A pre-existing Toxoplasma gondii infection exacerbates the pathophysiological response and extent of brain damage after traumatic brain injury in mice.

Traumatic brain injury (TBI) is a key contributor to global morbidity that lacks effective treatments. Microbial infections are common in TBI patients, and their presence could modify the physiological response to TBI. It is estimated that one-third of the human population is incurably infected with the feline-borne parasite, Toxoplasma gondii, which can invade the central nervous system and result in chronic low-grade neuroinflammation, oxidative stress, and excitotoxicity-all of which are also important pathophysiological processes in TBI. Considering the large number of TBI patients that have a pre-existing T. gondii infection prior to injury, and the potential mechanistic synergies between the conditions, this study investigated how a pre-existing T. gondii infection modified TBI outcomes across acute, sub-acute and chronic recovery in male and female mice. Gene expression analysis of brain tissue found that neuroinflammation and immune cell markers were amplified in the combined T. gondii + TBI setting in both males and females as early as 2-h post-injury. Glutamatergic, neurotoxic, and oxidative stress markers were altered in a sex-specific manner in T. gondii + TBI mice. Structural MRI found that male, but not female, T. gondii + TBI mice had a significantly larger lesion size compared to their uninfected counterparts at 18-weeks post-injury. Similarly, diffusion MRI revealed that T. gondii + TBI mice had exacerbated white matter tract abnormalities, particularly in male mice. These novel findings indicate that a pre-existing T. gondii infection affects the pathophysiological aftermath of TBI in a sex-dependent manner, and may be an important modifier to consider in the care and prognostication of TBI patients.

A historical review of pain disparities research: Advancing toward health equity and empowerment.

BACKGROUND AND PURPOSE: This theory-guided review draws on 30 years of published data to examine and interrogate the current and future state of pain disparities research. METHODS: Using the Hierarchy of Health Disparity Research framework, we synthesize and present an overview of "three generations" of pain disparities scholarship, while proposing directions for adopting a "fourth generation" that redefines, explains, and theorizes future pain disparities research in a diverse society. DISCUSSION: Prior research has focused on describing the scope of disparities, and throughout the historical context of human existence, racialized groups have been subjected to inadequate pain care. It is imperative that research not only illuminates existing problems but also provides solutions that can be implemented and sustained across varying social milieus. CONCLUSION: We must invest in new theoretical models that expand on current perspectives and ideals that position all individuals at the forefront of justice and equity in their health.

Catastrophic consequences: can the feline parasite Toxoplasma gondii prompt the purrfect neuroinflammatory storm following traumatic brain injury?

Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality worldwide; however, treatment development is hindered by the heterogenous nature of TBI presentation and pathophysiology. In particular, the degree of neuroinflammation after TBI varies between individuals and may be modified by other factors such as infection. Toxoplasma gondii, a parasite that infects approximately one-third of the world's population, has a tropism for brain tissue and can persist as a life-long infection. Importantly, there is notable overlap in the pathophysiology between TBI and T. gondii infection, including neuroinflammation. This paper will review current understandings of the clinical problems, pathophysiological mechanisms, and functional outcomes of TBI and T. gondii, before considering the potential synergy between the two conditions. In particular, the discussion will focus on neuroinflammatory processes such as microglial activation, inflammatory cytokines, and peripheral immune cell recruitment that occur during T. gondii infection and after TBI. We will present the notion that these overlapping pathologies in TBI individuals with a chronic T. gondii infection have the strong potential to exacerbate neuroinflammation and related brain damage, leading to amplified functional deficits. The impact of chronic T. gondii infection on TBI should therefore be investigated in both preclinical and clinical studies as the possible interplay could influence treatment strategies.

Health behaviors and related disparities of insured adults with a health care provider in the United States, 2015-2016.

Health care providers are in a unique position to address patients' health behaviors and social determinants of health, factors like income and social support that can significantly impact health. There is a need to better understand the risk behaviors of a population that providers may counsel (i.e., those who are insured and have a provider.) Using the 2015 and 2016 CDC's Behavioral Risk Factor Surveillance System, we examine the prevalence of health behaviors and the existence of disparities in health behaviors based on social determinants among American adults. Our sample included noninstitutionalized adults aged 18 to 64 years, in the U.S. (N > 300,000). We used multivariate logistic regression analysis to assess the independent effects of income, education, sex, race, and metropolitan status on nine key health behaviors. Among adults with insurance and a provider (n > 200,000): 1) rates of engaging in poor health behaviors ranged from 6.4% (heavy drinking) to 68.1% (being overweight or obese), 2) rural residence, lower income, and lower education were associated with decreased clinical preventive services, 3) lower income and lower education were associated with lifestyle-related risks, and 4) being black was associated with receiving more cancer screenings, no influenza vaccination, inadequate physical activity, and being overweight or obese. Insured adults, with a provider, are not meeting recommended guidelines for health behaviors. Significant disparities in health behaviors related to social factors exist among this group. Health care providers and organizations may find it helpful to consider these poor health behaviors and disparities when determining strategies to address SDOH.

Association of multiple chronic conditions and pain among older black and white adults with diabetes mellitus.

BACKGROUND: Aging is often associated with the challenge of navigating daily tasks with a painful chronic medical illness. Yet, there is concern of the number of older adults impacted with more than one chronic condition. Despite the increasing number of adults diagnosed with diabetes and comorbid chronic illnesses, there remains a lack of understanding in how multiple illnesses relate to experiences of pain. To assess the association between multiple chronic conditions and pain, this study aimed to identify clusters of chronic medical conditions and their association with pain among a sample of older Black and White adults diagnosed with diabetes. METHODS: Two hundred and thirty-six participants responded to a series of questions assessing pain frequency and severity, as well as health and social characteristics. A factor analysis was used to categorize clusters of medical conditions, and multiple regression models were used to examine predictors of pain. RESULTS: Seven of the assessed chronic medical conditions loaded on three factors, and accounted for 57.2% of the total variance, with heart disease (factor 1) accounting for 21.9%, musculoskeletal conditions (factor 2) for another 18.4%, and factor 3 (microvascular diseases) accounting for a final 16.9% of the variability among the chronic medical conditions. Covariate-adjusted models showed that fewer years of education and higher scores on the microvascular and musculoskeletal conditions factors were associated with higher pain frequency, with the musculoskeletal conditions factor being the strongest predictor. CONCLUSIONS: Findings from this study compliment existent literature underscoring the prevalence and importance of comorbid diagnoses in relation to pain. Examining health-related factors beyond a single disease diagnosis also provides an opportunity to explore underlying disease co-occurrences that may persist beyond organ system classifications.

Balance and Falls in Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Prospective Study.

Individuals with chronic obstructive pulmonary disease (COPD) have demonstrated balance impairment and a higher fall incidence. However, these have not been investigated in acute exacerbations of the disease (ECOPD). This study evaluates balance in patients during an ECOPD compared to stable COPD and healthy controls, and examines the fall incidence rate after hospitalisation due to ECOPD compared to individuals with stable COPD. Balance performance of 26 hospitalised patients with ECOPD was compared to 26 community-dwelling participants with stable COPD and 25 matched healthy controls. Balance was evaluated using computerised posturography and the Berg Balance Scale (BBS). Prospective falls were monitored by monthly calendars for 12 months in both COPD groups. Compared to controls, greater balance impairment was observed during ECOPD for most posturography variables across standing conditions (p ≤ 0.05). Both COPD groups had worse BBS scores (p ≤ 0.05) compared to controls. Increased dyspnoea and reduced quadriceps' strength were associated with impaired balance performance. A higher fall incidence (1.76 falls/person/year) was observed following hospitalisation in patients with ECOPD compared to stable COPD (0.53 falls/person/year) at 12 months. Patients with ECOPD demonstrate balance impairments which are associated with increased dyspnoea and reduced muscle strength. Balance impairment during ECOPD may contribute to a high incidence of falls following hospitalisation.

The Relationship between Pain, Disability, and Sex in African Americans.

Older African Americans consistently report diminished capacities to perform activities of daily living (ADL) compared with other racial groups. The extent to which bodily pain is related to declining abilities to perform ADL/ADL disability in African Americans remains unclear, as does whether this relationship exists to the same degree in African American men and women. For nurses to provide optimal care for older African Americans, a better understanding of the relationship between bodily pain and ADL disability and how it may differ by sex is needed. The aim of this study was to examine whether pain, age, education, income, marital status and/or comorbid conditions were associated with ADL disabilities in older African American women and men. This was a cross-sectional descriptive study. The sample included 598 participants (446 women, 152 men) from the first wave of the Baltimore Study on Black Aging. African American women (odds ratio [OR] = 4.06; 95% confidence interval [CI] 2.63-6.26) and African American men (OR = 6.44; 95% CI = 2.84-14.57) who reported bodily pain had greater ADL disability than those who did not report bodily pain. Having two or more comorbid conditions also was significantly associated with ADL disability in African American women (OR = 3.95; 95% CI: 2.09-7.47). Further work is needed to understand pain differences between older African American women and men to develop interventions that can be tailored to meet the individual pain needs of both groups.

Unresolved Pain Interference among Colorectal Cancer Survivors: Implications for Patient Care and Outcomes.

OBJECTIVE: Using a large sample of colorectal cancer (CRC) survivors we 1) describe pain interference (PI) prevalence across the cancer continuum; 2) identify demographic and clinical factors associated with PI and changes in PI; and 3) examine PI's relationship with survivors' job changes. METHODS: CRC participants of the Cancer Care Outcomes Research and Surveillance Consortium completed surveys during the initial phase of care (baseline, < 1 year, n = 2,961) and follow-up (about 1-year postdiagnosis, n = 2,303). PI was measured using the SF-12 item. Multiple logistic regression was used to identify predictors of PI. Model 1 evaluated moderate/high PI at baseline, Model 2 evaluated new/continued/increasing PI postdiagnosis follow-up, and Model 3 restricted to participants with baseline PI (N = 603) and evaluated predictors of equivalent/increasing PI. Multivariable logistic regression was also used to examine whether PI predicted job change. RESULTS: At baseline and follow-up, 24.7% and 23.7% of participants reported moderate/high PI, respectively. Among those with baseline PI, 46% had equivalent/increasing PI at follow-up. Near diagnosis and at follow-up, female gender, comorbidities, depression, chemotherapy and radiation were associated with moderate/high PI while older age was protective of PI. Pulmonary disease and heart failure comorbidities were associated with equivalent/increasing PI. PI was significantly associated with no longer having a job at follow-up among employed survivors. CONCLUSION: Almost half of survivors with PI during the initial phase of care had continued PI into post-treatment. Comorbidities, especially cardiovascular and pulmonary conditions, contributed to continued PI. PI may be related to continuing normal activities, that is, work, after completed treatment.

Experience and knowledge of pain management in patients receiving outpatient cancer treatment: what do older adults really know about their cancer pain?

OBJECTIVE: An individual's ability to effectively manage their cancer pain is influenced by knowledge and perceptions regarding the pain experience. While significance of the physician's knowledge of cancer pain management has been reported, much less is known how a patient's knowledge may influence their ability to optimally manage their pain. The purpose of this study is to determine the influence health and social factors have on the knowledge and experience of cancer pain among older adults. DESIGN: A prospective cross-sectional study of older Black and White patients presenting for outpatient cancer treatment. METHODS: Participants were surveyed on questions assessing pain severity, knowledge and experience of pain, self-efficacy for pain treatment, satisfaction with pain treatment, and additional social, health, and demographic characteristics. A series of hierarchical regression models were specified to examine predictors of cancer pain knowledge and experience. RESULTS: Education, race, and trust were significant predictors of pain knowledge, whereas self-efficacy for pain, pain interference, and pain severity were indicators of the experience of cancer pain. CONCLUSIONS: Knowledge and experience of (cancer) pain are contingent upon a myriad of social and clinical factors that are not exclusive but rather coexisting determinants of health. Understanding older adults' knowledge of pain may begin to diminish the imparities in the diagnosis and treatment of pain among this growing diverse population of older adults. It may similarly allow for programs to be tailored to fit the specific needs of the patient in the treatment and management of their cancer pain.

Certified nursing assistants' perspectives of nursing home residents' pain experience: communication patterns, cultural context, and the role of empathy.

This study explored the following issues related to pain management among nursing home (NH) residents: 1) communication patterns between NH residents and certified nursing assistants (CNAs) about pain; 2) how race and ethnicity influence NH residents' pain experiences; and 3) CNAs' personal experiences with pain that may affect their empathy toward the resident's pain experience. The study consisted of a convenience sample of four focus groups (n = 28) from a NH in central Florida. A content analysis approach was used. Data were analyzed with the use of Atlas.ti version 6.2. The content analysis identified four main themes: 1) attitudes as barriers to communication about resident pain care; 2) cultural, religious, and gender influences of resident pain care by CNAs; 3) the role of empathy in CNAs care of residents with pain; and 4) worker strategies to detect pain. Attitudes among CNAs about resident cognitive status and perceived resident burden need to be recognized as barriers to the detection and reporting of pain by CNAs and should be addressed. In addition, NHs should consider a person-centered approach to pain that is culturally competent given the cultural influences of both residents and staff. Finally, educational programs for CNAs that include empathy-inducing scenarios could potentially improve the care provided by CNAs when dealing with residents' pain.

Sleep behaviors in older African American females reporting nonmalignant chronic pain: understanding the psychosocial implications of general sleep disturbance.

This study examined factors that influence sleep quality in older African American women (N = 181) reporting chronic pain. Participants completed a series of questions assessing demographic and behavioral characteristics, health status, pain intensity, and sleep disturbance. Findings indicated that younger participants and those experiencing poorer physical functioning reported more difficulty sleeping due to pain. Similarly, participants who reported being awakened from sleep due to pain were younger and experienced greater pain intensity. Understanding the relationship between sleep and pain in this group of women may be useful in promoting effective disease management and sleep awareness among patients, caregivers, and healthcare professionals.

The Need to Appear Healthy: Concealment of Chronic Illness, Privacy, and Self-Sufficiency Among Chronically Ill Older Nigerians.

Background and Objectives: Prior research has highlighted the beneficial impact of social networks and social support on older adults' physical and psychosocial well-being. However, the impact of the relationship between chronic illness and social networks on the psychosocial well-being of older Nigerians remains understudied. This study explored how older Nigerians with chronic illnesses navigate the physical, mental, and emotional changes due to their chronic disease diagnosis within their social contexts. Research Design and Methods: The current qualitative study used semistructured in-depth interviews with 19 purposively sampled older adults, aged 50 years and over, chronically ill, and receiving clinical care to examine the role of social networks in how chronically ill older Nigerians cope with their diagnosis. Results: Three main themes reflecting participants' experiences emerged from the findings: (1) closely knit circles, (2) privacy and self-sufficiency, and (3) body image. Results show that chronically ill older Nigerians prefer to keep the knowledge of their conditions strictly within their close family circles. It was considered horrific to inform friends, community members, and religious groups about one's chronic illness. Findings further reveal that the need to appear healthy to one's social network stems from the fear of being discriminated against and attempts to maintain some level of normalcy when interacting with others. Additionally, feelings of inferiority and shame limited their participation in social activities and social network maintenance. Discussion and Implications: We discuss the implications of the results for the mental well-being and quality of life of chronically ill older Nigerians and make recommendations for policies and resources that can improve the well-being of chronically ill Nigerians.

Treatment with the vascular endothelial growth factor-A antibody, bevacizumab, has sex-specific effects in a rat model of mild traumatic brain injury.

Mild traumatic brain injury (mTBI) involves damage to the cerebrovascular system. Vascular endothelial growth factor-A (VEGF-A) is an important modulator of vascular health and VEGF-A promotes the brain's ability to recover after more severe forms of brain injury; however, the role of VEGF-A in mTBI remains poorly understood. Bevacizumab (BEV) is a monoclonal antibody that binds to VEGF-A and neutralises its actions. To better understand the role of VEGF-A in mTBI recovery, this study examined how BEV treatment affected outcomes in rats given a mTBI. Adult Sprague-Dawley rats were assigned to sham-injury + vehicle treatment (VEH), sham-injury + BEV treatment, mTBI + VEH treatment, mTBI + BEV treatment groups. Treatment was administered intracerebroventricularly via a cannula beginning at the time of injury and continuing until the end of the study. Rats underwent behavioral testing after injury and were euthanized on day 11. In both females and males, BEV had a negative impact on cognitive function. mTBI and BEV treatment increased the expression of inflammatory markers in females. In males, BEV treatment altered markers related to hypoxia and vascular health. These novel findings of sex-specific responses to BEV and mTBI provide important insights into the role of VEGF-A in mTBI.

The ATR inhibitor ceralasertib potentiates cancer checkpoint immunotherapy by regulating the tumor microenvironment.

The Ataxia telangiectasia and Rad3-related (ATR) inhibitor ceralasertib in combination with the PD-L1 antibody durvalumab demonstrated encouraging clinical benefit in melanoma and lung cancer patients who progressed on immunotherapy. Here we show that modelling of intermittent ceralasertib treatment in mouse tumor models reveals CD8+ T-cell dependent antitumor activity, which is separate from the effects on tumor cells. Ceralasertib suppresses proliferating CD8+ T-cells on treatment which is rapidly reversed off-treatment. Ceralasertib causes up-regulation of type I interferon (IFNI) pathway in cancer patients and in tumor-bearing mice. IFNI is experimentally found to be a major mediator of antitumor activity of ceralasertib in combination with PD-L1 antibody. Improvement of T-cell function after ceralasertib treatment is linked to changes in myeloid cells in the tumor microenvironment. IFNI also promotes anti-proliferative effects of ceralasertib on tumor cells. Here, we report that broad immunomodulatory changes following intermittent ATR inhibition underpins the clinical therapeutic benefit and indicates its wider impact on antitumor immunity.

A progressive agenda toward equity in pain care.

Background: There are inconsistencies documenting the pain experience of Black adults and other racially minoritized populations. Often disregarded, pain among these groups is characterized by misconceptions, biases, and discriminatory practices, which may lead to inequitable pain care. Methods: To address this issue, this professional commentary provides an overview of pain reform and the need to declare chronic pain as a critical public health issue, while requiring that equity be a key focus in providing comprehensive pain screening and standardizing epidemiological surveillance to understand the prevalence and incidence of pain. Results and Conclusions: This roadmap is a call to action for all sectors of research, practice, policy, education, and advocacy. More importantly, this progressive agenda is timely for all race and other marginalized groups and reminds us that adequate treatment of pain is an obligation that cannot be the responsibility of one person, community, or institution, but rather a collective responsibility of those willing to service the needs of all individuals.

Interrupting Biases in the Experience and Management of Pain Nurses can help address challenges faced by racially and ethnically diverse patients and caregivers.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. The articles in this new installment of the series provide practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Booker, S.Q., et al. Interrupting Biases in the Experience and Management of Pain. Am J Nurs 2022; 122(9): 48-54.

Sociocultural and Economic Disparities in Physical Therapy Utilization Among Insured Older Adults With Rheumatoid Arthritis.

OBJECTIVE: To examine influences of sociocultural and economic determinants on physical therapy (PT) utilization for older adults with rheumatoid arthritis (RA). METHODS: In these annual cross-sectional analyses between 2012 and 2016, we accessed Medicare enrollment data and fee-for-service claims. The cohort included Medicare beneficiaries with RA based on 3 diagnosis codes or 2 codes plus a disease-modifying antirheumatic drug medication claim. We defined race and ethnicity and dual Medicare/Medicaid coverage (proxy for income) using enrollment data. Adults with a Current Procedural Terminology code for PT evaluation were classified as utilizing PT services. Associations between race and ethnicity and dual coverage and PT utilization were estimated with logistic regression analyses. Potential interactions between race and ethnicity status and dual coverage were tested using interaction terms. RESULTS: Of 106,470 adults with RA (75.1% female; aged 75.8 [SD 7.3] years; 83.9% identified as non-Hispanic White, 8.8% as non-Hispanic Black, 7.2% as Hispanic), 9.6-12.5% used PT in a given year. Non-Hispanic Black (adjusted odds ratio [aOR] 0.77, 95% CI 0.73-0.82) and Hispanic (aOR 0.92, 95% CI 0.87-0.98) individuals had lower odds of PT utilization than non-Hispanic White individuals. Adults with dual coverage (lower income) had lower odds of utilization than adults with Medicare only (aOR 0.44, 95% CI 0.43-0.46). There were no significant interactions between race and ethnicity status and dual coverage on utilization. CONCLUSION: We found sociocultural and economic disparities in PT utilization in older adults with RA. We must identify and address the underlying factors that influence these disparities in order to mitigate them.

A biopsychosocial approach assessing pain indicators among Black men.

Introduction: The lack of empirical evidence documenting the pain experience of Black men may be the result of social messaging that men are to project strength and avoid any expression of emotion or vulnerability. This avoidant behavior however, often comes too late when illnesses/symptoms are more aggressive and/or diagnosed at a later stage. This highlights two key issues - the willingness to acknowledge pain and wanting to seek medical attention when experiencing pain. Methods: To better understand the pain experience in diverse raced and gendered groups, this secondary data analysis aimed to determine the influence identified physical, psychosocial, and behavioral health indicators have in reporting pain among Black men. Data were taken from a baseline sample of 321 Black men, >40 years old, who participated in the randomized, controlled Active & Healthy Brotherhood (AHB) project. Statistical models were calculated to determine which indicators (somatization, depression, anxiety, demographics, medical illnesses) were associated with pain reports. Results: Results showed that 22% of the men reported pain for more than 30 days, with more than half of the sample being married (54%), employed (53%), and earning an income above the federal poverty level (76%). Multivariate analyses showed that those reporting pain were more likely to be unemployed, earn less income, and reported more medical conditions and somatization tendencies (OR=3.28, 95% CI (1.33, 8.06) compared to those who did not report pain. Discussion: Findings from this study indicate that efforts are needed to identify the unique pain experiences of Black men, while recognizing its impact on their identities as a man, a person of color, and someone living with pain. This allows for more comprehensive assessments, treatment plans, and prevention approaches that may have beneficial impacts throughout the life course.

Definitions, terminology, and related concepts of "racial health equity": a scoping review protocol.

BACKGROUND: In the USA, access to quality healthcare varies greatly across racial and ethnic groups, resulting in significant health disparities. A new term, "racial health equity" (RHE), is increasingly reported in the medical literature, but there is currently no consensus definition of the term. Additionally, related terms such as "health disparities," "health inequities," and "equality" have been inconsistently used when defining RHE. METHODS: The primary purpose of this scoping review is to investigate the current use and underlying concepts used to define racial health equity. The study will address two key questions: (1) "What terminology and definitions have been used to characterize RHE?" and (2) "What knowledge gaps and challenges are present in the current state of RHE research and theory?" The review will collect and analyze data from three sources: (1) websites from key national and international health organizations, (2) theoretical and narrative published articles, and (3) evidence synthesis studies addressing interventions targeting racial health equity and minority stakeholder engagement. DISCUSSION: Defining "racial health equity" and related terminology is the first step to advancing racial health equity within the USA. This review aims to offer an improved understanding of RHE constructs and definitions, bringing greater unity to national racial health equity research efforts across disciplines. SYSTEMATIC REVIEW REGISTRATION: This protocol is registered with the Open Science Framework at https://osf.io/7pvzq .