Health Clinical Center.

Results: In response to NIH-HEALS, men and women significantly differed on the Reflection & Introspection factor. Women reported increased enjoyment of mind–body practices (p < 0.001), compassion (p = 0.005), gratitude (p = 0.014), and a desire to be more positive (p = 0.044) compared to men. Men rated their pain levels (p = 0.035) and severity of illness (p = 0.016) higher and their overall level of health (p = 0.010) poorer compared to women. Women's responses to items regarding compassion (r_s = 0.37, p < 0.001) and gratitude (r_s = 0.24, p = 0.015) correlated positively with better overall health ratings.

Conclusion: Men and women show some differences in their self-reported psycho-social-spiritual healing, which may have implications when designing interventions aimed at promoting a healing experience in the context of serious and life-limiting illness.

Higher levels of self-efficacy and readiness for a future career of Spanish speaking physician assistant students after their volunteer work in a student-run free clinic in the United States

Volunteering at a free clinic may influence career choice amongst health profession students. The purpose of this research is to explore knowledge, skill, attitudes, self-efficacy, interest in future work with the underserved, and interest in primary care amongst physician assistant (PA) students through the analysis of demographic characteristics of PA students at a student-run free clinic in the United States. Data were collected from 56 PA students with a quantitative survey collection in October 2018 after their participation at a student-run free clinic in Intermountain West, Salt Lake City, Utah, USA. Out of three sub-scales i. e. attitudes, effect, and readiness, students responded most positively to effect of experience of participating in free clinic. Students who spoke Spanish showed higher levels of self-efficacy and readiness for a future career in comparison to non-Spanish speakers.

Cancer Risk Awareness among Uninsured Primary Care Patients

OBJECTIVES

Underserved populations are at risk of low cancer risk awareness. The purpose of this study was to examine cancer risk awareness and lifestyle issues among uninsured primary care patients in the United States.

METHODS

Data were collected using a self-administered survey from May to July 2017 of adult free clinic patients (N = 506) who spoke English or Spanish.

RESULTS

The following factors were associated with higher levels of cancer risk awareness: higher educational attainment, better self-perceived health, and having a family history of cancer. More than 40% of free clinic patients reported a family history of cancer. Contradictory findings existed between perceived diet quality and perceived weight.

CONCLUSIONS

The intersection of cancer risk awareness and lifestyle issues among underserved populations is a vital topic to improve cancer prevention and promote screening uptake. Continued research is needed to understand which types of cancer underserved populations are cognizant of developing. In addition, because community-level interventions are effective in increasing cancer risk awareness, 3 research is needed to determine ways in which health education programs focused at cancer risk awareness directed to underserved populations can be effectively implemented and evaluated.

Continuity of Care: Perspectives of Uninsured Free Clinic Patients

Background:

Continuity of care is vital to the success of a health-care system because it improves patient satisfaction and health outcomes, and reduces hospitalizations and emergency room visits.

Objective:

The purpose of this study was to examine free clinic patients’ perspectives of continuity of care in the United States.

Method:

A convenience sample of free clinic patients who were the age of 18 or older and spoke English or Spanish participated in a self-administered survey from January to April in 2017 (N = 580).

Results:

Better instructions from providers were associated with higher levels of continuity of care (P < .01). Higher levels of stress and worse self-rated general health were related to lower levels of continuity of care (P < .05 for stress, P < .01 for general health). Being employed was associated with lower levels of continuity of care (P < .05). Non-US born English speakers and Spanish speakers rated continuity of care higher than US born English speakers (P < .01).

Conclusion:

Even if a patient is unable to see the same physician over time, quality instructions from a well-coordinated provider team may enhance continuity of care from patient perspectives. The social context of patients such as working poor individuals is very important for providers to understand in order to identify barriers to continuity of care.

Risks of opioid abuse among uninsured primary care patients utilizing a free clinic

The annual number of opioid prescriptions for pain relief has been increasing in the United States. This increase has raised concerns about prescription opioid abuse and overdose. The purpose of this study was to examine opioid risks (risk factors that increase the chance of opioid abuse) among uninsured primary care patients utilizing a free clinic. Data were collected using a self-administered paper survey in the waiting room of the free clinic from May to July 2017 (N = 506). Higher levels of somatic symptoms were associated with higher levels of opioid risks. U.S.-born English speakers had higher levels of opioid risk than non-U.S.-born English speakers and Spanish speakers. Being employed was associated with higher levels of opioid risk while attending college or being postcollegiate was related to lower levels of opioid risk. Research surrounding best practices, prescription trends, and population risk is vital in driving health and social policy. Further research would benefit from examining where people are obtaining opioids. In addition, further research on opioid abuse among Hispanic populations would be beneficial. Finally, future studies should examine how prescribing practices are different among free clinic health professionals in comparison to health care professionals working in-patient or at for-profit clinics.

Transportation and Other Nonfinancial Barriers Among Uninsured Primary Care Patients

Introduction:

Nonfinancial barriers are frequent causes of unmet need in health-care services. The significance of transportation barriers can weigh more than the issues of access to care. The purpose of this cross-sectional study was to examine transportation and other nonfinancial barriers among low-income uninsured patients of a safety net health-care facility (free clinic).

Methods:

The survey data were collected from patients aged 18 years and older who spoke English or Spanish at a free clinic, which served uninsured individuals in poverty in the United States.

Results:

Levels of transportation barriers were associated with levels of other nonfinancial barriers. Higher levels of nonfinancial barriers were associated with elevation in levels of stress and poorer self-rated general health. Higher educational attainment and employment were associated with an increase in other nonfinancial barriers.

Conclusion:

Focusing only on medical interventions might not be sufficient for the well-being of the underserved populations. Future studies should examine integrative care programs that include medical treatment and social services together and evaluate such programs to improve care for underserved populations.

Lef1-dependent hypothalamic neurogenesis inhibits anxiety

While innate behaviors are conserved throughout the animal kingdom, it is unknown whether common signaling pathways regulate the development of neuronal populations mediating these behaviors in diverse organisms. Here, we demonstrate that the Wnt/ß-catenin effector Lef1 is required for the differentiation of anxiolytic hypothalamic neurons in zebrafish and mice, although the identity of Lef1-dependent genes and neurons differ between these 2 species. We further show that zebrafish and Drosophila have common Lef1-dependent gene expression in their respective neuroendocrine organs, consistent with a conserved pathway that has diverged in the mouse. Finally, orthologs of Lef1-dependent genes from both zebrafish and mouse show highly correlated hypothalamic expression in marmosets and humans, suggesting co-regulation of 2 parallel anxiolytic pathways in primates. These findings demonstrate that during evolution, a transcription factor can act through multiple mechanisms to generate a common behavioral output, and that Lef1 regulates circuit development that is fundamentally important for mediating anxiety in a wide variety of animal species.

Identification of Wnt Genes Expressed in Neural Progenitor Zones during Zebrafish Brain Development

Wnt signaling regulates multiple aspects of vertebrate central nervous system (CNS) development, including neurogenesis. However, vertebrate genomes can contain up to 25 Wnt genes, the functions of which are poorly characterized partly due to redundancy in their expression. To identify candidate Wnt genes as candidate mediators of pathway activity in specific brain progenitor zones, we have performed a comprehensive expression analysis at three different stages during zebrafish development. Antisense RNA probes for 21 Wnt genes were generated from existing and newly synthesized cDNA clones and used for in situ hybridization on whole embryos and dissected brains. As in other species, we found that Wnt expression patterns in the embryonic zebrafish CNS are complex and often redundant. We observed that progenitor zones in the telencephalon, dorsal diencephalon, hypothalamus, midbrain, midbrain-hindbrain boundary, cerebellum and retina all express multiple Wnt genes. Our data identify 12 specific ligands that can now be tested using loss-of-function approaches.

Adaptations to a diet-based weight-reducing programme in obese women resistant to weight loss

The aim of this study was to assess energy intake, resting metabolic rate (RMR), appetite sensations, eating behaviours and sleep duration and quality in obese women resistant to body weight loss when subjected to a diet-based weight-reducing programme. A pooled cohort of obese women (n = 75; aged 39 ± 8 years; body mass index: 33 ± 4 kg m(-2)) participated in a 12-16-week diet-based weight loss programme targeting a daily energy deficit of 500-700 kcal d(-1). Women were classified in tertiles a posteriori based on the response of their body weight to dietary supervision (high, moderate and low responders). Post-intervention, mean weight loss was 3.3 ± 2.8 kg and explained by the 2.9 ± 2.6 kg reduction in fat mass. Mean weight loss was 6.2 ± 1.6, 3.4 ± 0.6 and 0.2 ± 1.4 kg in participants classified in the high, middle and low tertiles, respectively. Women in the low tertile reduced their daily energy intake and susceptibility to hunger during the programme to a lesser extent than those in the high tertile and had higher fasting hunger in response to the dietary intervention. Women in the high tertile maintained their RMR, which was in contrast to the significant decrease predicted by their weight loss. They also reported a significant improvement in sleep quality and an increase in sleep duration compared with other tertiles. The differences in the response of body weight to dietary supervision may be explained, in part, by variations in energy intake, eating behaviours, appetite sensations and sleep duration and quality.

Application of RNA interference in treating human diseases

Gene silencing can occur either through repression of transcription, termed transcriptional gene silencing (TGS), or through translation repression andmRNA degradation, termed posttranscriptional gene silencing (PTGS). PTGS results from sequence-specific mRNA degradation in the cytoplasm without dramatic changes in transcription of corresponding gene in nucleus. Both TGS and PTGS are used to regulate endogenous genes. Interestingly, mechanisms for gene silencing also protect the genome from transposons and viruses. In this paper, we first review RNAi mechanism and then focus on some of its applications in biomedical research such as treatment for HIV, viral hepatitis, cardiovascular and cerebrovascular diseases, metabolic disease, neurodegenerative disorders and cancer.

Viscosity of fiber preloads affects food intake in adolescents

BACKGROUND AND AIMS

Dietary fiber that develops viscosity in the gastrointestinal tract is capable of addressing various aspects of food intake control. The aim of this study was to assess subsequent food intake and appetite in relation to the level of viscosity following three liquid preloads each containing 5 g of either a high (novel viscous polysaccharide; NVP), medium (glucomannan; GLM), or low (cellulose; CE) viscosity fiber.

METHODS AND RESULTS

In this double-blind, randomized, controlled and crossover trial, 31 healthy weight adolescents (25 F:6 M; age 16.1+/-0.6 years; BMI 22.2+/-3.7 kg/m(2)) consumed one of the three preloads 90 min prior to an ad libitum pizza meal. Preloads were identical in taste, appearance, nutrient content and quantity of fiber, but different in their viscosities (10, 410, and 700 poise for CE, GLM, and NVP, respectively). Pizza intake was significantly lower (p=0.008) after consumption of the high-viscosity NVP (278+/-111 g) compared to the medium-viscosity GLM (313+/-123 g) and low-viscosity CE (316+/-138 g) preloads, with no difference between the GLM and CE preloads. Appetite scores, physical symptoms and 24-h intake did not differ among treatment groups.

CONCLUSION

A highly viscous NVP preload leads to reduced subsequent food intake, in terms of both gram weight and calories, in healthy weight adolescents. This study provides preliminary evidence of an independent contribution of viscosity on food intake and may form a basis for further studies on factors influencing food intake in adolescents.

Femoral neck geometry and hip fracture risk: the Geelong osteoporosis study

To determine the relationship between femoral neck geometry and the risk of hip fracture in post-menopausal Caucasian women, we conducted a retrospective study comparing the femoral neck dimensions of 62 hip fracture cases to those of 608 randomly selected controls. Measurements were made from dual-energy X-ray absorptiometry scans (Lunar DPX-L), using the manufacturer's ruler function, and included: hip axis length (HAL), femoral neck axis length (FNAL), femoral neck width (FNW), femoral shaft width (FSW), medial femoral shaft cortical thickness (FSCT(med)), and lateral femoral shaft cortical thickness (FSCT(lat)). The fracture group was older (median age 78.3 years vs 73.8 years), lighter (median weight 59.9 kg vs 64.5 kg), and, after adjustment for age, taller (mean height 158.7+/-0.8 cm vs 156.7+/-0.2 cm) than the controls. Furthermore, bone mineral density was lower in this group (0.682+/-0.016 g/cm(2) vs 0.791+/-0.006 g/cm(2)). After adjustment for age, bone mineral content (BMC) or height, hip fracture patients had greater FNW (up to 6.6%) and FSW (up to 6.3%) than did the controls. Each standard deviation increase in FNW and FSW was associated with a 1.7-fold (95% CI 1.3-2.3) and a 2.4-fold (95% CI 1.8-3.2) increase in the fracture risk, respectively. BMC-adjusted FNAL was greater in the fracture group (+2.1%) than in the controls, while the age-adjusted FSCT(med) was reduced (-7.2%). There was a trend towards longer HAL (up to 2.1%) after adjustment for age or BMC, and thinner age-adjusted FSCT(lat) (-1.7%) in fracture patients that did not reach statistical significance. In multivariate analysis, the risk of hip fracture was predicted by the combination of age, FNW, FSW, BMC and FSCT(med). HAL was not analyzed because of the small number of HAL measurements among fracture cases. We conclude that post-menopausal women with hip fractures have wider femoral necks and shafts, thinner femoral cortices and longer femoral neck axis lengths than do women with no fractures. Alteration in hip geometry is associated with the risk of hip fracture.

Oral contraceptives and bone mineral density: A population-based study

OBJECTIVE

We sought to test the hypothesis that exposure to oral contraceptives protects the skeleton.

STUDY DESIGN

Multiple regression techniques were used to analyze data for a random sample of 710 Australian women (age range, 20-69 years). Bone mineral density was measured at the lumbar spine, proximal femur, whole body, and distal forearm. Oral contraceptive exposure was assessed by a questionnaire.

RESULTS

Women exposed to oral contraceptives had a 3.3% greater mean bone mineral density adjusted for body mass index and age at the lumbar spine (partial r (2) = 0.009; P =.014). Adjusted mean vertebral bone mineral density was 3.3% greater for premenopausal women (partial r (2) = 0.008; P <.05), but the effect did not reach significance among postmenopausal women. Higher bone mineral density was associated with increased duration of exposure, with a mean increase of 3.2% associated with the first 5 years and a further 0.2% with >/=5 years of exposure. No association was detected at other sites.

CONCLUSION

Exposure to oral contraceptives may be associated with higher lumbar spine bone mineral density.

Femoral neck dimensions are unlikely to be associated with age at menarche

Hip axis length (HAL) has been reported as an independent risk factor for hip fracture. Later puberty may increase bone size because of delayed epiphyseal fusion. We sought to identify associations between bone size at the proximal femur with age at menarche and other indices of growth such as stature. Femoral neck dimensions were measured from dual-energy X-ray absorptiometry scans of the proximal femur in a random sample of 203 premenopausal Caucasian women (age 20-30 years). There were no associations between age at menarche and HAL, femoral axis length (FAL) or femoral neck width (FNW). Age at menarche was associated with height (r = 0.2, p = 0.02). Variations in HAL, FAL and FNW do not appear to be related to age at menarche.

The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community: the Geelong Osteoporosis Study

Fractures associated with severe trauma are generally excluded from estimates of the prevalence of osteoporotic fractures in the community. Because the degree of trauma is difficult to quantitate, low bone mass may contribute to fractures following severe trauma. We ascertained all fractures in a defined population and compared the bone mineral density (BMD) of women who sustained fractures in either "low" or "high" trauma events with the BMD of a random sample of women from the same population. BMD was measured by dual-energy X-ray absorptiometry and expressed as a standardized deviation (Z score) adjusted for age. The BMD Z scores (mean +/- SEM) were reduced in both the low and high trauma groups, respectively: spine-posterior-anterior (-0.50 +/- 0.05 and -0.21 +/- 0.08), spine-lateral (-0.28 +/- 0.06 and -0.19 +/- 0.10), femoral neck (-0.42 +/- 0.04 and -0.26 +/- 0.09), Ward's triangle (-0.44 +/- 0.04 and -0.28 +/- 0.08), trochanter (-0.44 +/- 0.05 and -0.32 +/- 0.08), total body (-0.46 +/- 0.06 and -0.32 +/- 0.08), ultradistal radius (-0.47 +/- 0.05 and -0.42 +/- 0.07), and midradius (-0.52 +/- 0.06 and -0.33 +/- 0.09). Except at the PA spine, the deficits were no smaller in the high trauma group. Compared with the population, the age-adjusted odds ratio for osteoporosis (t-score < -2.5) at one or more scanning sites was 3.1 (95% confidence interval 1.9, 5.0) in the high trauma group and 2.7 (1.9, 3.8) in the low trauma group. The data suggest that the exclusion of high trauma fractures in women over 50 years of age may result in underestimation of the contribution of osteoporosis to fractures in the community. Bone density measurement of women over 50 years of age who sustain fractures may be warranted irrespective of the classification of trauma.