A retrospective evaluation of inter-fraction motion in prostate cancer patients with involved nodes receiving prostate and pelvic ± para-aortic nodal irradiation.

INTRODUCTION: The inter-fraction motion of pelvic ± para-aortic (PA) nodal volumes in prostate cancer patients with involved nodes is yet to be quantified and the optimal IGRT strategy for these patients is currently unknown. METHODS: A single-centre retrospective evaluation was performed investigating inter-fraction motion in the prostate and involved nodal volumes of patients receiving pelvic ± PA nodal irradiation. Patients were selected for inclusion if they; were undergoing prostate + pelvic node +/- PA node radiation for prostate cancer with involved lymph nodes and had received daily online CBCT scans. The planning CT and subsequent CBCT images from each treatment fraction were selected for analysis. RESULTS: Out of 567 CBCTs, from 20 patients, there were no incidences where independent lymph node displacement was >0.5 cm from planning volumes. Lymph node motion relative to prostate was >0.5 cm on 15 occasions out of 567 scans (2.6%). Where the difference between prostate and lymph nodes was >0.5 cm, this was always a result of the rectum causing variation in the prostate position, not a change in nodal position. DISCUSSION: These results suggests that there is limited independent displacement between the involved pelvic ± PA nodal volumes and bony anatomy. Therefore, bony anatomy could be used as a lymph node match surrogate for prostate patients receiving nodal irradiation for active disease. The results also suggest additional emphasis should be placed on bowel preparation in these patients to reduce the risk of geographical miss. CONCLUSION: In conclusion, the results of this evaluation suggests that there is limited independent displacement between the involved pelvic ± PA nodal volumes and bony anatomy. This provides evidence to trials investigating the role of pelvic ± PA nodal irradiation to ensure appropriate margins and IGRT strategies are used when investigating this further.

Health Literacy, Individual and Community Engagement, and Cardiovascular Risks and Disparities: JACC: CardioOncology State-of-the-Art Review.

Cardiovascular and cancer outcomes intersect within the realm of cardio-oncology survivorship care, marked by disparities across ethnic, racial, social, and geographical landscapes. Although the clinical community is increasingly aware of this complex issue, effective solutions are trailing. To attain substantial public health impact, examinations of cancer types and cardiovascular risk mitigation require complementary approaches that elicit the patient's perspective, scale it to a population level, and focus on actionable population health interventions. Adopting such a multidisciplinary approach will deepen our understanding of patient awareness, motivation, health literacy, and community resources for addressing the unique challenges of cardio-oncology. Geospatial analysis aids in identifying key communities in need within both granular and broader contexts. In this review, we delineate a pathway that navigates barriers from individual to community levels. Data gleaned from these perspectives are critical in informing interventions that empower individuals within diverse communities and improve cardio-oncology survivorship.

Neighborhood racial income inequality and cognitive health.

INTRODUCTION: Neighborhood socioeconomic status (SES) has been linked to dementia, but the distribution of SES within a neighborhood may also matter. METHODS: Data from 460 (47% Black, 46% White) older adults from the Michigan Cognitive Aging Project were linked to census tract-level data from the National Neighborhood Data Archive (NaNDA). Neighborhood SES included two composites reflecting disadvantage and affluence. Neighborhood racial income inequality was the ratio of median incomes for White versus Black residents. Generalized estimating equations examined associations between neighborhood factors and cognitive domains. RESULTS: Neighborhood racial income inequality was uniquely associated with worse cognitive health, and these associations did not differ by participant race. Neighborhood disadvantage was only associated with worse cognitive health among Black participants. DISCUSSION: Both the level and racial distribution of SES within a neighborhood may be relevant for dementia risk. Racial differences in the level and impact of neighborhood SES contribute to dementia inequalities. HIGHLIGHTS: Black participants lived in neighborhoods with lower socioeconomic status (SES) than White participants, on average. Neighborhood SES and racial income inequality were associated with worse cognition. Effects of neighborhood racial income inequality did not differ across racial groups. Effects of neighborhood SES were only evident among Black participants.

Preoperative inflammatory biomarkers reveal renal involvement in postsurgical mortality in hip fracture patients: an exploratory study.

Background: Hip fractures in frail patients result in excess mortality not accounted for by age or comorbidities. The mechanisms behind the high risk of mortality remain undetermined but are hypothesized to be related to the inflammatory status of frail patients. Methods: In a prospective observational exploratory cohort study of hospitalized frail hip fracture patients, 92 inflammatory markers were tested in pre-operative serum samples and markers were tested against 6-month survival post-hip fracture surgery and incidence of acute kidney injury (AKI). After correcting for multiple testing, adjustments for comorbidities and demographics were performed on the statistically significant markers. Results: Of the 92 markers tested, circulating levels of fibroblast growth factor 23 (FGF-23) and interleukin-15 receptor alpha (IL15RA), both involved in renal disease, were significantly correlated with 6-month mortality (27.5% overall) after correcting for multiple testing. The incidence of postoperative AKI (25.4%) was strongly associated with 6-month mortality, odds ratio = 10.57; 95% CI [2.76-40.51], and with both markers plus estimated glomerular filtration rate (eGFR)- cystatin C (CYSC) but not eGFR-CRE. The effect of these markers on mortality was significantly mediated by their effect on postoperative AKI. Conclusion: High postoperative mortality in frail hip fracture patients is highly correlated with preoperative biomarkers of renal function in this pilot study. The effect of preoperative circulating levels of FGF-23, IL15RA, and eGFR-CYSC on 6-month mortality is in part mediated by their effect on postoperative AKI. Creatinine-derived preoperative renal function measures were very poorly correlated with postoperative outcomes in this group.

Generalisation of Social Communication Skills by Autistic Children During Play-Based Assessments Across Home, School and an Unfamiliar Research Setting.

We investigated autistic children's generalisation of social communication over time across three settings during a play-based assessment with different adults and explore the potential moderating effects on generalisation of age, nonverbal IQ and level of restricted and repetitive behaviours. The social communication abilities of 248 autistic children (2-11 years, 21% female, 22% single parent, 60% white) from three UK sites were assessed from 1984 video interactions in three contexts with three different interaction partners (parent/home, teaching assistant/school, researcher/clinic) at baseline, midpoint (+ 7m) and endpoint (+ 12m) within the Paediatric Autism Communication Trial-Generalised (PACT-G), a parent-mediated social communication intervention. Children's midpoint social communication at home generalised to school at midpoint and to clinic at endpoint. Generalisation was stronger from home to school and clinic than school to home and clinic. Generalisation was not moderated by age, nonverbal IQ or restricted and repetitive behaviour. Broader child development did not explain the pattern of results. The current study is the largest study to date to explore generalisation with autistic children and provides novel insight into their generalisation of social communication skills. Further research is needed to gain a more comprehensive understanding of facilitators of generalisation across settings and interaction partners in order to develop targeted strategies for interventions to enhance outcomes for young autistic children.

Macroergonomic components of the patient work system shaping dyadic care management during adolescence: a case study of type 1 diabetes.

The role of the social, physical, and organisational environments in shaping how patients and their caregivers perform work remains largely unexplored in human factors/ergonomics literature. This study recruited 19 dyads consisting of a parent and their child with type 1 diabetes to be interviewed individually and analysed using a macroergonomic framework. Our findings aligned with the macroergonomic factors as presented in previous models, while highlighting the need to expand upon certain components to gain a more comprehensive representation of the patient work system as relevant to dyadic management. Examples of design efforts that should follow from these findings include expanding existing data sharing options to include information from the external environment and capitalising on the capabilities of artificial intelligence as a decision support system. Future research should focus on longitudinally assessing patient work systems throughout transition periods in addition to more explicitly exploring the roles of social network members.

Work performed by patients and their caregivers is shaped by the social, physical, and organisational contexts they are embedded within. This paper explored how adolescents with type 1 diabetes managed their health alongside their parents in the context of these macroergonomic factors. These findings have implications for research and design.

Birth outcomes in relation to neighborhood food access and individual food insecurity during pregnancy in the Environmental Influences on Child Health Outcomes (ECHO)-wide cohort study.

BACKGROUND: Limited access to healthy foods, resulting from residence in neighborhoods with low-food access or from household food insecurity, is a public health concern. Contributions of these measures during pregnancy to birth outcomes remain understudied. OBJECTIVES: We examined associations between neighborhood food access and individual food insecurity during pregnancy with birth outcomes. METHODS: We used data from 53 cohorts participating in the nationwide Environmental Influences on Child Health Outcomes-Wide Cohort Study. Participant inclusion required a geocoded residential address or response to a food insecurity question during pregnancy and information on birth outcomes. Exposures include low-income-low-food-access (LILA, where the nearest supermarket is >0.5 miles for urban or >10 miles for rural areas) or low-income-low-vehicle-access (LILV, where few households have a vehicle and >0.5 miles from the nearest supermarket) neighborhoods and individual food insecurity. Mixed-effects models estimated associations with birth outcomes, adjusting for socioeconomic and pregnancy characteristics. RESULTS: Among 22,206 pregnant participants (mean age 30.4 y) with neighborhood food access data, 24.1% resided in LILA neighborhoods and 13.6% in LILV neighborhoods. Of 1630 pregnant participants with individual-level food insecurity data (mean age 29.7 y), 8.0% experienced food insecurity. Residence in LILA (compared with non-LILA) neighborhoods was associated with lower birth weight [ß -44.3 g; 95% confidence interval (CI): -62.9, -25.6], lower birth weight-for-gestational-age z-score (-0.09 SD units; -0.12, -0.05), higher odds of small-for-gestational-age [odds ratio (OR) 1.15; 95% CI: 1.00, 1.33], and lower odds of large-for-gestational-age (0.85; 95% CI: 0.77, 0.94). Similar findings were observed for residence in LILV neighborhoods. No associations of individual food insecurity with birth outcomes were observed. CONCLUSIONS: Residence in LILA or LILV neighborhoods during pregnancy is associated with adverse birth outcomes. These findings highlight the need for future studies examining whether investing in neighborhood resources to improve food access during pregnancy would promote equitable birth outcomes.

Decision-Making in Surgery.

Surgeons face unique challenges in perioperative decision-making and communication with patients and families. In cardiothoracic surgery, the stakes are high, life and death decisions must be made quickly, and surgeons often lack a longstanding relationship with patients and families prior to intervention. This review considers specific challenges in the preoperative period followed by those faced postoperatively. While preoperative deliberation and informed consent focus on reaching a decision between 2 or more alternative approaches, the most vexing postoperative decisions often involve the patient's discontent with the best-case outcome or how to ensure goal-concordant care when complications arise. This review explores the preoperative ethical and legal requirement for informed consent by describing the contemporary preferred method, shared decision-making. We also present a framework to optimize surgeon communication and promote patient and family engagement in the setting of high-risk surgery for older patients with serious illness. In the postoperative period the family is often tasked with deciding what to do about major complications when the patient has lost decision-making capacity. We discuss several examples and offer strategies for surgeons to navigate these challenging situations. We also explore the concepts of clinical heroism and futility in relation to communicating with patients and families about the outcomes of surgery. Persistent ethical challenges in decision-making suggest that surgeons should improve their skills in communicating with patients to better engage with them, both before and after surgery.

Insights From Implementation Of A Community-Based Model For Collaborative Public Good Investing.

Communities across the United States are looking for ways to reduce health inequities. Improving the social determinants of health (SDOH) is one fruitful pathway. In prior work we developed a financing model to incentivize and coordinate joint SDOH investments among local stakeholders, called the Collaborative Approach to Public Good Investments (CAPGI). A core thesis of our model is that at least some SDOH investments can be funded without reliance on philanthropic or government monies: Because they can produce value that flows to multiple organizations simultaneously, SDOH investments can be aligned with health organizations' self-interest. We describe our model's evolution in practice and synthesize insights drawn from our experiences providing technical assistance to three communities that have implemented CAPGI. Each community is unique, but we identified common themes related to governance processes and coalition dynamics that are relevant to any community trying to increase local, place-based investments in health.

Children's physical activity and sedentary behaviour in before school care: An observational study.

OBJECTIVE: In Australia, less than one quarter of children aged 5-12 years meet national physical activity (PA) guidelines. Before school care operates as part of Out of School Hours Care (OSHC) services and provide opportunities for children to meet their daily PA recommendations. The aim of this study was to explore factors associated with children meeting 15 min of moderate-to-vigorous-intensity physical activity (MVPA) while attending before school care. METHODS: A cross-sectional study was conducted in 25 services in New South Wales, Australia. Each service was visited twice between March and June 2021. Staff behaviours and PA type and context were captured using staff interviews and the validated System for Observing Staff Promotion of Physical Activity and Nutrition (SOSPAN) time sampling tool. Child PA data were collected using Actigraph accelerometers and associations between program practices and child MVPA analysed. RESULTS: PA data were analysed for 654 children who spent an average of 39.2% (±17.6) of their time sedentary; 45.4% (±11.4) in light PA; and 14.9% (±11.7) in MVPA. Only 17% of children (n = 112) reached ≥15 min MVPA, with boys more likely to achieve this. Children were more likely to meet this recommendation in services where staff promoted and engaged in PA; PA equipment was available; children were observed in child-led free play; and a written PA policy existed. CONCLUSIONS: Before school care should be supported to improve physical activity promotion practices by offering staff professional development and guidance on PA policy development and implementation practices.

Coronavirus Disease 2019 (COVID-19) Vaccination and Assisted Reproduction Outcomes: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the association between coronavirus disease 2019 (COVID-19) vaccination and female assisted reproduction outcomes through a systematic review and meta-analysis. DATA SOURCES: We searched Medline (OVID), EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov on January 11, 2023, for original articles on assisted reproduction outcomes after COVID-19 vaccination. The primary outcome was rates of clinical pregnancy; secondary outcomes included number of oocytes retrieved, number of mature oocytes retrieved, fertilization rate, implantation rate, ongoing pregnancy rate, and live-birth rate. METHODS OF STUDY SELECTION: Two reviewers independently screened citations for relevance, extracted pertinent data, and rated study quality. Only peer-reviewed published studies were included. TABULATION, INTEGRATION, AND RESULTS: Our query retrieved 216 citations, of which 25 were studies with original, relevant data. Nineteen studies reported embryo transfer outcomes, with a total of 4,899 vaccinated and 13,491 unvaccinated patients. Eighteen studies reported data on ovarian stimulation outcomes, with a total of 1,878 vaccinated and 3,174 unvaccinated patients. There were no statistically significant results among our pooled data for any of the primary or secondary outcomes: clinical pregnancy rate (odds ratio [OR] 0.94, 95% CI 0.88-1.01, P =.10), number of oocytes retrieved (mean difference -0.26, 95% CI -0.68 to 0.15, P =.21), number of mature oocytes retrieved (mean difference 0.31, 95% CI -0.14 to 0.75, P =.18), fertilization rate (OR 0.99, 95% CI 0.87-1.11, P =.83), implantation rate (OR 0.92, 95% CI 0.84-1.00, P =.06), ongoing pregnancy rate (OR 0.95, 95% CI 0.86-1.06, P =.40), or live-birth rate (OR 0.95, 95% CI 0.78-1.17, P =.63). A subanalysis based on country of origin and vaccine type was also performed for the primary and secondary outcomes and did not change the study results. CONCLUSION: Vaccination against COVID-19 is not associated with different fertility outcomes in patients undergoing assisted reproductive technologies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42023400023.

Automated Messaging Delivered Alongside Behavioral Treatment for Weight Loss: Qualitative Study.

BACKGROUND: Mobile health interventions for weight loss frequently use automated messaging. However, this intervention modality appears to have limited weight loss efficacy. Furthermore, data on users' subjective experiences while receiving automated messaging-based interventions for weight loss are scarce, especially for more advanced messaging systems providing users with individually tailored, data-informed feedback. OBJECTIVE: The purpose of this study was to characterize the experiences of individuals with overweight or obesity who received automated messages for 6-12 months as part of a behavioral weight loss trial. METHODS: Participants (n=40) provided Likert-scale ratings of messaging acceptability and completed a structured qualitative interview (n=39) focused on their experiences with the messaging system and generating suggestions for improvement. Interview data were analyzed using thematic analysis. RESULTS: Participants found the messages most useful for summarizing goal progress and least useful for suggesting new behavioral strategies. Overall message acceptability was moderate (2.67 out of 5). From the interviews, 2 meta-themes emerged. Participants indicated that although the messages provided useful reminders of intervention goals and skills, they did not adequately capture their lived experiences while losing weight. CONCLUSIONS: Many participants found the automated messages insufficiently tailored to their personal weight loss experiences. Future studies should explore alternative methods for message tailoring (eg, allowing for a higher degree of participant input and interactivity) that may boost treatment engagement and efficacy. TRIAL REGISTRATION: ClinicalTrials.gov NCT05231824; https://clinicaltrials.gov/study/NCT05231824.

Trust in Health Care and Science: Toward Common Ground on Key Concepts.

This essay summarizes key insights across the essays in the Hastings Center Report's special report "Time to Rebuild: Essays on Trust in Health Care and Science." These insights concern trust and trustworthiness as distinct concepts, competence as a necessary but not sufficient input to trust, trust as a reciprocal good, trust as an interpersonal as well as structural phenomena, the ethical impermissibility of seeking to win trust without being trustworthy, building and borrowing trust as distinct strategies, and challenges to trustworthiness posed by the contingent nature of science. Together, these insights stand to advance an area of research that we believe has been historically stymied by conceptual confusion and a long-standing insistence on treating trust as a purely instrumental good.

Surgical Resection in Nontuberculous Mycobacterial Pulmonary Disease.

Rates of nontuberculous mycobacterial pulmonary disease are increasing worldwide, particularly in the United States and other developed countries. While multidrug antimicrobial therapy is the mainstay of treatment, surgical resection has emerged as an important adjunct. In this article, we will review the indications for surgery, preoperative considerations, surgical techniques, and postoperative outcomes.

Does missing trust lead to overuse or underuse of health care services?

Research about mistrust in health care often relies on the narrative that lacking trust causes underuse of health care services. This narrative seemed to hold up in the COVID-19 pandemic era, when mistrust in systems and providers led to widely recognized vaccine hesitancy and reluctance to seek care. In this review, we suggest that the "mistrust leads to underuse" narrative is important but incomplete, as mistrust in health care may also cause patients to overuse health care services. We searched the literature for studies, meta-analyses, and interviews that assessed the effect of patient trust on health care utilization. Although overuse literature is sparse, surveys and physician interviews indicate that patients who do not trust their clinicians may seek multiple opinions on the same diagnosis and utilize more costly interventions that are not recommended. Physicians also report being more likely to utilize extraneous tests and medications when patients do not trust them. Hence, problems of trust may lead to both underuse and overuse of health care services. We postulate several factors that may influence whether a mistrustful patient underuses or overuses health care resources, including personal characteristics, environmental characteristics, and levels of analysis, and we encourage more investigation about mistrust and health care overutilization.

The role of self-compassion and its individual components in adaptive responses to dietary lapses.

Dietary lapses (i.e., instances of dietary non-adherence) are common during weight loss attempts, and compromise success in two ways: increasing caloric intake and demoralizing the participant, sometimes leading them to abandon their weight control goals altogether. Efforts to understand and prevent demoralization have received almost no research attention. Self-compassion has high potential to promote adaptive responses to these setbacks because it reframes "failure" and promotes self-improvement. Past research shows that when participants experience a lapse, those practicing higher self-compassion report higher self-efficacy and intentions to continue dieting. The current study extended this literature to examine whether self-compassion in response to a lapse would predict lower likelihood of a subsequent same-day lapse and greater reports of perceived control over weight management behaviors. We also examined whether the individual facets of self-compassion, including self-kindness (treating oneself the way one would a friend); common humanity (the understanding that everyone has struggles); and mindfulness (non-judgmental awareness of thoughts and feelings) are associated with these outcomes. Participants (N = 140) enrolled in a behavioral weight loss trial completed 6 ecological momentary assessment (EMA) surveys a day for seven days. Total self-compassion and each facet of self-compassion individually were all associated with less negative affect after a lapse. None of the self-compassion variables predicted the likelihood of participants reporting a lapse again that day. However, higher total self-compassion and higher self-kindness after a lapse were both associated with greater perceived self-control over weight management behaviors in the hours following. Common humanity and mindfulness, respectively, were not associated with reports of perceived control. Results suggest that self-compassion following dieting setbacks may prevent goal disengagement, and that self-kindness is the facet most strongly associated with adaptive responses to these setbacks.

A quantitative assessment of the extent and distribution of textile fibre transfer to persons involved in physical assault.

Knowledge of the number of fibres transferred during a particular activity is essential for the interpretation of findings in similar criminal cases. In this regard, violent contacts and physical assaults still present a challenge, due to a lack of robust published data. Hereby, we present the outcome of an empirical study where different assault activities were simulated by a Jiu Jitsu team and participants were asked to play either the role of an aggressive 'assailant' or a defensive 'victim', wearing cotton garments (i.e., Gi's). Four different scenarios were simulated in replicates (n = 5), each of them involving different intensity levels (low and high) and duration times (30 and 60 s). Results showed that approximately 1,000 to 44,000 fibres were cross-transferred between the participants' garments, with noticeable differences between the different scenarios. These values were significantly larger than those published in previous studies and, therefore, suggested the possibility of a current underestimation of the number of fibres transferred in physical assaults. Furthermore, statistical analysis by ANOVA indicated that the all the variables tested (i.e., intensity level, duration time, and participants role) had a significant effect on the number of transferred fibres (p < 0.001) and, consequently, that some knowledge of the case circumstances may be important to make more educated estimations. This is the first time that such a methodology has been applied for the quantitative assessment of fibre transfer between participants in assault activities. Data are expected to help practitioners with the interpretation of findings in real casework and lead to a more robust evidential assessment.

The Effect of Doulas on Maternal and Birth Outcomes: A Scoping Review.

A source of support during birth could be the solution to negative outcomes for the mother and her baby. To improve the birthing experience and increase positive birthing outcomes, sources of support during pregnancy should be evaluated and understood. The goal of this review was to synthesize the existing literature on how doulas might improve birth outcomes. This scoping review also aimed to shed light on the positive impact emotional support during childbirth can have on the health and well-being of mother and child. PubMed and EBSCOhost were used to identify articles using the search words with Boolean operators "doulas" AND "labor support" AND "birth outcomes" AND "pregnancy" AND "effects during labor." The eligibility criteria for article selection included primary studies investigating how doulas contributed to birth outcomes. The studies in this review indicated that doula guidance in perinatal care was associated with positive delivery outcomes including reduced cesarean sections, premature deliveries, and length of labor. Moreover, the emotional support provided by doulas was seen to reduce anxiety and stress. Doula support, specifically in low-income women, was shown to improve breastfeeding success, with quicker lactogenesis and continued breastfeeding weeks after childbirth. Doulas can be a great resource for birthing mothers, and consideration should be given to using them more, as they may have a positive impact on the well-being of the mother and child. This study raised questions about the accessibility of doulas and how they may help mitigate health disparities among women from different socioeconomic levels.