Momentary Emotion Regulation Strategies and Pain Experience Among Adults With Chronic Pain: An Ecological Momentary Assessment Study.

OBJECTIVES: The intention of this study was to characterize the real-time momentary relationship between emotion regulation strategies and the pain experience (ie intensity, interference, and negative affect) among adults with chronic pain. Chronic pain is a significant public health concern. Psychological treatments are effective for treating chronic pain, but long-term follow-up studies are limited, and treatment effect sizes are small. Identifying modifiable treatment targets, such as emotion regulation (ER), is critical to improve interventions. ER (ie, cognitive and attentional strategies to modulate or maintain emotional experience) has been linked to psychopathology and pain experience in adults. Yet, the existing work is limited and has largely focused on the relationship between emotional experience, not ER, and pain. MATERIALS AND METHODS: The current study utilized ecological momentary assessment 53 adults with chronic pain. Participants completed ecological momentary assessments of pain experience and ER strategies 5 times a day for 7 days. Associations by specific strategy type were also examined, highlighting the importance of worry, experiential avoidance, rumination, and expressive suppression in pain experience. RESULTS: Results of the current study provide evidence for the association between within-person maladaptive ER strategies and pain intensity ( b = 2.11, SE = 0.37, P < 0.001), pain interference ( b = 1.25, SE = 0.40, P = 0.002), and pain-related negative affect ( b = 2.20, SE = 0.41, P < 0.001). (77.4% females; M age = 27.10 y, SD = 5.16 y). DISCUSSION: Given that ER is readily targeted in psychological treatments for chronic pain, the results from the current study provide initial evidence to target these ER strategies in treatment.

Anxiety sensitivity in terms of mental health among a racially and ethnically diverse sample of sexual minority college students.

Objective: Limited work has focused on understanding the function of individual difference factors in terms of mental health among sexual minority college students. Anxiety sensitivity is one individual difference factor which has received substantial empirical attention, but its role is presently understudied among racially/ethnically diverse sexual minority college students.Participants: Participants included a racially and ethnically diverse sample of sexual minority college students (N = 217; Mage = 20.82 years; SD = 3.06).Methods: The present investigation evaluated the role of anxiety sensitivity in relation to anxious arousal, social anxiety, depression, and suicidality.Results: Results indicated that anxiety sensitivity was significantly related to increased anxious arousal, social anxiety, depression, and suicidality after adjusting for age, sex, relationship status, subjective social status, and neuroticism.Conclusions: This investigation provides the first empirical evidence that anxiety sensitivity is related to poorer mental health outcomes for racially/ethnically diverse sexual minority college students.

Perceived Discrimination, Experiential Avoidance, and Mental Health among Hispanic Adults in Primary Care.

The Hispanic population is the largest minority group in the United States and frequently experiences racial discrimination and mental health difficulties. Prior work suggests that perceived racial discrimination is a significant risk factor for poorer mental health among Hispanic in the United States. However, little work has investigated how perceived racial discrimination relates to anxiety and depression among Hispanic adults. Thus, the current study evaluated the explanatory role of experiential avoidance in the relation between perceived racial discrimination and anxiety/depressive symptoms and disorders among Hispanic adults in primary care. Participants included 202 Spanish-speaking adults (Mage = 38.99, SD = 12.43, 86.1% female) attending a community-based Federally Qualified Health Center. Results were consistent with the hypothesis that perceived racial discrimination had a significant indirect effect on depression, social anxiety, and anxious arousal symptoms as well as the number of mood and anxiety disorders through experiential avoidance. These findings suggest future work should continue to explore experiential avoidance in the association between perceived racial discrimination and other psychiatric and medical problems among the Hispanic population.

Realist Process Evaluation of the implementation and impact of an organisational cultural transformation programme in the Children and Young People's Secure Estate (CYPSE) in England: study protocol.

INTRODUCTION: Young people in contact with the youth justice system are more likely to present with complex ongoing needs than young people in the general population. To address this, the Framework for Integrated Care (SECURE STAIRS) is being implemented in the Children and Young People's Secure Estate: a 'whole systems' approach to support secure settings to develop trauma-informed and relationally based environments, supporting staff to provide consistent, therapeutic care. This paper aims to present the protocol for a national cohort study examining the impact and implementation of this cultural transformation programme. METHODS AND ANALYSIS: A mixed-methods realist evaluation will be conducted. Data collection will take place between August 2018 and December 2020. Eighteen sites will collect routine service activity data and questionnaires completed by young people, parents/guardians and staff. Semi-structured interviews and non-participant observations will be conducted across five qualitative focus sites with young people and staff. An economic evaluation will examine value for money. The results will be triangulated at the analysis stage to gain an in-depth understanding of experiences. ETHICS AND DISSEMINATION: Ethical approval was granted by the Health Research Authority, Her Majesty's Prison and Probation Service and UCL Ethics Committee. Findings will be disseminated via project reports, site feedback, peer-reviewed journal publications and conference presentations.

Healthcare Resource Utilization in Inguinal Hernia Repair: A Three-Year Cost Evaluation of Truven Health Marketscan Research Databases.

BACKGROUND: Inguinal hernia repair is the most commonly performed elective operation in the United States, with over 800,000 cases annually. While clinical outcomes comparing laparoscopic versus open techniques have been well documented, there is little data comparing costs associated with these techniques. This study evaluates the cost of healthcare resources during the 90-d postoperative period following inguinal hernia repair. METHODS: We analyzed data from the Truven Health MarketScan Research Databases. Adult patients with an ICD-9 or CPT code for inguinal hernia repair from 2012 to 2014 were included. Patients with continuous enrollment for 6 mo prior to surgery and 6 mo after surgery were analyzed. Related healthcare service costs (readmission and/or ER visit and/or outpatient visit) were calculated by clinical classification software and generalized linear modeling was used to compare healthcare utilization between groups. RESULTS: 124,582 cases were identified (open = 84,535; lap = 40,047). Index surgery cost was 41% higher in laparoscopic cases. The cost for readmission was close to $25,000 and similar between both groups, but the laparoscopic group were 12% less likely to be readmitted for surgical complications within 90-d when compared to the open group. Cost of bilateral laparoscopic repair is less than that of serial unilateral open repairs. CONCLUSION: Laparoscopic inguinal hernia repair carries a higher index surgery cost than open repair. However, open repair has an increased rate of readmission. To maximize value, efforts should be directed at minimizing readmissions and improving identification of bilateral hernias at the time of initial presentation.

Home-based narrowband UVB, topical corticosteroid or combination for children and adults with vitiligo: HI-Light Vitiligo three-arm RCT.

BACKGROUND: Systematic reviews suggest that narrowband ultraviolet B light combined with treatments such as topical corticosteroids may be more effective than monotherapy for vitiligo. OBJECTIVE: To explore the clinical effectiveness and cost-effectiveness of topical corticosteroid monotherapy compared with (1) hand-held narrowband ultraviolet B light monotherapy and (2) hand-held narrowband ultraviolet B light/topical corticosteroid combination treatment for localised vitiligo. DESIGN: Pragmatic, three-arm, randomised controlled trial with 9 months of treatment and a 12-month follow-up. SETTING: Sixteen UK hospitals - participants were recruited from primary and secondary care and the community. PARTICIPANTS: Adults and children (aged ≥ 5 years) with active non-segmental vitiligo affecting ≤ 10% of their body area. INTERVENTIONS: Topical corticosteroids [mometasone furoate 0.1% (Elocon®, Merck Sharp & Dohme Corp., Merck & Co., Inc., Whitehouse Station, NJ, USA) plus dummy narrowband ultraviolet B light]; narrowband ultraviolet B light (narrowband ultraviolet B light plus placebo topical corticosteroids); or combination (topical corticosteroids plus narrowband ultraviolet B light). Topical corticosteroids were applied once daily on alternate weeks and narrowband ultraviolet B light was administered every other day in escalating doses, with a dose adjustment for erythema. All treatments were home based. MAIN OUTCOME MEASURES: The primary outcome was self-assessed treatment success for a chosen target patch after 9 months of treatment ('a lot less noticeable' or 'no longer noticeable' on the Vitiligo Noticeability Scale). Secondary outcomes included blinded assessment of primary outcome and percentage repigmentation, onset and maintenance of treatment response, quality of life, side effects, treatment burden and cost-effectiveness (cost per additional successful treatment). RESULTS: In total, 517 participants were randomised (adults, n = 398; and children, n = 119; 52% male; 57% paler skin types I-III, 43% darker skin types IV-VI). At the end of 9 months of treatment, 370 (72%) participants provided primary outcome data. The median percentage of narrowband ultraviolet B light treatment-days (actual/allocated) was 81% for topical corticosteroids, 77% for narrowband ultraviolet B light and 74% for combination groups; and for ointment was 79% for topical corticosteroids, 83% for narrowband ultraviolet B light and 77% for combination. Target patch location was head and neck (31%), hands and feet (32%), and rest of the body (37%). Target patch treatment 'success' was 20 out of 119 (17%) for topical corticosteroids, 27 out of 123 (22%) for narrowband ultraviolet B light and 34 out of 128 (27%) for combination. Combination treatment was superior to topical corticosteroids (adjusted risk difference 10.9%, 95% confidence interval 1.0% to 20.9%; p = 0.032; number needed to treat = 10). Narrowband ultraviolet B light was not superior to topical corticosteroids (adjusted risk difference 5.2%, 95% confidence interval -4.4% to 14.9%; p = 0.290; number needed to treat = 19). The secondary outcomes supported the primary analysis. Quality of life did not differ between the groups. Participants who adhered to the interventions for > 75% of the expected treatment protocol were more likely to achieve treatment success. Over 40% of participants had lost treatment response after 1 year with no treatment. Grade 3 or 4 erythema was experienced by 62 participants (12%) (three of whom were using the dummy) and transient skin thinning by 13 participants (2.5%) (two of whom were using the placebo). We observed no serious adverse treatment effects. For combination treatment compared with topical corticosteroids, the unadjusted incremental cost-effectiveness ratio was £2328.56 (adjusted £1932) per additional successful treatment (from an NHS perspective). LIMITATIONS: Relatively high loss to follow-up limits the interpretation of the trial findings, especially during the post-intervention follow-up phase. CONCLUSION: Hand-held narrowband ultraviolet B light plus topical corticosteroid combination treatment is superior to topical corticosteroids alone for treatment of localised vitiligo. Combination treatment was relatively safe and well tolerated, but was effective in around one-quarter of participants only. Whether or not combination treatment is cost-effective depends on how much decision-makers are willing to pay for the benefits observed. FUTURE WORK: Development and testing of new vitiligo treatments with a greater treatment response and longer-lasting effects are needed. TRIAL REGISTRATION: Current Controlled Trials ISRCTN17160087. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 64. See the NIHR Journals Library website for further project information.

The Home Interventions and Light therapy for the treatment of vitiligo (HI-Light Vitiligo) trial aimed to find out whether or not treating vitiligo at home with a narrowband ultraviolet B light, either by itself or with a steroid ointment, is better than treatment using a steroid ointment only. We enrolled 517 children (aged ≥ 5 years) and adults who had small, active (i.e. recently changing) patches of vitiligo into the study. Participants received one of three possible treatment options: steroid ointment (plus dummy light), hand-held narrowband ultraviolet B light therapy (plus placebo ointment) or both treatments used together. We asked participants to judge how noticeable their target vitiligo patch was after 9 months of treatment. We considered the treatment to be successful if the participants' responses were either 'a lot less noticeable' or 'no longer noticeable'. The results showed that using both treatments together was better than using a steroid ointment on its own. Around one-quarter of participants (27%) who used both treatments together said that their vitiligo was either 'no longer noticeable' or 'a lot less noticeable' after 9 months of treatment. This was compared with 17% of those using steroid ointment on its own and 22% of those using narrowband ultraviolet B light on its own. All treatments were able to stop the vitiligo from spreading. Patches on the hands and feet were less likely to respond to treatment than patches on other parts of the body. The trial found that the vitiligo tended to return once treatments were stopped, so ongoing intermittent treatment may be needed to maintain the treatment response. The treatments were found to be relatively safe and easy to use, but light treatment required a considerable time commitment (approximately 20 minutes per session, two or three times per week). This trial showed that using steroid ointment and narrowband ultraviolet B light together is likely to be better than steroid ointment alone for people with small patches of vitiligo. Steroid ointment alone can still be effective for some people and remains a useful treatment that is able to stop vitiligo from spreading. The challenge is to make hand-held narrowband ultraviolet B light treatment available as normal care in the NHS for people with vitiligo.

Worry Among Latinx Young Adults: Relations to Pain Experience, Pain-Related Anxiety, and Perceived Health.

Latinx are one of the largest and most rapidly growing segments of the United States (U.S.) population that is significantly impacted by health disparities, including somatic health problems. Young Latinx adults (ages 18-25 years) are at a greater risk for being affected by such health inequalities and there is a need to understand individual-based differences that may contribute to and maintain somatic symptoms, including pain experience, pain beliefs, and perceptions of health. Thus, the current study investigated the explanatory role of worry in association between pain intensity, pain disability, pain-related anxiety, and perceived health among Latinx college students. Participants included 401 (Mage = 21 years; SD = 2.02; 83% female) Latinx students at a large, southwestern university. Results indicated that greater levels of worry were related to increased levels of pain intensity, pain disability, pain-related anxiety, and lower levels of perceived health. These findings were evident above and beyond variance accounted for by gender, age, physical functioning, and subjective social status. Overall, the results from the present investigation suggest that there is greater risk for more severe pain experiences, maladaptive beliefs regarding pain, and worse perceptions of health status among Latinx young adults who experience elevated levels of worry.

Perceived Racial Discrimination and Pain Intensity/Disability Among Economically Disadvantaged Latinos in a Federally Qualified Health Center: The Role of Anxiety Sensitivity.

The present study examined the role of anxiety sensitivity (AS; fear of the negative consequences of anxiety) in the relation between perceived racial discrimination and pain-related problems among Latinos seeking health services at a Federally Qualified Health Center. Participants included 145 adult Latinos (87.80% female, Mage = 38.07 years, SD = 11.98, and 96.2% reported Spanish as their first language). Results indicated that perceived racial discrimination was indirectly related to the pain intensity and pain disability through AS. These effects were evident above and beyond the variance accounted for by gender, age, marital status, educational status, employment status, years living in the United States, and number of axis I diagnoses. Overall, the present findings highlight the merit in focusing further scientific attention on the interplay between perceived racial discrimination and AS to better understand and inform interventions to reduce pain problems among Latinos in primary care.

Clinically Competent and Fiscally at Risk: Impact of Debt and Financial Parameters on the Surgical Resident.

BACKGROUND: While the costs of medical training continue to increase, surgeon income and personal financial decisions may be challenged to manage this expanding debt burden. We sought to characterize the financial liability, assets, income, and debt of surgical residents, and evaluate the necessity for additional financial training. STUDY DESIGN: All surgical trainees at a single academic center completed a detailed survey. Questions focused on issues related to debt, equity, cash flow, financial education, and fiscal parameters. Responses were used to calculate debt-to-asset and debt-to-income ratios. Predictors of moderate risk debt-to-asset ratio (0.5 to 0.9), high risk debt-to-asset ratio (≥0.9), and high risk debt-to-income ratio (>0.4) were evaluated. All analyses were performed in SPSS v.21. RESULTS: One hundred five trainees completed the survey (80% response rate), with 38% of respondents reporting greater than $200,000 in educational debt. Overall, 82% of respondents had a moderate or high risk debt-to-asset ratio. Residency program, year, sex, and perception of financial knowledge did not correlate with high risk debt-to-asset ratio. Residents with high debt-to-asset ratios were more likely to have a high level of concern about debt (52% vs 0%, p < 0.001) when compared with residents who had low debt-to-asset ratios. The majority (79%) of respondents felt strongly that inclusion of additional financial training in residency education is a critical need. CONCLUSIONS: In a climate of increasingly delayed financial gratification, surgical trainees are on critically unstable financial footing. There is a major gap in current surgical education that requires reassessment for the long-term financial health of residents.

The cost effectiveness and utility of a "quick MRI" for the evaluation of intra-abdominal abscess after acute appendicitis in the pediatric patient population.

INTRODUCTION: Contrast-enhanced CT remains the first-line imaging for evaluating postoperative abscess (POA) after appendicitis. Given concerns of ionizing radiation use in children, we began utilizing quick MRI to evaluate POA and summarize our findings in this study. MATERIALS AND METHODS: Children imaged with quick MRI from 2015 to 2017 were compared to children evaluated with CT from 2012 to 2014 using an age and weight matched case-control model. Radiation exposure, size and number of abscesses, length of exam, drain placement, and patient outcomes were compared. RESULTS: There was no difference in age or weight (p>0.60) between children evaluated with quick MRI (n=16) and CT (n=16). Mean imaging time was longer (18.2±8.5min) for MRI (p<0.001), but there was no difference in time from imaging order to drain placement (p=0.969). No children required sedation or had non-diagnostic imaging. There were no differences in abscess volume (p=0.346) or drain placement (p=0.332). Thirty-day follow-up showed no difference in readmissions (p=0.551) and no missed abscesses. Quick MRI reduced imaging charges to $1871 from $5650 with CT. CONCLUSION: Quick MRI demonstrated equivalent outcomes to CT in terms of POA detection, drain placement, and 30-day complications suggesting that MRI provides an equally effective, less expensive, and non-radiation modality for the identification of POA. TYPE OF STUDY: Retrospective Case-Control Study. LEVEL OF EVIDENCE: Level III.

Acculturative stress and mental health among economically disadvantaged Spanish-speaking Latinos in primary care: The role of anxiety sensitivity.

The present study examined the role of anxiety sensitivity in the relation between acculturative stress and mood and anxiety symptoms and disorders among Latinos seeking health services at a primary healthcare facility. Participants included 142 adult Latinos (86.6% female, Mage = 39.05 years, SD = 12.46%, and 96.3% reported Spanish as their first language). Results indicated that acculturative stress was indirectly related to the number of mood and anxiety disorders, anxious arousal, social anxiety, and depressive symptoms through anxiety sensitivity. The observed effects were evident above and beyond the variance accounted for by gender, age, marital status, educational status, employment status, years living in the United States, and negative affectivity. Overall, the present findings suggest that there is merit in focusing further scientific attention on the interplay between acculturative stress and anxiety sensitivity to better understand and inform interventions to reduce anxiety/depressive vulnerability among Latinos in primary care.

Filling the void: a low-cost, high-yield approach to addressing incidental findings in trauma patients.

BACKGROUND: Incidental findings are prevalent in imaging but often go unreported to patients. Such unreported findings may present the potential for harm as well as medico-legal ramifications. METHODS: A chart review of trauma patients was undertaken over a year. Systems-based changes were made utilizing our electronic medical record system and our staff protocols to improve the disclosure of clinically relevant incidental findings to patients. RESULTS: During the preintervention period, 674 charts were reviewed. Trauma patients had a rate of incidental findings of 70%, and 36% of patients had clinically relevant incidentals. Rates of follow-up recommendation and disclosure to patients were 22% and 27%, respectively. In the postintervention period, of the 648 charts were reviewed, the rates of a clinically relevant incidental finding were 35%, but the rates of follow-up recommendation and disclosure to patients were 68% and 85%, respectively. CONCLUSION: Incidental findings are more prevalent herein than previously reported. With simple changes and minimal resources, clinically relevant and important improvement in reporting incidental findings can be made to mitigate the harm and medico-legal impact of an incidental finding going unreported.

Higher Hospital Spending on Occupational Therapy Is Associated With Lower Readmission Rates.

Hospital executives are under continual pressure to control spending and improve quality. While prior studies have focused on the relationship between overall hospital spending and quality, the relationship between spending on specific services and quality has received minimal attention. The literature thus provides executives limited guidance regarding how they should allocate scarce resources. Using Medicare claims and cost report data, we examined the association between hospital spending for specific services and 30-day readmission rates for heart failure, pneumonia, and acute myocardial infarction. We found that occupational therapy is the only spending category where additional spending has a statistically significant association with lower readmission rates for all three medical conditions. One possible explanation is that occupational therapy places a unique and immediate focus on patients' functional and social needs, which can be important drivers of readmission if left unaddressed.