Family Planning Experiences and Challenges of Mohs Fellowship Trainees.

BACKGROUND: There is a paucity of literature describing family planning challenges faced by Mohs fellows. OBJECTIVE: To characterize perceptions about and experiences with family planning, fertility, lactation, and parental leave and identify ways to support parental health and family planning for Mohs fellows. MATERIALS AND METHODS: A voluntary, anonymous survey was distributed to Mohs surgeons who recently completed fellowship. RESULTS: In total, 116 Mohs surgeons completed the survey. Their mean age was 34.5 years old, and more were female ( n = 81, 69.8%) than male ( n = 35, 30.2%). Most had children before completion of their Mohs training ( n = 73, 62.9%). The most significant barrier to having children during fellowship was "loss of education or training time." Over 20% ( n = 23) of respondents or their partner had experienced infertility. Half of the 20 respondents ( n = 10) who breastfed or pumped did not have a convenient place to do so. CONCLUSION: This study elucidates trainee perceptions and gaps in parental support for Mohs fellowship trainees. In addition, barriers to implementing a universal family planning policy in Mohs surgery are discussed.

Training Psychology and Psychiatry Diversity Dialogue Facilitators.

This article describes a Diversity Dialogue Facilitator Training Program for Trainees, an innovative project that prepares psychology and psychiatry learners to facilitate diversity dialogues with healthcare professionals (i.e., clinical and research faculty, staff, and learners) in academic healthcare settings. Through participating in this program, trainees learn to facilitate discussions in which participants reflect upon oppression, discrimination, and disparities; explore their biases; connect and exchange views with colleagues regarding challenging societal events; and delineate action steps for advancing equity, inclusion, social responsivity, and justice in their professional and personal lives. After outlining contextual factors that informed project development, implementation, and dissemination, the iterative process of creating and implementing the training curriculum is detailed, with the aim of offering a model for other academic health center-based training programs interested in establishing a similar initiative. Lessons learned also are shared with the hope of contributing to future efforts to advance training in diversity dialogue facilitation and expand the role of psychologists in medical settings.

A Markov Analysis of Surgical versus Medical Management of Chronic Migraines.

BACKGROUND: Refractory chronic migraine is a common and debilitating neurologic condition, affecting over 8 million people in the United States. It is associated with billions of dollars in lost productivity annually. Novel medical (anti-calcitonin gene-related peptide antibodies) and surgical treatment modalities have emerged for chronic migraine in recent years. The current study investigated the cost-utility of surgical versus medical management of refractory chronic migraine. METHODS: A Markov cohort analysis using hybrid Monte Carlo patient simulation was performed to compare surgical decompression versus erenumab for the treatment of refractory chronic migraine in adults. Both societal and payer perspectives were considered. Primary model outcomes included incremental cost-effectiveness ratio, or cost per quality-adjusted life-year gained. RESULTS: Over a 5-year period, migraine surgery was associated with an increase of 0.2 quality-adjusted life-year per patient when compared to erenumab. In terms of costs, the results demonstrated a $19,337 decrease in direct medical costs and a $491 decrease in indirect costs (productivity lost) for the surgery cohort compared to erenumab. Because surgery improved quality of life and decreased costs compared to erenumab, even when considering revision surgery needs, surgery was the overall dominant treatment in terms of cost-effectiveness. Sensitivity analyses demonstrated that surgery was cost-effective compared to erenumab when patients required therapy for at least 1 year. CONCLUSIONS: Surgical deactivation of migraine trigger sites may pose a cost-effective approach to treating refractory chronic migraine in adults. This is especially the case when patients are anticipated to require therapy for more than 1 year.

Antiracist Practice in Psychiatry: Principles and Recommendations.

The COVID-19 pandemic has amplified mental health disparities among people of color, particularly for Black, Latinx, and American Indian populations. In addition to experiencing overt hostility and systemic injustice, people from marginalized racial-ethnic groups experience prejudice and bias from clinicians that has disrupted rapport and trust in mental health systems; these experiences, in turn, have deepened these health disparities. In this article, the authors describe factors that have served to perpetuate mental health disparities and outline key components of antiracist practice in psychiatry (and in mental health practice, more generally). With lessons learned in recent years, this article presents practical ways to incorporate antiracist practices into clinical care.

Integrating Diversity, Equity, and Inclusion Into an Academic Department of Psychiatry and Behavioral Sciences.

This article highlights one department's efforts to bolster diversity, equity, and inclusion as an exemplar for other academic departments. It offers an approach for building an infrastructure and leadership group and details accomplishments associated with strategic plan priorities related to visibility, values, stakeholder education, recruitment, retention, promotion, and community engagement. It also delineates challenges encountered in transforming a departmental culture to one that is more diverse, equitable, and inclusive and strategies for overcoming these challenges. Finally, it discusses next steps and recommendations for other academic departments.

Rodent Malaria Erythrocyte Preference Assessment by an Ex Vivo Tropism Assay.

Circulating red blood cells consist of young erythrocytes (early and late reticulocytes) and mature erythrocytes (normocytes). The human malaria parasites, Plasmodium falciparum and P. vivax, have a preference to invade reticulocytes during blood-stage infection. Rodent malaria parasites that also prefer reticulocytes could be useful tools to study human malaria reticulocyte invasion. However, previous tropism studies of rodent malaria are inconsistent from one another, making it difficult to compare cell preference of different parasite species and strains. In vivo measurements of cell tropism are also subjected to many confounding factors. Here we developed an ex vivo tropism assay for rodent malaria with highly purified fractions of murine reticulocytes and normocytes. We measured invasion into the different erythrocyte populations using flow cytometry and evaluated the tropism index of the parasite strains. We found that P. berghei ANKA displayed the strongest reticulocyte preference, followed by P. yoelii 17X1.1, whereas P. chabaudi AS and P. vinckei S67 showed mixed tropism. These preferences are intrinsic and were maintained at different reticulocyte and normocyte availabilities. Our study shed light on the true erythrocyte preference of the parasites and paves the way for future investigations on the receptor-ligand interactions mediating erythrocyte tropism.

Social justice advocacy in mental health services: Consumer, community, training, and policy perspectives.

This article addresses important aspects of and strategies for social justice advocacy in mental health care across consumer, community, educational, and policy domains. Social justice advocacy is intentional and sustained action intended to influence public policy outcomes, with and/or on behalf of a vulnerable individual, group, community, or the public at large. The paper presents a series of policy and advocacy levels of change, which may be used to promote social justice among individuals with mental health disorders with an emphasis on how psychologists can be valuable in these efforts. These social justice advocacy approaches are presented in a 3-level bio/socioecological framework at the micro, meso, and macro levels based on Bronfenbrenner's theoretical model. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Psoriasis-associated itch: etiology, assessment, impact, and management.

Pruritus, a very broad, subjective, and complex symptom, troubles the majority of patients with psoriasis. However, the subjective and multidimensional nature of the symptom renders it challenging for patients to appropriately communicate their experiences with itch to providers. This review explores current perspectives regarding the underlying mechanisms, assessment tools, burden, and treatment modalities for psoriatic pruritus. It emphasizes the significance of incorporating a standardized, thorough, and verified metric that incorporates severity, distribution, and character of pruritus as well as its effects on various aspects of quality of life. It also underscores the importance of continued research to fully understand the pathogenesis of psoriatic itch for establishment of novel, targeted therapeutics.

Patient-reported Outcome Measures: The FACE-Q Skin Cancer Module: The Dutch Translation and Linguistic Validation.

BACKGROUND: Patient-reported outcome measures are becoming a standard component in the evaluation of surgical treatments. In 2010, the FACE-Q skin cancer module was developed: an English psychometric validated questionnaire that measures both patient quality of life and satisfaction with the surgical experience. The questionnaire consists of 11 subscales with a total of 96 questions. An officially translated version in Dutch is needed for accepted use in the Netherlands. METHODS: We translated the FACE-Q skin cancer module from English into Dutch in accordance with to the International Society for Pharmacoeconomics and Outcomes Research and World Health Organization guidelines. The translation occurs in three stages. First, a forward translation is performed by two independent professional translators, where discrepancies are solved by a third translator, a subject area expert. Secondly, a backward translation is performed and is compared with the original. Any discrepancies are solved by an expert panel. Version two is then pretested (cognitive debriefing) by 30 patients who have had a resection (Mohs surgery) of non-melanoma skin cancer in the face followed by reconstruction. The results of the pretesting exercise are evaluated and a final version of the translation was produced by the expert panel. RESULTS: In the first step, a conceptually equivalent Dutch translation of the FACE-Q was translated. In the second phase, the comparison between the forward and backward translation led to multiple retranslations. In step three, 48 annotations were evaluated by the expert panel, which led to 26 minor changes in items or instructions. CONCLUSION: We created a conceptually and linguistically similar translation of the FACE-Q Skin Cancer Module through a thorough translation and linguistic validation process.

Institute for clinical and economic review (ICER) psoriasis update 2018: what it means for dermatologists treating moderate-to-severe plaque psoriasis.

Objective: This paper aims to summarize the key findings of the updated report issued in August 2018 by the Institute of Clinical and Economic Review (ICER) regarding the clinical efficacy and budget impact of various immunomodulators. Methods: This paper specifically focuses on the inclusion of two new biologics, guselkumab and certolizumab in the context of their relative cost-effectiveness using analyses on sequential implementation of specific first- and second-line therapies. Results: The ICER found that initiating biologic therapy with an IL-17 inhibitor or guselkumab results in the most clinical improvement, but is also associated with higher costs. The ICER also found that guselkumab and certolizumab would need to be discounted significantly in order to achieve cost-effectiveness by standard metrics of $50,000-$150,000 per QALY. Conclusion: The ICER report demonstrates a need for more consensus guidelines in the use of biologics in the treatment of psoriasis, and perhaps consideration of costs within these guidelines.

Psoriasis-associated cutaneous pain: etiology, assessment, impact, and management.

Cutaneous pain, a very broad, subjective, and complex symptom, is prevalent in patients with psoriasis. It is prompted by neurogenic inflammation and augmented by physical and psychosocial stress. Many psoriasis patients are troubled by aching, burning, stinging, tenderness, cramping, and tingling in their skin. However, there lacks a thorough and verified metric that allows patients to adequately report their unique skin pain experiences. Limited literature exists that aims to understand cutaneous pain in psoriasis patients; most studies focus on joint pain and generalized pain, and many do not specify the location of pain. This review explores and analyzes current literature on the etiology, assessment, burden, and management of skin pain in psoriasis patients. It emphasizes the significance of appropriately quantifying the skin pain experience in psoriasis and developing therapeutics that target the underlying processes that contribute to noxious skin sensations.

Quality of Maternal Height and Weight Data from the Revised Birth Certificate and Pregnancy Risk Assessment Monitoring System.

BACKGROUND: The 2003 revision of the US Standard Certificate of Live Birth (birth certificate) and Pregnancy Risk Assessment Monitoring System (PRAMS) are important for maternal weight research and surveillance. We examined quality of prepregnancy body mass index (BMI), gestational weight gain, and component variables from these sources. METHODS: Data are from a PRAMS data quality improvement study among a subset of New York City and Vermont respondents in 2009. We calculated mean differences comparing prepregnancy BMI data from the birth certificate and PRAMS (n = 734), and gestational weight gain data from the birth certificate (n = 678) to the medical record, considered the gold standard. We compared BMI categories (underweight, normal weight, overweight, obese) and gestational weight gain categories (below, within, above recommendations), classified by different sources, using percent agreement and the simple κ statistic. RESULTS: For most maternal weight variables, mean differences between the birth certificate and PRAMS compared with the medical record were less than 1 kg. Compared with the medical record, the birth certificate classified similar proportions into prepregnancy BMI categories (agreement = 89%, κ = 0.83); PRAMS slightly underestimated overweight and obesity (agreement = 84%, κ = 0.73). Compared with the medical record, the birth certificate overestimated gestational weight gain below recommendations and underestimated weight gain within recommendations (agreement = 81%, κ = 0.69). Agreement varied by maternal and pregnancy-related characteristics. CONCLUSIONS: Classification of prepregnancy BMI and gestational weight gain from the birth certificate or PRAMS was mostly similar to the medical record but varied by maternal and pregnancy-related characteristics. Efforts to understand how misclassification influences epidemiologic associations are needed.

An Evaluation of New York City's 2015 Birth Certificate Gender Marker Regulation.

PURPOSE: In 1971, the New York City (NYC) Department of Health and Mental Hygiene amended Section 207.05 of the NYC Health Code to allow individuals who had undergone "convertive surgery" (interpreted by the code to mean genital surgery) to amend the gender on their birth certificates. This surgery requirement was removed in 2015. In a survey evaluating the regulation change, we sought to characterize the transgender population newly eligible to obtain a gender-congruent NYC birth certificate by comparing respondents with and without genital surgery. METHODS: We mailed a 42-question survey with each newly issued birth certificate. We compared respondents across current gender identity, race, Hispanic ethnicity, age, insurance status, income, current general health status, other transition-related care obtained, and healthcare access, stigma, and discrimination. RESULTS: Of 642 applicants, 219 responded and were thus enrolled in our 5-year study (34.1%). Most (n = 158 out of 203 who answered, 77.8%) had not received genital surgery. Compared to respondents with genital surgery, respondents without surgery were significantly more likely to be transgender men (50.0% vs. 20.0%); younger (median age 32 vs. 56.5); on Medicaid (31.6% vs. 11.1%); identify as Hispanic (28.5% vs. 8.9%); and live in households making <$20,000 annually (35.3% vs. 12.8%). CONCLUSIONS: Removing a genital surgery requirement more equitably enables transgender men and those with limited resources to obtain a gender-congruent birth certificate. Jurisdictions with such requirements should consider similar regulation changes to address the inequities that this requirement likely imposes in accessing birth certificates.

Assessment of intraoperative pain during Mohs micrographic surgery (MMS): An opportunity for improved patient care.

BACKGROUND: Intraoperative pain during Mohs micrographic surgery (MMS) has not been characterized. However, many patients report postoperative pain on the day of MMS. OBJECTIVE: We sought to determine if patients experience pain during their MMS visit. METHODS: In phase I of this study, patients were asked to report intraoperative pain level using the verbal numerical rating scale (0-10) at discharge. In phase II, pain levels were assessed before each Mohs layer and at discharge, to determine whether pain was experienced throughout the day. RESULTS: Pain was reported at some point during the MMS day for 32.8% of patients (n = 98). The mean pain number reported was 3.7 (range 1-8) out of 10. Pain was more commonly reported by patients who spent a longer time in the office, had 3 or more Mohs layers, and had a flap or graft repair. Patients most frequently reported pain with surgical sites of the periorbital area and nose. LIMITATIONS: Time between Mohs layers was not measured. There was nonstandardized use of intraoperative local anesthesia volume and oral pain medications. CONCLUSION: Some patients experience pain during MMS. However, the majority of patients report a low level of pain. Additional preventative measures could be considered in patients at higher risk.

Comorbidity Assessment in Skin Cancer Patients: A Pilot Study Comparing Medical Interview with a Patient-Reported Questionnaire.

Background. Comorbidities are conditions that occur simultaneously but independently of another disorder. Among skin cancer patients, comorbidities are common and may influence management. Objective. We compared comorbidity assessment by traditional medical interview (MI) and by standardized patient-reported questionnaire based on the Adult Comorbidity Evaluation-27 (ACE-27). Methods. Between September 2011 and October 2013, skin cancer patients underwent prospective comorbidity assessment by a Mohs surgeon (MI) and a radiation oncologist (using a standardized patient-reported questionnaire based on the ACE-27, the PRACE-27). Comorbidities were identified and graded according to the ACE-27 and compared for agreement. Results. Forty-four patients were evaluated. MI and PRACE-27 identified comorbidities in 79.5% and 88.6% (p = 0.12) of patients, respectively. Among 27 comorbid ailments, the MI identified 9.9% as being present, while the PRACE-27 identified 12.5%. When there were discordant observations, PRACE-27 was more likely than MI to identify the comorbidity (OR = 5.4, 95% CI = 2.4-14.4, p < 0.001). Overall comorbidity scores were moderate or severe in 43.2% (MI) versus 59.1% (PRACE-27) (p = 0.016). Limitations. Small sample size from a single institution. Conclusion. Comorbidities are common in skin cancer patients, and a standardized questionnaire may better identify and grade them. More accurate comorbidity assessments may help guide skin cancer management.

Chinese American immigrant parents' emotional expression in the family: Relations with parents' cultural orientations and children's emotion-related regulation.

The present study examined 2 measures of Chinese American immigrant parents' emotional expression in the family context: self-reported emotional expressivity and observed emotional expression during a parent-child interaction task. Path analyses were conducted to examine the concurrent associations between measures of emotional expression and (a) parents' American and Chinese cultural orientations in language proficiency, media use, and social affiliation domains, and (b) parents' and teachers' ratings of children's emotion-related regulation. Results suggested that cultural orientations were primarily associated with parents' self-reported expressivity (rather than observed emotional expression), such that higher American orientations were generally associated with higher expressivity. Although parents' self-reported expressivity was only related to their own reports of children's regulation, parents' observed emotional expression was related to both parents' and teachers' reports of children's regulation. These results suggest that self-reported expressivity and observed emotional expression reflect different constructs and have differential relations to parents' cultural orientations and children's regulation.

Neighborhood characteristics, parenting styles, and children's behavioral problems in Chinese American immigrant families.

Using data from a socioeconomically diverse sample of Chinese American children (n = 258, aged 6-9 years) in immigrant families, we examined the concurrent relations among neighborhood economic disadvantage and concentration of Asian residents, parenting styles, and Chinese American children's externalizing and internalizing problems. Neighborhood characteristics were measured with 2000 U.S. Census tract-level data, parents (mostly mothers) rated their own parenting styles, and parents and teachers rated children's behavioral problems. Path analysis was conducted to test two hypotheses: (a) parenting styles mediate the relations between neighborhood characteristics and children's behavioral problems, and (b) children's behavioral problems mediate the relations between neighborhood and parenting styles. We found that neighborhood Asian concentration was positively associated with authoritarian parenting, which in turn was associated with Chinese American children's higher externalizing and internalizing problems (by parents' reports). In addition, neighborhood economic disadvantage was positively related to children's externalizing problems (by parents' reports), which in turn predicted lower authoritative parenting. The current results suggest the need to consider multiple pathways in the relations among neighborhood, family, and child adjustment, and they have implications for the prevention and intervention of behavioral problems in Chinese American children.

Can a multi-disciplinary assessment approach improve outcomes for children with attention deficit hyperactivity disorder?

OBJECTIVE: Public, consumer and professional views about attention deficit hyperactivity disorder, its assessment and treatment - especially with medication - remain a highly contested domain. Parents in particular express disquiet with services. One response to this tension is a multidisciplinary evaluation. Parental and education perceptions of this process have not been evaluated previously. A community multidisciplinary approach was assessed in terms of diagnostic outcomes and client satisfaction. METHOD: A comprehensive multidisciplinary structured assessment of the first 50 referred children with severe attentional problems was documented. Demographic and symptom/behavioural profiles, developmental history and indicated multi-disciplinary evaluation were recorded. A team consensus process arrived at diagnostic classification. Post-assessment satisfaction of parents and school staff was surveyed. RESULTS: Thirteen children (26%) were diagnosed with attention deficit hyperactivity disorder and three commenced stimulants. The majority of parents and educators were satisfied with the service. CONCLUSIONS: A multidisciplinary assessment clinic for children presenting with attention problems resulted in minimal prescribing. Overall, education staff and parents were satisfied with the service. The model may be a suitable response to the multiple concerns in the community.

Current delivery of infant mental health services: are infant mental health needs being met?

OBJECTIVE: To identify services supporting the well-being of infants and their families in an area of South Brisbane, Australia, highlight problems of accessing these services and recommend strategies to make them more readily available. METHOD: Semistructured interviews were conducted with staff from 18 service providers offering antenatal services, or programmes primarily focused on children under the age of 2 years and/or their families. The interview aimed to identify the precise nature of the services offered, problems encountered in providing those services, perceived gaps in services and potential strategies for improvement. RESULTS: Services were diverse, provided by a range of different professionals, in varying locations (home, community, hospital) and with funding from various sources. The major findings were: (i) the fragmentation of services, lack of communication between them, and lack of continuity in services from one stage of family formation to another; (ii) the shortage of services working with the parents and infant together; and (iii) the difficulty of providing services for some at-risk populations. CONCLUSIONS: Recommendations included: (i) maintaining a range of different services networked through a centralized resource/referral centre; (ii) expanding joint mother-infant services and providing training for such services; and (iii) supporting outreach services for difficult to engage populations.