Mental health, pain and likelihood of opioid misuse among adults with sickle cell disease.

Depressive symptoms are prevalent in individuals living with sickle cell disease (SCD) and may exacerbate pain. This study examines whether higher depressive symptoms are associated with pain outcomes, pain catastrophizing, interference and potential opioid misuse in a large cohort of adults with SCD. The study utilized baseline data from the 'CaRISMA' trial, which involved 357 SCD adults with chronic pain. Baseline assessments included pain intensity, daily mood, the Patient Health Questionnaire (PHQ), the Generalized Anxiety Disorders scale, PROMIS Pain Interference, Pain Catastrophizing Scale, the Adult Sickle Cell Quality of Life Measurement Information System and the Current Opioid Misuse Measure. Participants were categorized into 'high' or 'low' depression groups based on PHQ scores. Higher depressive symptoms were significantly associated with increased daily pain intensity, negative daily mood, higher pain interference and catastrophizing, poorer quality of life and a higher likelihood of opioid misuse (all p < 0.01). SCD patients with more severe depressive symptoms experienced poorer pain outcomes, lower quality of life and increased risk of opioid misuse. Longitudinal data from this trial will determine whether addressing depressive symptoms may potentially reduce pain frequency and severity in SCD.

Prevalence of Substance Use Disorders in Sickle Cell Disease Compared to Other Chronic Conditions: a Population-Based Study of Black American Adults.

BACKGROUND: Sickle cell disease (SCD) is a heritable chronic health condition characterized by pain symptoms throughout the life course that are routinely treated with opioids. OBJECTIVE: This study examined differences in substance use disorders in Black American adults with SCD compared to those with other chronic conditions or with no chronic conditions. DESIGN: Data from a population-representative sample of Black Americans with SCD, other chronic conditions, and no chronic conditions were obtained from the National Survey of American Life (NSAL) database. Diagnosis of substance use disorder was determined by structured clinical interview. Hierarchical models controlling for covariates (demographics, socioeconomic status, self-rated health, and mood disorders) compared odds of diagnosis between the three groups. PARTICIPANTS: The sample included 4238 African-American and Black Caribbean participants from the NSAL study who were 18 years of age or older. MAIN MEASURES: Measures included age, sex, income, education, marital status, employment, possession of health insurance, health conditions, and substance use disorders diagnosed by structured clinical interview. KEY RESULTS: Controlling for age, sex, and socioeconomic status, there were no differences in odds of a drug use disorder when comparing individuals with SCD to Black adults with other chronic conditions (OR = 1.12; p = 0.804) or no chronic condition (OR = 2.09; p = 0.102). SCD was, however, associated with greater odds of alcohol use disorders when compared to the groups with other chronic conditions (OR = 2.15; p = 0.01) and no chronic conditions (OR = 5.11; p < 0.001). This effect was not better accounted for by socioeconomic status, marital status, self-rated physical health, or the presence of a mood disorder. CONCLUSIONS: SCD was not a risk factor for drug use disorders. Further data will be needed to understand the factors contributing to increased risk of alcohol use disorders in SCD and the role uncontrolled pain symptoms may have in driving substance use.

Decision fatigue among clinical nurses during the COVID-19 pandemic.

AIMS AND OBJECTIVES: The purpose of this study was to report the psychometric properties, including validity and reliability, of the decision fatigue scale (DFS). BACKGROUND: Decision fatigue may impair nurses' ability to make sound clinical decisions and negatively impact patient care. Given the negative impact of the COVID-19 pandemic on psychological well-being and the workplace environment, decision fatigue may be even more apparent among clinical nurses. Valid assessment of this condition among clinical nurses may inform supportive interventions to mitigate the negative sequelae associated with states of decision fatigue. DESIGN: This study was a secondary analysis of a parent study using a cross-sectional descriptive design. METHODS: A convenience sample of 160 staff nurses was recruited online from across the United States. Participants completed a demographic questionnaire and subjective measures of decision fatigue, nursing practice environment scale and traumatic stress. Exploratory factor analysis (EFA), correlation coefficients and internal consistency reliability coefficients were computed to examine the DFS's validity and reliability within this sample. RESULTS: The EFA yielded a single factor, 9-item version of the DFS. The DFS scores were strongly correlated with traumatic stress and moderately correlated with the nursing practice environment, and the scale displayed appropriate internal consistency. CONCLUSIONS: This is the first known study to provide evidence of the DFS's validity and reliability in a sample of registered nurses working during the COVID-19 pandemic. The results of this study provide evidence of a reliable and valid assessment instrument for decision fatigue that can be used to measure the burden of decision-making among registered nurses. RELEVANCE TO CLINICAL PRACTICE: Given the relationship between traumatic stress and the nursing work environment, decision fatigue may be a modifiable target for interventions that can enhance the quality of decision-making among clinical nurses.

Impact of Disgust on Intentions to Undergo Colorectal Surgery.

BACKGROUND: Surgeons present patients with complex information at the perioperative appointment. Emotions likely play a role in surgical decision-making, and disgust is an emotion of revulsion at a stimulus that can lead to avoidance. OBJECTIVE: The purpose of this study was to determine the impact of disgust on intention to undergo surgical resection for colorectal cancer and recall of perioperative instructions. DESIGN: This was a cross-sectional observational study conducted online using hypothetical scenarios with nonpatient subjects. SETTINGS: The study was conducted using Amazon's Mechanical Turk. PATIENTS: Survey respondents were living in the United States. MAIN OUTCOME MEASURES: Surgery intention and recall of perioperative instructions were measured. RESULTS: A total of 319 participants met the inclusion criteria. Participants in the experimental condition, who were provided with detailed information and pictures about stoma care, had significantly lower surgery intentions (mean ± SD, 4.60 ± 1.15) compared with the control condition with no stoma prompt (mean ± SD, 5.14 ± 0.91; p = 0.05) and significantly lower recall for preoperative instructions (mean ± SD, 13.75 ± 2.38) compared with the control condition (mean ± SD, 14.36 ± 2.19; p = 0.03). Those within the experimental conditions also reported significantly higher state levels of disgust (mean ± SD, 4.08 ± 1.74) compared with a control condition (mean ± SD, 2.35 ± 1.38; p < 0.001). State-level disgust was found to fully mediate the relationship between condition and recall (b = -0.31) and to partially mediate the effect of condition on surgery intentions (b = 0.17). LIMITATIONS: It is unknown whether these results will replicate with patients and the impact of competing emotions in clinical settings. CONCLUSIONS: Intentions to undergo colorectal surgery and recall of preoperative instructions are diminished in patients who experience disgust when presented with stoma information. Surgeons and care teams must account for this as they perform perioperative counseling to minimize interference with recall of important perioperative information. See Video Abstract at http://links.lww.com/DCR/A776.

Naïve models of dietary splurges: Beliefs about caloric compensation and weight change following non-habitual overconsumption.

The mechanisms that lead to overeating and the consumption of tempting, unhealthy foods have been studied extensively, but the compensatory actions taken afterwards have not. Here we describe the naïve models individuals hold around dietary splurges (single bouts of overeating) and associated weight changes. Across six online experiments, we found that, following a hypothetical dietary splurge, participants did not plan to adequately adjust calorie consumption to account for the additional calories consumed (Studies 1 and 2), and this pattern was worse following hypothetical splurges characterized by a large amount of food consumed in a single bout (Study 3). Participants expected weight changes to happen faster than they do in reality (Study 4) and they expected that weight gained from a dietary splurge would disappear on its own without explicit compensation attempts through diet or exercise (Study 5). Similarly, participants expected that when compensation attempts were made through calorie restriction, the rate of weight loss would be faster following a dietary splurge compared to normal eating (Study 6). This research contributes novel data demonstrating an important mechanism that likely contributes to weight gain and failed weight loss attempts.

Leveraging the lived experience of surrogate decision makers of the seriously ill to develop a decision support intervention.

BACKGROUND: Surrogate decision makers of seriously ill patients are frequently asked to make healthcare decisions without evidence-based decision support. AIMS: To describe the lived experiences of surrogate decision makers who have made advance care decisions and identify relevant features of a decision support intervention from their perspectives. METHODS: A convenience sample of surrogate decision makers (n=10) of seriously ill patients discharged to an extended care facility within the past 6 months participated in focus group discussions. Data were analyzed using content analysis. RESULTS: Three salient themes were identified: (1) limited preparation, (2) decisional and emotional burden, and (3) content and features of a decision support intervention. CONCLUSIONS: Surrogate decision makers of the seriously ill are not prepared for their new role, and experience decisional and emotional burden. Effective decision support interventions must address the decisional and emotional needs of surrogate decision makers to enhance the quality of their decisions.

Cost-effectiveness of noninvasive liver fibrosis tests for treatment decisions in patients with chronic hepatitis C.

UNLABELLED: The cost-effectiveness of noninvasive tests (NITs) as alternatives to liver biopsy is unknown. We compared the cost-effectiveness of using NITs to inform treatment decisions in adult patients with chronic hepatitis C (CHC). We conducted a systematic review and meta-analysis to calculate the diagnostic accuracy of various NITs using a bivariate random-effects model. We constructed a probabilistic decision analytical model to estimate health care costs and outcomes (quality-adjusted life-years; QALYs) using data from the meta-analysis, literature, and national UK data. We compared the cost-effectiveness of four treatment strategies: testing with NITs and treating patients with fibrosis stage≥F2; testing with liver biopsy and treating patients with ≥F2; treat none; and treat all irrespective of fibrosis. We compared all NITs and tested the cost-effectiveness using current triple therapy with boceprevir or telaprevir, but also modeled new, more-potent antivirals. Treating all patients without any previous NIT was the most effective strategy and had an incremental cost-effectiveness ratio (ICER) of £9,204 per additional QALY gained. The exploratory analysis of currently licensed sofosbuvir treatment regimens found that treat all was cost-effective, compared to using an NIT to decide on treatment, with an ICER of £16,028 per QALY gained. The exploratory analysis to assess the possible effect on results of new treatments, found that if SVR rates increased to >90% for genotypes 1-4, the incremental treatment cost threshold for the "treat all" strategy to remain the most cost-effective strategy would be £37,500. Above this threshold, the most cost-effective option would be noninvasive testing with magnetic resonance elastography (ICER=£9,189). CONCLUSIONS: Treating all adult patients with CHC, irrespective of fibrosis stage, is the most cost-effective strategy with currently available drugs in developed countries.

On Stage, But Not on Cue.

This comic considers how patients can work to use the right vocabulary to help their physicians help them, since patients suffer when physicians fail to properly diagnose and intervene on their ailments. This comic also considers how patients can experience performance anxiety after what might be months of preparation for a key clinic visit in hopes of getting help.

A Clinical Encounter in Historical Context.

This drawing considers the importance of understanding history's role in contextualizing many patients' present-day health care experiences.

"What Race Are You?"

This comic shares a true story of a physician's fraught interaction with and examination of a patient and prompts consideration of how context, empathy, and emotional intelligence play key roles in how well patient-physician conversation is likely to go in the moment and when replayed by a patient after an awkward, uncomfortable encounter.

Tailoring a Digital Mental Health Program for Patients With Sickle Cell Disease: Qualitative Study.

BACKGROUND: Depression and other mental health disorders are prevalent among people living with chronic health conditions. Although digital cognitive behavioral therapy (CBT) is considered an effective treatment, African American individuals are less likely to engage in and adhere to digital therapies for mental health disorders compared with White individuals. OBJECTIVE: The aim of this study was to understand digital CBT mental health treatment perceptions and preferences of African American individuals with sickle cell disease (SCD). METHODS: African American individuals with SCD from various US locations were invited to participate in a series of focus groups. Participants were introduced to a health coach-supported mental health app and then asked a series of questions about the usability and appeal of the program as well as, more generally, what would make a digital mental health program effective for them. The authors reviewed the focus group transcripts and conducted a qualitative analysis of the results. RESULTS: A total of 25 people participated in 5 focus groups. Overall, 5 primary themes emerged regarding how app content and related coaching could be modified to enhance digital CBT engagement. These themes included connection with others living with SCD, the personalization of app content and coaching, characteristics of coaches, journaling and pain tracking, and considerations for optimal engagement. CONCLUSIONS: Enhancing the user experience by making digital CBT tools relevant to patient populations is critical for optimizing program engagement and its uptake. Our findings highlight potential strategies to modify and design digital CBT tools for users with SCD and may also be applicable to patients with other chronic conditions. TRIAL REGISTRATION: ClinicalTrials.gov NCT04587661; https://clinicaltrials.gov/ct2/show/NCT04587661.

Health Literacy, Perceived Stigma, Self-Efficacy, and HRQOL in Sickle Cell Disease.

Little is known about the relationships among self-efficacy, social determinants of health, and health outcomes in adults living with sickle cell disease (SCD). We conducted mediation analyses examining the relationships among health literacy, perceived stigma, self-efficacy, and health outcomes in an online cohort of adults living with SCD. The health outcomes explored were physical and mental health-related quality of life (HRQOL) and pain interference; covariates included gender, disease severity, and depressive symptoms. Data came from a cross-sectional, descriptive study of 60 adults with SCD. Perceived stigma and self-efficacy had significant relationships with the study outcomes, while health literacy did not. Self-efficacy partially mediated the relationship between perceived stigma and physical HRQOL, when controlling for depressive symptoms. Future research should investigate the influence of stigma and self-efficacy on health outcomes in patients with SCD and consider stigma when creating interventions to modify self-efficacy.

The Effect of an Adapted Digital Mental Health Intervention for Sickle Cell Disease on Engagement: A Pilot Randomized Controlled Trial.

INTRODUCTION: Despite promising outcomes, lack of engagement and poor adherence are barriers to treating mental health using digital CBT, particularly in minority groups. After conducting guided focus groups, a current mental health app was adapted to be more inclusive for minorities living with SCD. METHODS: Patients between the ages of 16-35 with SCD who reported experiencing anxiety or depression symptoms were eligible for this study. Once enrolled, participants were randomly assigned to receive one of two versions of a mental health app 1) the current version designed for the general population and 2) the adapted version. Baseline measures for depression, anxiety, pain and self-efficacy were completed at the start of the study and again at postintervention (minimum 4 weeks). RESULTS: Compared to baseline, pain (p = 0.03), self-efficacy (p = 0.007) and depression symptoms (p = 0.016) improved for the group that received the adapted app. Regardless of group assignment, a positive relationship (r = 0.47) was shown between app engagement and a change in depression symptoms (p = 0.042). DISCUSSION: Target enrollment for this study sought to enroll 40 participants. However, after difficulties locating qualified participants, enrollment criteria were adjusted to expand the population pool. Regardless of these efforts, the sample size for this study was still smaller than anticipated (n = 21). Additionally, irrespective of group approximately 40% of participants did not engage with the app. However, despite a small sample size and poor engagement, participants in the intervention group displayed better outcomes and showed trends for greater app interaction. CONCLUSION: These promising results should encourage future researchers to continue exploring ideal adaptations for implementing digital CBT in minority populations. Future studies should also consider implementing post-intervention surveys to help identify common factors relating to a lack of engagement.

The Effect of Race and Area Deprivation on Symptom Profiles over the Course of Early-Stage Breast Cancer.

Purpose: This study compared common symptoms (fatigue, pain), overall physical functioning and changes over time between Black and White women receiving early-stage breast cancer (ESBC) chemotherapy. Methods: A longitudinal, repeated measures comparative design was employed. Time points of symptom measurement (PROMIS domains) at baseline, mid and end point were adjusted as per patient chemotherapy schedule. Analyses: Linear mixed models were applied. Results: There were 147 patients, 36% Black 64% White (54±12 years) recommended to receive early-stage breast cancer chemotherapy with adequate data for symptom analysis. Pain: Main effect of race was significant (F(1, 390) = 29.43, p<.001) for pain with Black patients experiencing significantly higher pain scores compared to White patients at pretherapy (Mean Difference; MD=3.7, p=.034), midpoint (MD=5.8, p=.002), and endpoint (MD=7.8, p<.001). Fatigue: Fatigue significantly increased (deteriorated) at endpoint (MDT1-T3= 8.7, p<.001) for Black patients. Among White patients, fatigue significantly increased at midpoint (MDT1-T2= 5.7) and at endpoint (MDT1-T3=10.1, p<.001; MDT2-T3=4.3, p= .017). Physical function: Black patients had significantly lower physical function scores compared to White patients at midpoint (MD=4.0, p=.027). Physical function decreased by endpoint in Black (MDT1-T3=7.8, p<.001), and White patients (MDT1-T3=7.7, p<.001). Conclusion: Symptom burden significantly increased over the course of chemotherapy for all patients. Scores for pain and physical function were higher overall for Black patients and deteriorated at a greater rate for Black vs. White women over the course of chemotherapy. This assessment holds implication for proactive assessment and mitigation strategies.

Association between trauma triage and time-to-vaso-occlusive events in patients with sickle cell disease after traumatic injury: a retrospective study.

Introduction: Sickle cell disease (SCD) is associated with vaso-occlusive events (VOEs) that can lead to disease complications, including early mortality. Given that similar inflammatory responses characterize VOE and traumatic injury, injured patients with SCD may be vulnerable to acute complications. This study is the first to examine whether traumatic injury is associated with increased severity of future VOEs. Methods: This cohort study was conducted using electronic health record data from an SCD clinic in Western Pennsylvania; 356 patients with SCD from January 2000 to July 2021 were identified via retrospective chart review. 55 patients were eligible based on continuous medical record data spanning 1 year preinjury and postinjury. Patients were sorted into three treatment groups based on injury management: (1) Neither triage to trauma team activation (TTA) nor inpatient admission (Early Discharge), (2) Triage but no inpatient admission (Triage Only), and (3) Triage and In-patient. Outcomes included time from injury to first VOE, annual VOE counts requiring an emergency department (ED) visit, and ED length of stay (LOS) for the first VOE after injury. Results: Early Discharge individuals experienced a VOE event within 2.93 days of injury, significantly shorter time to event than Triage and In-patient individuals at 52.375 days and Triage Only individuals at 100.16 days (p=0.0058). No difference in annual VOE counts was noted postinjury across all groups. However, a significant increase in VOE LOS preinjury (16.1 hours) to postinjury (77.4 hours) was noted only for the Triage Only group (p=0.038). Cox regression model showed that shortened time to VOE events was marginally associated with TTA status (p=0.06). Conclusion: Despite minimal changes in long-term VOE outcomes after injury, traumatic injuries may accelerate the time-to-VOE among the Early Discharge group. Therefore, future research is warranted to analyze whether the absence of postinjury triage assessment and intervention may cause unforeseen physiologic stressors contributing to VOE outcomes. Level of evidence: Level IV: retrospective case-control study with three negative criteria.

Psychometrics of the Sickle Cell Disease Health-Related Stigma Scale-Short Form.

Health-related stigma, a form of devaluation related to a health condition, is common in individuals with sickle cell disease (SCD). Pain is the hallmark symptom of SCD, and health-related stigma is often described during care-seeking for pain management. Few published instruments measure health-related stigma in individuals with SCD. This study builds on the psychometrics of the 30- and 40-item Sickle Cell Disease Health-Related Stigma Scale (SCD-HRSS). In a sample of 197 adults with SCD, the results support the reliability and validity of a 21-item scale, the SCD-HRSS-Short Form, with an overall Cronbach's alpha reliability of 0.91 and discriminant validity with the PROMIS-29 subscales (anxiety, depressive symptoms, pain interference, physical fatigue, sleep, and role satisfaction). A shorter yet reliable and valid scale may decrease the burden for this underrepresented, minoritized population while still providing important information regarding their experiences of stigmatization.

Bank Cards Might as Well Be Tarot Cards.

This comic compares a lack of price transparency in health care billing to psychic card readings.

Why Would Having Learned to Cope While Waiting for This Appointment Make This Pain Normal?

This comic investigates ethical dimensions of the experiences of patients whose pain has become normalized while waiting for clinical attention.

The Limits of Cognitive Reappraisal: Changing Pain Valence, but not Persistence, during a Resistance Exercise Task.

Physiological discomfort is commonly cited as a barrier for initiating and persisting with exercise. Although individuals may think of physiological discomfort as determined by physical sensations, it can also be influenced by cognitive and emotional factors. We explored the impacts of interpreting the purpose of pain as a sign of muscle building (helpful) vs. a sign of muscle tearing and possible injury (harmful) and tested the effect of cognitive reappraisals, or shifting interpretations of pain, on exercise persistence and the subjective experience of discomfort during exercise. Seventy-eight participants were randomized to listen to voice recordings that framed exercise-related pain as helpful vs. harmful before participating in a standard muscular endurance test using the YMCA protocol. Although the two experimental groups did not differ in the overall number of resistance training repetitions achieved, participants who were asked to think about the benefits (rather than the negative consequences) of pain reported less negative pain valence during exercise. Thus, the experience of pain was influenced by appraisals of the meaning of pain, but differences in pain valence did not impact exercise persistence. Theoretical implications and applications for affect-based exercise interventions are discussed.