Community Health Workers Deliver Mental Health Intervention to Uninsured Latinx in Baltimore: Evaluation and Lessons Learned in a Pilot Program

BACKGROUND

Implementation of evidence-based interventions to reduce depression among uninsured Latinx patients who are at high risk of depression are rare.

OBJECTIVES

Our goal was to evaluate Strong Minds, a language and culturally tailored, evidence-based intervention adapted from cognitive behavioral therapy (CBT) for mild-moderate depression and anxiety, delivered by community health workers (CHWs) in Spanish to uninsured Latinx immigrants.

METHODS

As part of the pilot, 35 participants, recruited from a free community primary care clinic, completed Strong Minds. Assessments and poststudy interviews were conducted. Paired t-tests were used to assess change of depressive symptoms at 3 and 6 months.

LESSONS LEARNED

CHW delivery of depression care to this population was feasible and among those who completed the program, preliminary evidence of depression outcomes suggests potential benefit. CHWs had specific training and support needs related to mental health care delivery.

CONCLUSIONS

Further implementation studies of depression care interventions using CHWs for underserved Latinx is needed.

Increasing the Repertoire for Depression Care: Methods and Challenges of a Randomized Controlled Trial of Peer Support for Vulnerable Older Adults

OBJECTIVE

Low-income White and older adults of color face barriers to depression care. Our purpose is to describe the methods and challenges encountered during the implementation of a randomized controlled trial to test the effectiveness of a peer support depression care intervention for low-income White and older adults of color during the COVID-19 pandemic.

METHODS

Peer Enhanced Depression Care (Peers) is an 8-week community-based intervention that uses peer mentors who are trained and supervised to provide social support and self-care skills to depressed older adults. The effectiveness of the intervention in reducing depression will be evaluated by following a sample of older adults recruited in the community over a 12-month period. Target enrollment is 160 older adults. We hypothesize that participants randomized to the Peer Enhanced Depression Care intervention will experience greater decrease in depressive symptoms compared to participants randomized to the social interaction control. We provide lessons learned regarding the recruitment of BIPOC and White low-income older adults and peer mentors during the COVID-19 pandemic.

RESULTS

Recruitment challenges occurred in primary care clinics that were unable to accommodate recruitment efforts during the pandemic. This led to focused outreach to community-based organizations serving older adults. Challenges to participant recruitment have included barriers related to stigma, distrust, as well as unfamiliarity with research. Peer mentor recruitment was facilitated by existing government-supported resources.

CONCLUSIONS

This study will provide knowledge regarding the effectiveness, mechanism, and processes of delivering an informal psychosocial intervention such as peer support to a vulnerable older adult population.

Addressing chronic pain disparities between Black and White people: a narrative review of socio-ecological determinants

A 2019 review article modified the socio-ecological model to contextualize pain disparities among different ethnoracial groups; however, the broad scope of this 2019 review necessitates deeper socio-ecological inspection of pain within each ethnoracial group. In this narrative review, we expanded upon this 2019 article by adopting inclusion criteria that would capture a more nuanced spectrum of socio-ecological findings on chronic pain within the Black community. Our search yielded a large, rich body of literature composed of 174 articles that shed further socio-ecological light on how chronic pain within the Black community is influenced by implicit bias among providers, psychological and physical comorbidities, experiences of societal and institutional racism and biomedical distrust, and the interplay among these factors. Moving forward, research and public-policy development must carefully take into account these socio-ecological factors before scaling up pre-existing solutions with questionable benefit for the chronic pain needs of Black individuals.

The impact of anti-Asian racism on routine activities and mental health among Korean American older adults and their caregivers

Introduction

Reported anti-Asian discrimination has been on the rise since the COVID-19 pandemic. Nevertheless, limited research addresses the health impact of perceived anti-Asian racism on Asian Americans, especially among older adults, during COVID-19. To address the gap, we examined how the novel coronavirus pandemic affected Korean American older adults, one of the largest Asian subgroups. Specifically, this study addressed the magnitude of racism or discrimination related to the pandemic and impact of anti-Asian racism on negative mental health symptoms among Korean American older adults and their caregivers.

Methods

We used survey data collected from 175 Korean American older adults with probable dementia and their primary caregivers (female = 62%, mean age = 71 years) who went through eligibility screening for an ongoing randomized controlled trial involving dyads in the Baltimore-Washington and the New York Metropolitan areas (ClinicalTrials.gov Identifier: NCT03909347).

Results

Nearly a quarter of the survey sample reported they were fearful for their safety due to anti-Asian racism related to the pandemic. Additionally, 47% of the respondents indicated changes to routine activities due to anti-Asian racism or discrimination related to COVID-19. The most common changes included avoiding walking alone or physical activities outside, followed by avoiding public transportation or leaving the house to go to any public places such as grocery stores, churches, or schools, not carrying out usual social activities, and avoiding going to health care appointments. Multinomial logistic regression revealed that people who reported changes to routine activities were at least five times more likely (adjusted odds ratio = 5.017, 95% confidence interval = 1.503, 16.748) to report negative mental health symptoms than those who did not. Being fearful for their own safety was not associated with experiencing negative mental health symptoms in the survey sample.

Discussion

Study findings indicate that the increased reporting of anti-Asian racism during the COVID-19 pandemic has substantially affected Korean American older adults and their caregivers. The mechanism by which changes to routine activities is related to negative mental health symptoms is unclear, future research is needed to elucidate this pathway. Furthermore, our findings highlight the importance of identifying multi-level strategies to raise awareness of and to mitigate the reported surge of racism.

The benefits and challenges of established peer support programmes for patients, informal caregivers, and healthcare providers

PURPOSE

Peer support programmes that provide services for various health conditions have been in existence for many years; however, there is little study of their benefits and challenges. Our goal was to explore how existing peer support programmes help patients with a variety of health conditions, the challenges that these programmes meet, and how they are addressed.

METHODS

We partnered with 7 peer support programmes operating in healthcare and community settings and conducted 43 semi-structured interviews with key informants. Audiorecordings were transcribed and qualitative analysis was conducted using grounded theory methods.

RESULTS

Peer support programmes offer informational and psychosocial support, reduce social isolation, and connect patients and caregivers to others with similar health issues. These programmes provide a supportive community of persons who have personal experience with the same health condition and who can provide practical information about self-care and guidance in navigating the health system. Peer support is viewed as different from and complementary to professional healthcare services. Existing programmes experience challenges such as matching of peer supporter and peer recipient and maintaining relationship boundaries. They have gained experience in addressing some of these challenges.

CONCLUSIONS

Peer support programmes can help persons and caregivers manage health conditions but also face challenges that need to be addressed through organizational processes. Peer support programmes have relevance for improving healthcare systems, especially given the increased focus on becoming more patient-centred. Further study of peer programmes and their relevance to improving individuals' well-being is warranted.

Exploring Challenges and Strategies in Partnering With Community-Based Organizations to Advance Intervention Development and Implementation With Older Adults

Minoritized older adults face multiple health inequities and disparities, but are less likely to benefit from evidence-based health care interventions. With the increasing diversity of the U.S. aging population, there is a great promise for gerontology researchers to partner with racial/ethnic minority organizations and underrepresented communities to develop and implement evidence-based health interventions. Community-Based Participatory Research and Implementation Science offer guidance and strategies for researchers to develop and sustain community partnerships. However, researchers partnering with community organizations continue to face challenges in these collaborations, study outcomes, and sustainability. This may be especially true for those junior in their career trajectory or new to community-engaged research. The purpose of this forum article is to detail critical challenges that can affect gerontology researcher-community partnerships and relationships from the perspective of researchers. Seven challenges (pre- or mid-intervention design, implementation, and postimplementation phases) described within the Equity-focused Implementation Research for health programs framework are identified and discussed. Potential solutions are also presented. Planning for potential obstacles of the researcher-community partnerships can inform innovative solutions that will facilitate successful partnerships, thereby promoting the advancement of collaborative research between academic institutions and community organizations to improve older adult health outcomes.

Development of the Mental Health Peer Support Questionnaire in colleges and vocational schools in Singapore

Background

A nation-wide mental health peer support initiative was established in college and vocational schools in Singapore. The purpose of this cross-sectional study was to develop and validate a 20-item self-report instrument, the Mental Health Peer Support Questionnaire (MHPSQ), to assess young adults’ perceived knowledge and skills in mental health peer support.

Methods

We administered the questionnaire to 102 students who were trained as peer supporters, and 306 students who were not trained as peer supporters (denoted as non-peer supporters), in five college and vocational schools. Exploratory factor analysis and descriptive statistics were conducted. Cronbach’s α was used to assess reliability, and independent sample t-tests to assess criterion validity.

Results

Exploratory factor analysis indicated a three-factor structure with adequate internal reliability (discerning stigma [α = .76], personal mastery [α = .77], skills in handling challenging interpersonal situations [α = .74]; overall scale [α = .74]). Consistent with establishing criterion validity, peer supporters rated themselves as significantly more knowledgeable and skilled than non-peer supporters on all items except two: (1) letting peer support recipients make their own mental health decisions, and (2) young adults’ self-awareness of feeling overwhelmed. Peer supporters who had served the role for a longer period of time had significantly higher perceived awareness of stigma affecting mental health help-seeking. Peer supporters who had reached out to more peer support recipients reported significantly higher perceived skills in handling challenging interpersonal situations, particularly in encouraging professional help-seeking and identifying warning signs of suicide.

Conclusions

The MHPSQ may be a useful tool for obtaining a baseline assessment of young adults’ perceived knowledge and skills in mental health peer support, prior to them being trained as peer supporters. This could facilitate tailoring of training programs based on young adults’ initial understanding of mental health peer support. Subsequent to young adults’ training and application of skills, the MHPSQ could also be applied to evaluate the effectiveness of peer programs and mental health training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00555-6.

Regional amyloid correlates of cognitive performance in ageing and mild cognitive impairment

Beta-amyloid deposition is one of the earliest pathological markers associated with Alzheimer's disease. Mild cognitive impairment in the setting of beta-amyloid deposition is considered to represent a preclinical manifestation of Alzheimer's disease. In vivo imaging studies are unique in their potential to advance our understanding of the role of beta-amyloid deposition in cognitive deficits in Alzheimer's disease and in mild cognitive impairment. Previous work has shown an association between global cortical measures of beta-amyloid deposition ('amyloid positivity') in mild cognitive impairment with greater cognitive deficits and greater risk of progression to Alzheimer's disease. The focus of the present study was to examine the relationship between the regional distribution of beta-amyloid deposition and specific cognitive deficits in people with mild cognitive impairment and cognitively normal elderly individuals. Forty-seven participants with multi-domain, amnestic mild cognitive impairment (43% female, aged 57-82 years) and 37 healthy, cognitively normal comparison subjects (42% female, aged 55-82 years) underwent clinical and neuropsychological assessments and high-resolution positron emission tomography with the radiotracer 11C-labelled Pittsburgh compound B to measure beta-amyloid deposition. Brain-behaviour partial least-squares analysis was conducted to identify spatial patterns of beta-amyloid deposition that correlated with the performance on neuropsychological assessments. Partial least-squares analysis identified a single significant (P < 0.001) latent variable which accounted for 80% of the covariance between demographic and cognitive measures and beta-amyloid deposition. Performance in immediate verbal recall (R = -0.46 ± 0.07, P < 0.001), delayed verbal recall (R = -0.39 ± 0.09, P < 0.001), immediate visual-spatial recall (R = -0.39 ± 0.08, P < 0.001), delayed visual-spatial recall (R = -0.45 ± 0.08, P < 0.001) and semantic fluency (R = -0.33 ± 0.11, P = 0.002) but not phonemic fluency (R = -0.05 ± 0.12, P < 0.705) negatively covaried with beta-amyloid deposition in the identified regions. Partial least-squares analysis of the same cognitive measures with grey matter volumes showed similar associations in overlapping brain regions. These findings suggest that the regional distribution of beta-amyloid deposition and grey matter volumetric decreases is associated with deficits in executive function and memory in mild cognitive impairment. Longitudinal analysis of these relationships may advance our understanding of the role of beta-amyloid deposition in relation to grey matter volumetric decreases in cognitive decline.

Engaging an Asian Immigrant Older Adult in Depression Care: Collaborative Care, Patient-Provider Communication and Ethnic Identity

Minority older adults face multiple barriers when trying to access mental health services and often present with more severe symptoms of mental health conditions. We describe the multilevel factors that contributed to the engagement of an Asian immigrant older adult with depression. Systems-level innovations such as collaborative care in primary care can increase access to care for all, including minority older adults; however, one size fits all interventions may not meet the needs of communities of older adults with different life experiences, language needs, norms and values regarding help-seeking for mental health. Health outcomes remain unequal , suggesting the need to tailor interventions for minority older adults. For the patient, specific factors related to language and ethnic concordance between patient and healthcare provider, communication behaviors, ethnic identity, and social norms may be important to take into account. The recognition of the heterogeneity of patients and the limitations of cultural competence approaches defined as broad, general knowledge about ethnic cultures may be needed. A need to learn continuously from clinical experience and adopt a patient-oriented model of communication and decision-making may successfully engage Asian immigrant older adults in depression care services.

Positron emission tomography imaging of serotonin degeneration and beta-amyloid deposition in late-life depression evaluated with multi-modal partial least squares

Depression in late-life is associated with increased risk of cognitive decline and development of all-cause dementia. The neurobiology of late-life depression (LLD) may involve both neurochemical and neurodegenerative mechanisms that are common to depression and dementia. Transgenic amyloid mouse models show evidence of early degeneration of monoamine systems. Informed by these preclinical data, the hypotheses were tested that a spatial covariance pattern of higher beta-amyloid (Aβ) and lower serotonin transporter availability (5-HTT) in frontal, temporal, and parietal cortical regions would distinguish LLD patients from healthy controls and the expression of this pattern would be associated with greater depressive symptoms. Twenty un-medicated LLD patients who met DSM-V criteria for major depression and 20 healthy controls underwent PET imaging with radiotracers for Aβ ([11C]-PiB) and 5-HTT ([11C]-DASB). A voxel-based multi-modal partial least squares (mmPLS) algorithm was applied to the parametric PET images to determine the spatial covariance pattern between the two radiotracers. A spatial covariance pattern was identified, including higher Aβ in temporal, parietal and occipital cortices associated with lower 5-HTT in putamen, thalamus, amygdala, hippocampus and raphe nuclei (dorsal, medial and pontine), which distinguished LLD patients from controls. Greater expression of this pattern, reflected in summary 5-HTT/Aβ mmPLS subject scores, was associated with higher levels of depressive symptoms. The mmPLS method is a powerful approach to evaluate the synaptic changes associated with AD pathology. This spatial covariance pattern should be evaluated further to determine whether it represents a biological marker of antidepressant treatment response and/or cognitive decline in LLD patients.

Molecular imaging of the serotonin transporter availability and occupancy by antidepressant treatment in late-life depression

Patients with late-life depression (LLD) have a more variable response to pharmacotherapy relative to patients with mid-life depression. Degeneration of the serotonergic system and lower occupancy of the initial target for antidepressant medications, the serotonin transporter (5-HTT), may contribute to variability in treatment response. The focus of this study was to test the hypotheses that lower cortical and limbic serotonin transporter (5-HTT) availability in LLD patients relative to controls and less 5-HTT occupancy by antidepressant medications would be associated with less improvement in mood and cognition with treatment in LLD patients. Twenty LLD patients meeting DSM-IV criteria for a current major depressive episode and 20 non-depressed controls underwent clinical and neuropsychological assessments, magnetic resonance imaging to measure gray matter volumes and high-resolution positron emission tomography (PET) scanning to measure 5-HTT before and after 10-12 weeks of treatment with Citalopram or Sertraline (patients only). Prior to treatment, 5-HTT was lower in LLD patients relative to controls in mainly temporal cortical and limbic (amygdala and hippocampus) regions. Gray matter volumes were not significantly different between groups. 5-HTT occupancy was detected throughout cortical, striatal, thalamic and limbic regions. The magnitude of regional 5-HTT occupancy by antidepressants was 70% or greater across cortical and sub-cortical regions, consistent with the magnitude of 5-HTT occupancy observed in mid-life depressed patients. Greater regional 5-HTT occupancy correlated with greater improvement in depressive symptoms and visual-spatial memory performance. These data support the hypothesis that serotonin degeneration and variability in 5-HTT occupancy may contribute to heterogeneity in treatment response in LLD patients.

Association of exposure to secondhand smoke at home with early age at menarche in South Korea

OBJECTIVES

The secular trend in age at menarche (AAM) has declined both worldwide and in Korea. Early AAM is associated with the risk of several diseases, reproductive capacity, and psychological problems. We aimed to investigate the relationship between secondhand smoke (SHS) exposure at home and early puberty onset using AAM in Korean adolescents.

STUDY DESIGN

This is a retrospective cross-sectional study.

METHODS

This study used data from the Korea Youth Risk Behavior Web-based Survey 2014-2015. We used the mean AAM (12.2 years) as a determinant of early AAM. After the exclusion of girls without menarche or who did not respond, the total population comprised 63,618 participants. We categorized AAM as 'early' and 'average or late.' Adolescents with SHS exposure were assigned to the 'never exposed,' 'light exposure,' and 'heavy exposure' groups. Multiple logistic regression analyses were performed.

RESULTS

We observed a positive association, approximately 1.12 times, between early AAM and high SHS exposure (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.05-1.19). Girls who started smoking before the age of 12 years (OR, 1.68; 95% CI, 1.41-1.99) showed a stronger association with early AAM than non-smokers. Active smoking showed a stronger association with early AAM. Never smokers with high SHS exposure at home were 1.13 times likelier to have an early AAM (OR, 1.13; 95% CI, 1.05-1.22) than those without SHS exposure.

CONCLUSIONS

In addition to active smoking, SHS may also be a risk factor for early AAM. Education aimed at active and secondhand smoking prevention is needed to protect children against early AAM.

Effect of Sedentary Time on the Risk of Orthopaedic Problems in People Aged 50 Years and Older

OBJECTIVE

Many people experience orthopaedic problems (OPPs), such as knee joint pain, hip joint pain, low back pain, and knee stiffness in their lifetimes. OPPs can impair lower extremity function, cause depression, and worsen quality of life. The aim of this study was to investigate the association between sedentary time (SDT) and OPPs.

DESIGN

Retrospective cross-sectional study.

SETTING

This study used data from the 2014-2015 Korea National Health and Nutrition Examination Survey. Survey participants with previous or current osteoarthritis or rheumatoid arthritis, as diagnosed by a doctor, were excluded. OPPs were defined as knee joint pain, hip joint pain, low back pain, and knee stiffness. The cut-off value for SDT was 7.5 hours/day. The study population comprised 3,671 people (1,856 men and 1,815 women), all of whom were ≥50 years-old. Multiple logistic regression analyses were performed.

RESULTS

A total of 328 men (17.7%) and 519 women (28.6%) had OPPs. Men with SDTs ≥7.5 hours had a greater risk of OPPs than did men with SDTs <7.5 hours (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.08-1.93). A pink-collar job, physical inactivity during leisure time, and passive (e.g. riding in a car or train) versus active (e.g. walking or riding a bicycle) transportation predicted OPPs in men with SDTs ≥7.5 hours. SDT was a risk factor for knee joint pain in men (OR, 1.80; 95% CI, 1.11-2.92) and hip joint pain in women (OR, 2.05; 95% CI, 1.35-3.11).

CONCLUSIONS

In men, prolonged SDT is a risk factor for OPPs. More physical activity programmes should be launched at the community level for people ≥50 years-old to reduce the occurrence of OPPs.

Neurometabolites and associations with cognitive deficits in mild cognitive impairment: a magnetic resonance spectroscopy study at 7 Tesla

The levels of several brain metabolites were investigated in the anterior cingulate cortex (ACC) and posterior cingulate cortex (PCC) in 13 healthy controls (HC) and 13 patients with mild cognitive impairment (MCI) using single-voxel magnetic resonance spectroscopy at 7T. Levels of γ-aminobutyric acid (GABA), glutamate (Glu), glutathione (GSH), N-acetylaspartylglutamate (NAAG), N-acetylaspartate (NAA), and myo-inositol (mI) were quantified relative to total creatine (tCr). The effect of diagnosis on metabolite levels, and relationships between metabolite levels and memory and executive function, correcting for age, were investigated. MCI patients showed significantly decreased GABA/tCr (ACC, PCC), Glu/tCr (PCC), and NAA/tCr (PCC), and significantly increased mI/tCr (ACC). In the combined group, worse episodic verbal memory performance was correlated with lower Glu/tCr (PCC), lower NAA/tCr (PCC), and higher mI/tCr (ACC, PCC). Worse verbal fluency performance was correlated with lower GSH/tCr (PCC). In summary, MCI is associated with decreased GABA and Glu, most consistently in the PCC. Further studies in larger patient samples should be undertaken to determine the utility of 7T magnetic resonance spectroscopy in detecting MCI-related neurochemical changes.

The impact of peer mentor communication with older adults on depressive symptoms and working alliance: A pilot study

OBJECTIVE

The objective of this pilot study was to describe peer communication in meetings with depressed elders, associate their relationship with working alliance and depression and assess congruence of communication with training.

METHODS

Three peers with a history of depression, in recovery, received 20h of training in peer mentoring for depression as part of an 8-week pilot program for 23 depressed older adults. Each peer-client meeting was recorded; a sample of 69 recorded meetings were chosen across the program period and coded with the Roter Interaction Analysis System, a validated medical interaction analysis system. Generalized linear mixed models were used to examine peer talk during meetings in relation to working alliance and client depression.

RESULTS

Peers used a variety of skills congruent with their training including client-centered talk, positive rapport building and emotional responsiveness that remained consistent or increased over time. Client-centered communication and positive rapport were associated with increased working alliance and decreased depressive symptoms (all p<0.001).

CONCLUSION

Trained peer mentors can use communication behaviors useful to older adults with depression. Specifically, client-centered talk may be important to include in peer training.

PRACTICE IMPLICATIONS

Peer mentors can be a valuable resource in providing depression counseling to older adults.

What Does Depression Mean for Korean American Elderly?: A Qualitative Follow-Up Study

OBJECTIVE

Korean American Elderly (KAE) have high rates of depression but underuse mental health services. The purpose of this study was to assess the meaning of depression and help seeking among KAE residing in the United States who have clinically significant depressive symptoms.

METHODS

As a follow up to the Memory and Aging Study of Koreans (MASK; n=1,118), a descriptive epidemiological study which showed that only one in four of KAE with clinically significant depressive symptoms (Patient Health Questionnaire-9≥10) used mental health services, we conducted a qualitative study using semi-structured interviews with participants with clinically significant depressive symptoms regarding the meaning of depression and beliefs about help seeking. Ten participants with clinically significant depressive symptoms were approached and 8 were recruited for semi-structured interviews.

RESULTS

KAE did not identify themselves as depressed though experiencing clinically significant depressive symptoms. They associated depression with social discrimination, social isolation, and suicide in the extreme circumstance. They attributed depression to not achieving social and material success in America and strained relationships with their children. Participants attempted to self-manage distress without telling others in their social network. However, KAE were willing to consult with mental health professionals if the services were bilingual, affordable, and confidential.

CONCLUSION

KAE with clinically significant depressive symptoms are a vulnerable group with need and desire for linguistically and culturally relevant mental health services who are isolated due to a complex array of psychological and social factors.

An Innovative Model of Depression Care Delivery: Peer Mentors in Collaboration with a Mental Health Professional to Relieve Depression in Older Adults

OBJECTIVES

Traditional mental health services are not used by a majority of older adults with depression, suggesting a need for new methods of health service delivery. We conducted a pilot study using peer mentors to deliver depression care to older adults in collaboration with a mental health professional. We evaluated the acceptability of peer mentors to older adults and examined patient experiences of the intervention.

METHODS

Six peer mentors met 30 patients for 1 hour weekly for 8 weeks. A mental health professional provided an initial clinical evaluation as well as supervision and guidance to peer mentors concurrent with patient meetings. We measured depressive symptoms at baseline and after study completion, and depressive symptoms and working alliance at weekly peer-patient meetings. We also interviewed participants and peer mentors to assess their experiences of the intervention.

RESULTS

Ninety-six percent of patients attended all eight meetings with the peer mentor and PHQ-9 scores decreased for 85% of patients. Patients formed strong, trusting relationships with peer mentors. Patients emphasized the importance of trust, of developing a strong relationship, and of the credibility and communication skills of the peer mentor. Participants described benefits such as feeling hopeful, and reported changes in attitude, behavior, and insight.

CONCLUSIONS

Use of peer mentors working in collaboration with a mental health professional is promising as a model of depression care delivery for older adults. Testing of effectiveness is needed and processes of recruitment, role definition, and supervision should be further developed.

Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review

BACKGROUND

Community-based health workers (CBHWs) are frontline public health workers who are trusted members of the community they serve. Recently, considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable populations who often face health inequities.

OBJECTIVES

We performed a systematic review to synthesize evidence concerning the types of CBHW interventions, the qualification and characteristics of CBHWs, and patient outcomes and cost-effectiveness of such interventions in vulnerable populations with chronic, noncommunicable conditions.

SEARCH METHODS

We undertook 4 electronic database searches-PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane-and hand searched reference collections to identify randomized controlled trials published in English before August 2014.

SELECTION

We screened a total of 934 unique citations initially for titles and abstracts. Two reviewers then independently evaluated 166 full-text articles that were passed onto review processes. Sixty-one studies and 6 companion articles (e.g., cost-effectiveness analysis) met eligibility criteria for inclusion.

DATA COLLECTION AND ANALYSIS

Four trained research assistants extracted data by using a standardized data extraction form developed by the authors. Subsequently, an independent research assistant reviewed extracted data to check accuracy. Discrepancies were resolved through discussions among the study team members. Each study was evaluated for its quality by 2 research assistants who extracted relevant study information. Interrater agreement rates ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions.

MAIN RESULTS

All but 4 studies were conducted in the United States. The 2 most common areas for CBHW interventions were cancer prevention (n = 30) and cardiovascular disease risk reduction (n = 26). The roles assumed by CBHWs included health education (n = 48), counseling (n = 36), navigation assistance (n = 21), case management (n = 4), social services (n = 7), and social support (n = 18). Fifty-three studies provided information regarding CBHW training, yet CBHW competency evaluation (n = 9) and supervision procedures (n = 24) were largely underreported. The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in 24 studies that reported length of training. Eight studies reported the frequency of supervision, which ranged from weekly to monthly. There was a trend toward improvements in cancer prevention (n = 21) and cardiovascular risk reduction (n = 16). Eight articles documented cost analyses and found that integrating CBHWs into the health care delivery system was associated with cost-effective and sustainable care.

CONCLUSIONS

Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions, particularly when partnering with low-income, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.

Nuclear ULK1 promotes cell death in response to oxidative stress through PARP1

Reactive oxygen species (ROS) may cause cellular damage and oxidative stress-induced cell death. Autophagy, an evolutionarily conserved intracellular catabolic process, is executed by autophagy (ATG) proteins, including the autophagy initiation kinase Unc-51-like kinase (ULK1)/ATG1. Although autophagy has been implicated to have both cytoprotective and cytotoxic roles in the response to ROS, the role of individual ATG proteins, including ULK1, remains poorly characterized. In this study, we demonstrate that ULK1 sensitizes cells to necrotic cell death induced by hydrogen peroxide (H2O2). Moreover, we demonstrate that ULK1 localizes to the nucleus and regulates the activity of the DNA damage repair protein poly (ADP-ribose) polymerase 1 (PARP1) in a kinase-dependent manner. By enhancing PARP1 activity, ULK1 contributes to ATP depletion and death of H2O2-treated cells. Our study provides the first evidence of an autophagy-independent prodeath role for nuclear ULK1 in response to ROS-induced damage. On the basis of our data, we propose that the subcellular distribution of ULK1 has an important role in deciding whether a cell lives or dies on exposure to adverse environmental or intracellular conditions.

Shared conceptualizations and divergent experiences of counseling among African American and white older adults

Research findings suggest that older adults prefer counseling for depression treatment; however, few older adults use counseling services. In this article we present the results of our analysis of semistructured interviews with 102 older adults to explore conceptualizations of counseling and impediments to use among African American and White older adults. We found that older adults believe counseling is beneficial; however, use was hindered in multiple ways. Older adults were skeptical about establishing a caring relationship with a professional. African American older adults did not mention social relationships to facilitate depression care, whereas White older adults described using personal relationships to navigate counseling services. African American older men were least familiar with counseling. Our findings suggest that African American and White older adults share a strong cultural model of counseling as beneficial; however, significant impediments exist and affect older adults differentially based on ethnicity.

Comparison of total hip replacement with and without cement in patients younger than 50 years of age: the results at 18 years

There have been comparatively few studies of the incidence of osteolysis and the survival of hybrid and cementless total hip replacements (THRs) in patients younger than 50 years of age. We prospectively reviewed 78 patients (109 hips) with a hybrid THR having a mean age of 43.4 years (21 to 50) and 79 patients (110 hips) with a cementless THR with a mean age of 46.8 years (21 to 49). The patients were evaluated clinically using the Harris hip score, the Western Ontario and McMaster Universities (WOMAC) osteoarthritis score and the University of California, Los Angeles (UCLA) activity score. Radiographs and CT scans were assessed for loosening and osteolysis. The mean follow-up was for 18.4 years (16 to 19) in both groups. The mean post-operative Harris hip scores (91 points versus 90 points), the mean WOMAC scores (11 points versus 13 points) and UCLA activity scores (6.9 points versus 7.1 points) were similar in both groups. The revision rates of the acetabular component (13% versus 16%) and the femoral component (3% versus 4%), and the survival of the acetabular component (87% versus 84%) and the femoral component (97% versus 96%) were similar in both groups. Although the long-term fixation of the acetabular metallic shell and the cemented and cementless femoral components was outstanding, wear and peri-acetabular osteolysis constitute the major challenges of THR in young patients.

Disparity in use of psychotherapy offered in primary care between older african-american and white adults: results from a practice-based depression intervention trial

The purpose of this study was to assess ethnic differences in use of psychotherapy (having met at least once with a psychotherapist) for late-life depression in primary care. Participants were identified through a two-stage, age-stratified (60-74, > or =75) depression screening of randomly sampled patients from 20 practices in New York City, Philadelphia, and Pittsburgh in a practice-randomized trial. Practices were randomly assigned to usual care or to an intervention with a depression care manager who worked with primary care physicians to provide algorithm-based care. Depression status based on clinical interview and any use of psychotherapy within the 2-year follow-up interval were the primary dependent variables under study. The focus was on 582 persons with complete data. Participants were sorted into major depression (n=385, 112 African American and 273 white) and clinically significant minor depression (n=197, 51 African American and 146 white) based on clinical diagnostic assessment. Persons who self-identified as African American were less likely than whites to use interpersonal therapy (IPT) if they had minor depression, even after adjusting for potentially influential variables including age, cognitive functioning, and whether the dose of antidepressant was adequate (adjusted odds ratio (AOR)=0.22, 95% confidence interval (CI)=0.06-0.80). Ethnicity was not significantly associated with IPT use in persons with major depression (AOR=0.71, 95% CI=0.37-1.37). Older African Americans with minor depression were less likely than whites to use psychotherapy. Targeted strategies are needed to mitigate the disparity in use of psychotherapy.

Crosstalk mitigation using adaptive time reversal

Although the spatial focusing property of the conventional time reversal approach facilitates multiuser communications, there always is residual crosstalk between users. A recent paper [Kim and Shin, J. Acoust. Soc. Am. 115, 600-606 (2004)] proposed an adaptive active time reversal approach for simultaneous multiple focusing with minimal interference. This letter applies the adaptive approach to passive time reversal, multiuser communications for additional suppression of crosstalk among users. Experimental data at 3.5 kHz with a 1-kHz bandwidth demonstrate as much as 6.5-dB improvement per user in terms of output signal-to-noise ratio for three-user communications over a 20-km range in 120-m deep shallow water.

Losing faith and using faith: older African Americans discuss spirituality, religious activities, and depression

BACKGROUND AND OBJECTIVES

Older African Americans are often under diagnosed and under treated for depression. Given that older African Americans are more likely than whites to identify spirituality as important in depression care, we sought to understand how spirituality may play a role in the way they conceptualize and deal with depression in order to inform possible interventions aimed at improving the acceptability and effectiveness of depression treatment.

DESIGN

Cross-sectional qualitative interview study of older African American primary care patients.

PARTICIPANTS AND SETTING

Forty-seven older African American patients recruited from primary care practices in the Baltimore, MD area, interviewed in their homes.

MEASUREMENTS

Semi-structured interviews lasting approximately 60 minutes. Interviews were transcribed and themes related to spirituality in the context of discussing depression were identified using a grounded-theory approach.

MAIN RESULTS

Participants in this study held a faith-based explanatory model of depression with a particular emphasis on the cause of depression and what to do about it. Specifically, participants described depression as being due to a "loss of faith" and faith and spiritual/religious activities were thought to be empowering in the way they can work together with medical treatments to provide the strength for healing to occur.

CONCLUSIONS

The older African Americans in this study described an intrinsically spiritual explanatory model of depression. Addressing spirituality in the clinical encounter may lead to improved detection of depression and treatments that are more congruent with patient's beliefs and values.

Optimization of submerged culture condition for the production of mycelial biomass and exopolysaccharides by Agrocybe cylindracea

The optimization of submerged culture conditions and nutritional requirements was studied for the production of exopolysaccharide (EPS) from Agrocybe cylindracea ASI-9002 using the statistically based experimental design in a shake flask culture. Both maximum mycelial biomass and EPS were observed at 25 degrees C. The optimal initial pH for the production of mycelial biomass and EPS were found to be pH 4.0 and pH 6.0, respectively. Subsequently, optimum concentration of each medium component was determined using the orthogonal matrix method. The optimal combination of the media constituents for mycelial growth was as follows: maltose 80 g/l, Martone A-1 6 g/l, MgSO4 x 7H2O 1.4 g/l, and CaCl2 1.1 g/l; for EPS production: maltose 60 g/l, Martone A-1 6 g/l, MgSO4 x 7H2O 0.9 g/l, and CaCl2 1.1 g/l. Under the optimal culture condition, the maximum EPS concentration achieved in a 5-l stirred-tank bioreactor indicated 3.0 g/l, which is about three times higher than that at the basal medium.

Perception of wheezing in the elderly asthmatics

BACKGROUND

In elderly asthmatics, underdiagnosis is one of the important features. The main reason for underdiagnosis is thought to be a low frequency in complaining of symptoms due to the reduction of intellectual recognition and physical activity. Among the various symptoms, wheezing is the principal clue in diagnosing bronchial asthma, and decreased complaints for wheezing are also noted in elderly asthmatics. The objective of this study is to determine if less complaints of wheezing in elderly asthmatic is due to decrease in the development of wheezing.

METHODS

61 young (20-39 years old), 68 middle-aged (40-59 years old) and 65 elderly (older than 60 years old) stable asthmatic subjects were studied (each group shall be called, hereafter, Young Group, Middle-aged Group and Old Group, respectively). During the methacholine induced airway narrowing, lung auscultation and questionnaire survey about presence and perception of wheezing were conducted in 194 asthmatics.

RESULTS

One hundred and sixty-nine patients (87%) developed wheezing during the methacholine induced airway obstruction. The frequency of wheezing during the methacholine challenge was found to be comparable among the groups. The methacholine concentration, % fall in FEV1, and FEV1 levels of the initial detection of wheezing were not different among the groups. Among the patients who developed wheezing, 47 patients (77%), 42 patients (61.8%) and 26 patients (40%) complained of wheezing in Young, Middle and Old Group, respectively.

CONCLUSION

In conclusion, the decreased perception of wheezing is a main factor for the low frequency of complaints of wheezing in elderly asthmatics.

Inhibition of c-erbB-2 expression an activity in human ovarian carcinoma cells by hypericin

The c-erbB-2 oncogene encodes a tyrosine kinase that constitutes the internal and transmembrane part of the epidermal growth factor receptor (EGFR). ErbB-2 overexpression has been reported in 20% to 30% of human adenocarcinomas of the breast and ovary, and has been linked to an unfavorable prognosis in patients. Hypericin is a protein tyrosine kinase inhibitor that has been exploited in models for anti-tumor and anti-viral activity. In this study, we investigated the effects of hypericin on the activity of the c-erbB-2 oncoprotein and its downstream kinases. We also investigated the effect of hypericin on metastasis. We used ovarian SK-OV-3 cells as a model to determine whether hypericin-induced cell death was associated with inhibition of c-erbB-2 expression and activation. The IC50 of hypericin after 72 hrs exposure was 7.5 microM as determined by the MTT assay. Apoptosis, which was assessed by morphological changes and a flow cytometric assay, was observed at 24 h after continuous exposure to 5 microM hypericin. Inhibition of expression of the c-erbB-2 protein was detected, using a monoclonal anti-erbB-2 antibody after 12-48 hrs of exposure to hypericin. Hypericin was found to inhibit autophosphorylation of the erbB-2 protein and downstream kinases such as MEK and ERK1/2. We also found up-regulation of p21WAF1 expression and down-regulation of Bcl-2 in hypericin treated cells. An invasion assay showed that hypericin inhibited the movement of SK-OV-3 cells into the Matrigel. However, gelatin zymography showed that hypericin had no effect on the secretion of matrix metalloproteinases (MMPs) in SK-OV-3 cells. From these results, we conclude that hypericin inhibits the growth of SK-OV-3 ovarian cancer cells, inhibits the autophosphorylation of c-erbB-2, induces apoptosis, and may inhibit invasion.

Role of auxin-induced reactive oxygen species in root gravitropism

We report our studies on root gravitropism indicating that reactive oxygen species (ROS) may function as a downstream component in auxin-mediated signal transduction. A transient increase in the intracellular concentration of ROS in the convex endodermis resulted from either gravistimulation or unilateral application of auxin to vertical roots. Root bending was also brought about by unilateral application of ROS to vertical roots pretreated with the auxin transport inhibitor N-1-naphthylphthalamic acid. Furthermore, the scavenging of ROS by antioxidants (N-acetylcysteine, ascorbic acid, and Trolox) inhibited root gravitropism. These results indicate that the generation of ROS plays a role in root gravitropism.

A new antioxidant monoterpene glycoside, alpha-benzoyloxypaeoniflorin from Paeonia suffruticosa

Alpha-benzoyloxypaeoniflorin (1), a new antioxidant monoterpene alpha-glycoside anomer was isolated from Paeonia suffruticosa along with known compounds, beta-benzoyloxypaeoniflorin (2), paeonolide, paeoniflorin and mudanpioside H. The structure of 1 has been determined by comparing spectral data with those of beta-benzoyloxypaeoniflorin (2). Compound 1 exhibited moderately potent radical scavenging activity on DPPH radical.

Colonoscopic diagnosis of whipworm infection

Trichuriasis is an intestinal infection found in human beings which is caused by Trichuris trichiura, more commonly known as whipworm because of its whip-like appearance. It is characterized by the invasion of the colonic mucosa by the adult Trichuris and produces minor inflammatory changes at the sites of localization. It is prevalent throughout the world, especially in tropical areas. Its diagnosis is usually made by identification of the typical eggs in the stool; adult whipworm is rarely seen during colonoscopy. Colonoscopy can directly diagnose trichuriasis, confirming the threadlike form of worms with an attenuated end. The worms can be overlooked, particularly if colon preparation is imperfect. Attenuated whip-like ends of whipworms, which are embedded in the colonic mucosa, were removed with biopsy forceps. We report on 5 cases of whipworm infection that were diagnosed on total colonoscopy.

Effectiveness of endoscopic ultrasonography in the diagnosis of choledocholithiasis prior to laparoscopic cholecystectomy

BACKGROUND AND STUDY AIMS

To reduce the rate of conversion to open cholecystectomy, and to avoid retained bile duct stones, it is essential to detect choledocholithiasis prior to laparoscopic cholecystectomy. The aim of the present study was to evaluate the usefulness and safety of performing endoscopic ultrasonography (EUS) for the diagnosis of choledocholithiasis prior to laparoscopic cholecystectomy.

PATIENTS AND METHODS

One hundred thirty-two patients with symptomatic cholelithiasis were evaluated prospectively using standard abdominal ultrasonography (US), US plus EUS, and US plus endoscopic retrograde cholangiography (ERC) for the detection of choledocholithiasis prior to laparoscopic cholecystectomy.

RESULTS

Twenty-eight patients (21.2%) had choledocholithiasis, and six patients with common bile duct stones had normal-sized ducts on US. The common bile duct was successfully examined in all patients using EUS, but only in 65.9% of patients when US was used and 94.7% of patients when ERC was used. US plus EUS detected choledocholithiasis in 25 of 28 patients (89.3%), US in 19 of 28 patients (67.9%), and US plus ERC in 26 of 28 patients (92.9%). While no complications as a result of EUS were encountered, complications resulting from ERC occurred in seven patients (5.3%), including cholecystitis in two patients, cholangitis in three patients, and pancreatitis in two patients. In view of the complication and failure rates, EUS appears to offer significant advantages over ERC. These results suggest that EUS is more sensitive than standard abdominal ultrasonography, and as sensitive as ERC.

CONCLUSIONS

EUS appears to be as sensitive as, and safer than, ERC in the detection of choledocholithiasis prior to laparoscopic cholecystectomy.

Expression of yeast O6-methylguanine-DNA methyltransferase (MGMT) gene

We cloned the full genomic DNA of yeast (Saccharomyces cerevisiae) O6-methylguanine-DNA methyltransferase (MGMT) gene and examined its expression. The expression of yeast MGMT gene is decreased when cells reach stationary phase and cannot be induced by the pretreatment with alkylating agents, methylmethanesulfonate (MMS) or N-methyl-N'-nitroso-N-nitrosoguanidine (MNNG). The transcription initiation site was determined by primer extension analysis. This analysis showed that the authentic start codon is the ATG at position +32 from transcription initiation site.