A mixed methods analysis of youth mental health intervention feasibility and acceptability in a North American city: Perspectives from Seattle, Washington.

In March 2021, the Governor of Washington declared a youth mental health crisis. State data revealed high rates of youth suicide and inadequate access to services. This study aims to ascertain the kinds of support across the mental health care continuum recommended by young people and key stakeholders who could assist with implementation in Seattle. We interviewed 15 key informants to identify the contextual, structural, and individual-level factors that increase the risk of poor mental health and deter access to care among youth. We complimented these data with a 25-item survey of 117 participants in King County to assess the feasibility and acceptability of interventions for youth mental health. We conducted a deductive thematic qualitative analysis of the interviews and performed descriptive analyses of the quantitative data, using t-tests and χ2 tests to summarize and compare participant characteristics stratified by age group. Qualitative informants attributed challenges to youth mental health to social isolation and relational problems. Example interventions included creating environments that increase belonging and implementation of culturally congruent mental health services. Quantitative study participants rated all evidence-based mental health interventions presented as highly acceptable. However, youth preferred interventions promoting social connectedness, peer support, and holistic approaches to care, while non-youth preferred interventions focused on suicide, and substance abuse prevention. Key informants and survey participants identified schools as the most important setting for mental health interventions. There were no significant differences among quantitative outcomes. Our findings highlight the need for interventions that reduce isolation and increase social connectedness to support youth mental health. As the city designs youth responsive interventions, schools and digital platforms should be prioritized. Engaging multiple stakeholders, particularly young people, tackling cultural stigma surrounding mental health, and improving access to safe community spaces are important considerations for youth mental health interventions.

Developing lygus bug control strategies in potatoes: plant variety, vertical distribution effect, and insecticide efficacy studies.

The Columbia Basin of Oregon and Washington is one of the most productive potatoes, Solanum tuberosum L., growing regions in the United States affected by numerous insect pests. Lygus bugs, Lygus spp. (Hemiptera: Miridae), are an increasing problem in potatoes. In 2015, after an outbreak of lygus bugs in potatoes in the Columbia Basin, potato producers used multiple applications of insecticides to control lygus bugs. However, it is poorly researched whether lygus bugs can cause economic damage to the crop. Therefore, our objectives were (i) to determine lygus bugs presence in potato plants, (ii) to determine damage on most commonly grown potato varieties (e.g., Alturas Russet, Ranger Russet, Umatilla Russet, Russet Burbank, and Clearwater Russet), (iii) to determine the number of insecticide applications needed to control lygus bugs, and (iv) to estimate the relationship between lygus bug density and potato yield loss. This study demonstrated that the lygus complex is widely present in the Columbia Basin, Lygus spp. prefers the upper 1/3 section of potato plants in all varieties tested, and the number of applications throughout a field season does not affect yield regardless of variety.

ABSTRACTS FROM THE FORUM ON ADVANCES IN HEALTHCARE MANAGEMENT RESEARCH.

The following two abstracts are from presentations at the Forum on Advances in Healthcare Management Research that took place in March 2023 during the Congress on Healthcare Leadership of the American College of Healthcare Executives. An annual event, the Forum presents theoretical and empirical research with the potential for high impact on healthcare management. An abstract by Jennifer Ford of the Veterans Health Administration and Patricia MacTaggart of George Washington University titled "Innovative Comprehensive Care Model: Pittsburgh VA Oncology" also was presented at the Forum after publication in the November/December 2021 issue of the Journal of Healthcare Management.

Bacterial and Fungal Symbionts in Pollen Provisions of a Native Solitary Bee in Urban and Rural Environments.

Among insects, symbionts such as bacteria and fungi can be linked to their physiology and immature development, and in some cases are part of a defense system against parasites and diseases. Current bacterial and fungal symbiont associations in solitary bees are understudied, especially in the Pacific Northwest region of the USA. We collected pollen provisions from the native spring-foraging solitary bee, Osmia lignaria Say, across two distinct foraging periods over 2 years at 22 sites along an urban-to-rural gradient in western Washington. We then used next-generation sequencing to identify bacterial and fungi within pollen provisions and assessed the effect of their richness and diversity on O. lignaria larval development success and adult emergence. We detected a significantly positive relationship between bacterial diversity in pollen with O. lignaria larval developmental success, and higher bacterial richness and diversity during the later foraging period. Fungal generic richness and diversity decreased with increasing plant richness. Although neither was associated with O. lignaria developmental success, we did detect Ascosphaera spp. known to be pathogenic to O. lignaria and other bee species. Neither bacterial or fungal richness or diversity was affected by site type when classified as urban or rural. This study provides new information on bacterial and fungal symbionts present in pollen provisions of a native solitary bee when foraging across urban and rural areas of the Pacific Northwest.

External Validation of the eRADAR Risk Score for Detecting Undiagnosed Dementia in Two Real-World Healthcare Systems.

BACKGROUND: Fifty percent of people living with dementia are undiagnosed. The electronic health record (EHR) Risk of Alzheimer's and Dementia Assessment Rule (eRADAR) was developed to identify older adults at risk of having undiagnosed dementia using routinely collected clinical data. OBJECTIVE: To externally validate eRADAR in two real-world healthcare systems, including examining performance over time and by race/ethnicity. DESIGN: Retrospective cohort study PARTICIPANTS: 129,315 members of Kaiser Permanente Washington (KPWA), an integrated health system providing insurance coverage and medical care, and 13,444 primary care patients at University of California San Francisco Health (UCSF), an academic medical system, aged 65 years or older without prior EHR documentation of dementia diagnosis or medication. MAIN MEASURES: Performance of eRADAR scores, calculated annually from EHR data (including vital signs, diagnoses, medications, and utilization in the prior 2 years), for predicting EHR documentation of incident dementia diagnosis within 12 months. KEY RESULTS: A total of 7631 dementia diagnoses were observed at KPWA (11.1 per 1000 person-years) and 216 at UCSF (4.6 per 1000 person-years). The area under the curve was 0.84 (95% confidence interval: 0.84-0.85) at KPWA and 0.79 (0.76-0.82) at UCSF. Using the 90th percentile as the cut point for identifying high-risk patients, sensitivity was 54% (53-56%) at KPWA and 44% (38-51%) at UCSF. Performance was similar over time, including across the transition from International Classification of Diseases, version 9 (ICD-9) to ICD-10 codes, and across racial/ethnic groups (though small samples limited precision in some groups). CONCLUSIONS: eRADAR showed strong external validity for detecting undiagnosed dementia in two health systems with different patient populations and differential availability of external healthcare data for risk calculations. In this study, eRADAR demonstrated generalizability from a research sample to real-world clinical populations, transportability across health systems, robustness to temporal changes in healthcare, and similar performance across larger racial/ethnic groups.

Technical Assistance and Training Needs of Comprehensive Cancer Control Programs: a Qualitative Analysis.

The National Comprehensive Cancer Control Program (NCCCP) was established in 1998 by the Centers for Disease Control and Prevention (CDC) to advance national cancer control implementation across US states and affiliated tribes and territories. To build capacity of NCCCP recipients, technical assistance and training (TAT) is offered in the form of online trainings, webinars, toolkits, workshops, tip sheets, and other products. To determine TAT needs of NCCCP recipients, the George Washington University (GW) Cancer Center conducted a qualitative evaluation to inform TAT planning and implementation. Data on the utilization, applicability, impact, and dissemination of TAT received were collected from comprehensive cancer control practitioners through semi-structured interviews. Detailed memos of interviewee responses were documented and deductively coded based on three themes: promotion of TAT, use of existing TAT, and recommendations for future TAT. Interviewees reported a need for diverse topics, modalities, and TAT reminders. The most widely used TAT resources were social media toolkits, webinars, newsletters, patient navigation resources, and online trainings. Recommendations for future TAT included a focus on coalition support, adaptation and evaluation of evidence-based cancer control strategies, and health equity. Offering a blend of TAT, including educational webinars and trainings, was preferred by CCC professionals and could increase use. Future TAT will provide new opportunities for coalition capacity building, adaptation of evidence-based strategies for cancer control, and center health equity.

Accuracy of tumor registry versus pharmacy dispensings for breast cancer adjuvant endocrine therapy.

PURPOSE: Accounting for endocrine therapy use for breast cancer treatment is important for studies of survivorship. We evaluated the accuracy of Surveillance, Epidemiology, and End Results (SEER) breast cancer endocrine therapy data compared with pharmacy dispensings from an integrated health system. METHODS: We included women with non-metastatic hormone receptor positive primary breast cancer diagnosed between 1995 and 2017 enrolled in Kaiser Permanente Washington, linking their data with SEER. We used pharmacy dispensings for endocrine therapy within one year following diagnosis as our reference standard. We calculated kappa (concordance), positive predictive value (PPV), and negative predictive values (NPV) overall and stratified by woman and tumor characteristics of interest. RESULTS: Of 5,055 women, mean age at diagnosis was 62 years (interquartile range = 53-71); 53% had localized stage, 56% received lumpectomy with radiation, and 31% received chemotherapy. SEER data alone identified 67% of women as having received endocrine therapy; this increased to 75% with pharmacy dispensings. SEER's concordance with pharmacy dispensings was 0.68 (PPV = 91%; NPV = 76%). PPV did not vary by tumor or women characteristics; however, NPV declined with younger age at diagnosis (64% in < 45 years vs. 86% in 75+ years), increasing tumor stage (49% in regional stage vs. 91% in DCIS), and chemotherapy treatment (41% in those with chemotherapy vs. 83% in those without chemotherapy). CONCLUSION: Pharmacy dispensings enable more complete endocrine therapy capture, particularly in women with more advanced tumors or who receive chemotherapy. We determined woman, tumor, and treatment characteristics that contribute to underascertainment of endocrine therapy use in tumor registries.

Optimization and Evaluation of Sensor Angles for Precise Assessment of Architectural Traits in Peach Trees.

Fruit industries play a significant role in many aspects of global food security. They provide recognized vitamins, antioxidants, and other nutritional supplements packed in fresh fruits and other processed commodities such as juices, jams, pies, and other products. However, many fruit crops including peaches (Prunus persica (L.) Batsch) are perennial trees requiring dedicated orchard management. The architectural and morphological traits of peach trees, notably tree height, canopy area, and canopy crown volume, help to determine yield potential and precise orchard management. Thus, the use of unmanned aerial vehicles (UAVs) coupled with RGB sensors can play an important role in the high-throughput acquisition of data for evaluating architectural traits. One of the main factors that define data quality are sensor imaging angles, which are important for extracting architectural characteristics from the trees. In this study, the goal was to optimize the sensor imaging angles to extract the precise architectural trait information by evaluating the integration of nadir and oblique images. A UAV integrated with an RGB imaging sensor at three different angles (90°, 65°, and 45°) and a 3D light detection and ranging (LiDAR) system was used to acquire images of peach trees located at the Washington State University's Tukey Horticultural Orchard, Pullman, WA, USA. A total of four approaches, comprising the use of 2D data (from UAV) and 3D point cloud (from UAV and LiDAR), were utilized to segment and measure the individual tree height and canopy crown volume. Overall, the features extracted from the images acquired at 45° and integrated nadir and oblique images showed a strong correlation with the ground reference tree height data, while the latter was highly correlated with canopy crown volume. Thus, selection of the sensor angle during UAV flight is critical for improving the accuracy of extracting architectural traits and may be useful for further precision orchard management.

Results of the George Washington University cancer center's comprehensive cancer control cancer communication mentorship program and implications for future practice.

PURPOSE: The Comprehensive Cancer Control Cancer Communication Mentorship Program ("Mentorship Program") was created by the George Washington University Cancer Center (GWCC) to provide technical assistance (TA) in implementing evidence-based cancer screening communication interventions and support networking for comprehensive cancer control (CCC) professionals. The Mentorship Program matched entry-to mid-level CCC professionals with health communication and/or CCC experts and offered monthly web-based discussions with academic researchers and practitioners who shared their knowledge and provided applied learning opportunities throughout mentees' project planning, implementation and evaluation. The program objective was for mentees to improve health communication skills and apply evidence-based knowledge to reduce the burden of cancer. METHODS: A mixed methods evaluation was conducted, including a qualitative description of each project and its outcomes as well as quantitative measures of satisfaction with the program and self-rated changes in competence. RESULTS: Mentees represented the following locations: New Jersey, Arkansas, Michigan, West Virginia, and Republic of Palau. Project topics ranged from increasing Human papillomavirus (HPV) vaccinations to increasing screening uptake for colorectal cancer, lung cancer, cervical cancer, and breast cancer. Evaluation results from pre- and post-program communication competency self-assessments and mid- and post-program surveys revealed that the Mentorship Program advanced personal and professional goals and improved public health communication skills. CONCLUSION: The Mentorship Program achieved its objectives for peer networking and offering expert TA in cancer prevention and control communication, offering a promising model for others involved in supporting implementation of evidence in practice.

Flight Potential of Western Tarnished Plant Bug (Hemiptera: Miridae).

The western tarnished plant bug, Lygus hesperus Knight, is an economically important pest of several agricultural crops in the western United States. It is an increasing threat to potato, Solanum tuberosum L. (Solanales: Solanaceae), in the diverse landscape of the Columbia Basin of Oregon and Washington. In this study, flight mills were used to investigate the flight capacity of L. hesperus with the aim of better understand its dispersive characteristics in the agricultural landscape. Explicitly, we investigated the effects of biological factors such as generation, gender, and body weight on the flight potential of adult L. hesperus adults collected from field populations during spring and summer of 2019 and 2020. The study flight parameters assessed were distance, activity, velocity, and diel periodicity. In 24-h flight mill assays, a clear dichotomy pattern was found in sum flown distance for adults that travelled 1 km or shorter and adults that travelled greater than 1 km. Individuals from the summer population flew farther and more actively than those from the overwintered population. Female L. hesperus flew farther and were more active compared to males. Adult body weight before the flight was directly proportional to flight distance and number of flights, but not with velocity. Overwintered L. hesperus adults lost a higher percentage of their pre-flight body weight compared to summer adults over the course of the study. To the best of our knowledge, this is the first study that demonstrated that L. hesperus summer adult population has the flight ability to disperse greater distance in the agricultural landscape than overwintered population.

Prevalence of Recombinant Strains of Potato Virus Y in Seed Potato Planted in Idaho and Washington States Between 2011 and 2021.

Potato virus Y (PVY) has emerged as the main reason for potato seed lot rejections, seriously affecting seed potato production in the United States throughout the past 20 years. The dynamics of PVY strain abundance and composition in various potato growing areas of the United States has not been well documented or understood up to now. The objective of this study was to find out the prevalence of PVY strains in potato fields in the Pacific Northwest (PNW), including seed potato production systems in the State of Idaho and commercial potato fields in the Columbia Basin of Washington State between 2011 and 2021. Based on the testing of >10,000 foliar samples during Idaho seed certification winter grow-out evaluations of seed potato lots and seed lot trials in Washington State, a dramatic shift in the PVY strain composition was revealed in the PNW between 2011 and 2016. During this time period, the prevalence of the ordinary, PVYO strain in seed potato dropped 8- to 10-fold, concomitantly with the rise of recombinant strains PVYN-Wi and PVYNTNa, which together accounted for 98% of all PVY positives by 2021. In Idaho seed potato, PVYNTNa strain associated with the potato tuber necrotic ringspot disease (PTNRD) was found to increase threefold between 2011 and 2019, accounting for 24% of all PVY positives in 2019. Mild foliar symptoms induced by recombinant PVY strains may be partially responsible for the proliferation of PVYN-Wi and PVYNTNa in potato crops. A spike of another PTNRD-associated recombinant, PVY-NE11, was recorded in the PNW between 2012 and 2016, but after reaching a 7 to 10% level in 2012 to 2013 this recombinant disappeared from the PNW potato by 2019. Whole genome sequence analysis of the PVY-NE11 suggested this recombinant was introduced in the United States at least three times. The data on PVY strain abundance in the PNW potato crops suggest that virus management strategies must consider the current dominance of the two recombinant PVY strains, PVYN-Wi and PVYNTNa.

Incidence of SARS-CoV-2 Infection, Emergency Department Visits, and Hospitalizations Because of COVID-19 Among Persons Aged ≥12 Years, by COVID-19 Vaccination Status - Oregon and Washington, July 4-September 25, 2021.

Population-based rates of infection with SARS-CoV-2 (the virus that causes COVID-19) and related health care utilization help determine estimates of COVID-19 vaccine effectiveness and averted illnesses, especially since the SARS-CoV-2 B.1.617.2 (Delta) variant began circulating in June 2021. Among members aged ≥12 years of a large integrated health care delivery system in Oregon and Washington, incidence of laboratory-confirmed SARS-CoV-2 infection, emergency department (ED) visits, and hospitalizations were calculated by COVID-19 vaccination status, vaccine product, age, race, and ethnicity. Infection after full vaccination was defined as a positive SARS-CoV-2 molecular test result ≥14 days after completion of an authorized COVID-19 vaccination series.* During the July-September 2021 surveillance period, SARS-CoV-2 infection occurred among 4,146 of 137,616 unvaccinated persons (30.1 per 1,000 persons) and 3,009 of 344,848 fully vaccinated persons (8.7 per 1,000). Incidence was higher among unvaccinated persons than among vaccinated persons across all demographic strata. Unvaccinated persons with SARS-CoV-2 infection were more than twice as likely to receive ED care (18.5%) or to be hospitalized (9.0%) than were vaccinated persons with COVID-19 (8.1% and 3.9%, respectively). The crude mortality rate was also higher among unvaccinated patients (0.43 per 1,000) than in fully vaccinated patients (0.06 per 1,000). These data support CDC recommendations for COVID-19 vaccination, including additional and booster doses, to protect individual persons and communities against COVID-19, including illness and hospitalization caused by the Delta variant (1).

Birth Outcomes for Planned Home and Licensed Freestanding Birth Center Births in Washington State.

OBJECTIVE: To describe rates of maternal and perinatal birth outcomes for community births and to compare outcomes by planned place of birth (home vs state-licensed, freestanding birth center) in a Washington State birth cohort, where midwifery practice and integration mirrors international settings. METHODS: We conducted a retrospective cohort study including all births attended by members of a statewide midwifery professional association that were within professional association guidelines and met eligibility criteria for planned birth center birth (term gestation, singleton, vertex fetus with no known fluid abnormalities at term, no prior cesarean birth, no hypertensive disorders, no prepregnancy diabetes), from January 1, 2015 through June 30, 2020. Outcome rates were calculated for all planned community births in the cohort. Estimated relative risks were calculated comparing delivery and perinatal outcomes for planned births at home to state-licensed birth centers, adjusted for parity and other confounders. RESULTS: The study population included 10,609 births: 40.9% planned home and 59.1% planned birth center births. Intrapartum transfers to hospital were more frequent among nulliparous individuals (30.5%; 95% CI 29.2-31.9) than multiparous individuals (4.2%; 95% CI 3.6-4.6). The cesarean delivery rate was 11.4% (95% CI 10.2-12.3) in nulliparous individuals and 0.87% (95% CI 0.7-1.1) in multiparous individuals. The perinatal mortality rate after the onset of labor (intrapartum and neonatal deaths through 7 days) was 0.57 (95% CI 0.19-1.04) per 1,000 births. Rates for other adverse outcomes were also low. Compared with planned birth center births, planned home births had similar risks in crude and adjusted analyses. CONCLUSION: Rates of adverse outcomes for this cohort in a U.S. state with well-established and integrated community midwifery were low overall. Birth outcomes were similar for births planned at home or at a state-licensed, freestanding birth center.

Association of Bactericera cockerelli (Hemiptera: Triozidae) With the Perennial Weed Physalis longifolia (Solanales: Solanaceae) in the Potato-Growing Regions of Western Idaho.

The potato psyllid, Bactericera cockerelli (Sulc), is a major pest of potato (Solanales: Solanaceae) as a vector of 'Candidatus Liberibacter solanacearum' (Lso). Bactericera cockerelli colonizes potato from noncrop host plants, yet we do not yet know which noncrop species are the primary sources of Lso-infected psyllids. The perennial weed, Physalis longifolia Nutt., is a high-quality host for B. cockerelli and Lso under laboratory conditions but has been overlooked in recent field studies as a source of Lso-infected psyllids. Our current study had four objectives: 1) determine whether P. longifolia is abundant in potato-growing regions of Washington and Idaho, 2) determine whether stands of P. longifolia harbor B. cockerelli and Lso, 3) identify the psyllid haplotypes occurring on P. longifolia, and 4) use molecular gut content analysis to infer which plant species the psyllids had previously fed upon prior to their capture from P. longifolia. Online herbaria and field searches revealed that P. longifolia is abundant in western Idaho and is present at low densities in the Columbia Basin of Washington. Over 200 psyllids were collected from P. longifolia stands in 2018 and 2019, confirming that B. cockerelli colonizes stands of this plant. Gut content analysis indicated that a proportion of B. cockerelli collected from P. longifolia had arrived there from potato. Confirmation that P. longifolia is abundant in certain potato-growing regions of the Pacific Northwest, and that B. cockerelli readily uses this plant, could improve models to predict the risk of future psyllid and Lso outbreaks.

Aligning care with the personal values of patients with complex care needs.

OBJECTIVE: To identify opportunities to align care with the personal values of patients from three distinct groups with complex medical, behavioral, and social needs. DATA SOURCES/STUDY SETTING: Between June and August 2019, we conducted semi-structured interviews with individuals with complex care needs in two integrated health care delivery systems. STUDY DESIGN: Qualitative study using semi-structured interviews. DATA COLLECTION METHODS: We interviewed three groups of patients at Kaiser Permanente Washington and Kaiser Permanente Colorado representing three distinct profiles of complex care needs: Group A ("obesity, opioid prescription, and low-resourced neighborhood"), Group B ("older, high medical morbidity, emergency department, and hospital use"), and Group C ("older, mental and physical health concerns, and low-resourced neighborhood"). These profiles were identified based on prior work and prioritized by internal primary care stakeholders. Interview transcripts were analyzed using thematic analysis. PRINCIPAL FINDINGS: Twenty-four patients participated; eight from each complex needs profile. Mean age across groups was 71 (range 48-86) years. We identified five themes common across the three groups that captured patients' views regarding values-aligned care. These themes focused on the importance of care teams exploring and acknowledging a patient's values, providing access to nonphysician providers who have different perspectives on care delivery, offering values-aligned mental health care, ensuring connection to community-based resources that support values and address needs, and providing care that supports the patient plus their family and caregivers. CONCLUSIONS: Our results suggest several opportunities to improve how care is delivered to patients with different complex medical, behavioral, and social needs. Future research is needed to better understand how to incorporate these opportunities into health care.

Association Between Self-reported Importance of Religious or Spiritual Beliefs and End-of-Life Care Preferences Among People Receiving Dialysis.

Importance: Although people receiving maintenance dialysis have limited life expectancy and a high burden of comorbidity, relatively few studies have examined spirituality and religious beliefs among members of this population. Objective: To examine whether there is an association between the importance of religious or spiritual beliefs and care preferences and palliative care needs in people who receive dialysis. Design, Setting, and Participants: A cross-sectional survey study was conducted among adults who were undergoing maintenance dialysis at 31 facilities in Seattle, Washington, and Nashville, Tennessee, between April 22, 2015, and October 2, 2018. The survey included a series of questions assessing patients' knowledge, preferences, values, and expectations related to end-of-life care. Data were analyzed from February 12, 2020, to April 21, 2021. Exposures: The importance of religious or spiritual beliefs was ascertained by asking participants to respond to this statement: "My religious or spiritual beliefs are what really lie behind my whole approach to life." Response options were definitely true, tends to be true, tends not to be true, or definitely not true. Main Outcomes and Measurements: Outcome measures were based on self-reported engagement in advance care planning, resuscitation preferences, values regarding life prolongation, preferred place of death, decision-making preference, thoughts or discussion about hospice or stopping dialysis, prognostic expectations, and palliative care needs. Results: A total of 937 participants were included in the cohort, of whom the mean (SD) age was 62.8 (13.8) years and 524 (55.9%) were men. Overall, 435 (46.4%) participants rated the statement about religious or spiritual beliefs as definitely true, 230 (24.6%) rated it as tends to be true, 137 (14.6%) rated it as tends not to be true, and 135 (14.4%) rated it as definitely not true. Participants for whom these beliefs were more important were more likely to prefer cardiopulmonary resuscitation (estimated probability for definitely true: 69.8% [95% CI, 66.5%-73.2%]; tends to be true: 60.8% [95% CI, 53.4%-68.3%]; tends not to be true: 61.6% [95% CI, 53.6%-69.6%]; and definitely not true: 60.6% [95% CI, 52.5%-68.6%]; P for trend = .003) and mechanical ventilation (estimated probability for definitely true: 42.6% [95% CI, 38.1%-47.0%]; tends to be true: 33.5% [95% CI, 25.9%-41.2%]; tends not to be true: 35.1% [95% CI, 27.2%-42.9%]; and definitely not true: 27.9% [95% CI, 19.6%-36.1%]; P for trend = .002) and to prefer a shared role in decision-making (estimated probability for definitely true: 41.6% [95% CI, 37.7%-45.5%]; tends to be true: 35.4% [95% CI, 29.0%-41.8%]; tends not to be true: 36.0% [95% CI, 26.7%-45.2%]; and definitely not true: 23.8% [95% CI, 17.3%-30.3%]; P for trend = .001) and were less likely to have thought or spoken about stopping dialysis. These participants were no less likely to have engaged in advance care planning, to value relief of pain and discomfort, to prefer to die at home, to have ever thought or spoken about hospice, and to have unmet palliative care needs and had similar prognostic expectations. Conclusions and Relevance: The finding that religious or spiritual beliefs were important to most study participants suggests the value of an integrative approach that addresses these beliefs in caring for people who receive dialysis.

A cross-sectional survey of cannabis use by people with MS in Oregon and Southwest Washington.

BACKGROUND: Evidence supports that cannabinoids reduce self-reported spasticity and neuropathic pain in people with MS (PwMS), and legal access to cannabis for medical and recreational use continues to rise. However, there are limited data regarding patterns of cannabis use and perceived benefits of cannabis among PwMS in the US. This study describes the prevalence of cannabis use, routes of administration, perceived benefit of cannabis for MS, and characteristics associated with cannabis use and perception of benefit among a population of PwMS living in two states where cannabis is legal for both medical and recreational use. METHODS: A survey about treatments used by PwMS, focusing on complementary and alternative medicine (CAM), was sent to PwMS living in Oregon and Southwest Washington. This survey included questions about current and past cannabis use, route of cannabis administration, and perceived benefits, as well as personal demographics. RESULTS: Of the 1188 returned surveys, 1000 had at least 75% complete survey responses and also completed the questions about current and past cannabis use. Thirty percent (n=303) of respondents reported currently using cannabis, 21% (n=210) used in the past but not currently, and 49% (n=487) had never used cannabis. Among current users, rates of use by smoking, vaping, topicals, tinctures and oils, or edibles were similar (35-46%), and most (59%) reported using multiple routes of administration. Most (64-78%, varying by route) current and past users reported cannabis being very or somewhat beneficial for their MS. The odds of current cannabis use were higher in PwMS who: 1) were younger (OR 2.24 [95% CI 1.39-3.61] for those age 18-40 compared with age >60]; 2) had lower household income (OR 3.94 [95% CI 2.55-6.09] with annual income <$25k compared with those with >$100k); 3) had secondary progressive MS (OR 1.77 [95% CI 1.07-2.92]); and 4) had more than minimal MS disability (OR 2.05 [95% CI 1.03-4.10] for those using a walker compared to those with none/minimal disability). The odds of perceiving cannabis as beneficial for MS were higher in: 1) younger individuals (OR 5.61 [95% CI 2.62-11.98] for those age 18-40 compared with age >60); 2) those with lower household income (OR 3.35 [95% CI 1.65-6.80] with annual income <$25k compared with those with >$100k), 3) those not currently using disease modifying therapies (OR 2.32 [95% CI 1.30-4.13]), and 4) those with the greatest disability (OR 17.96; [95% CI 2.00-161.22]). CONCLUSION: In this survey, 30% of PwMS reported currently using cannabis for their MS, mostly by multiple routes of administration, and most of these people report this being helpful for their MS. People who were younger, had lower household income, had progressive disease, and had more than minimal disability were more likely to use cannabis and report it was beneficial for their MS. People who were not using disease modifying therapies were also more likely to report benefit from cannabis use.

Prevalence of Medical Cannabis Use and Associated Health Conditions Documented in Electronic Health Records Among Primary Care Patients in Washington State.

Importance: Many people use cannabis for medical reasons despite limited evidence of therapeutic benefit and potential risks. Little is known about medical practitioners' documentation of medical cannabis use or clinical characteristics of patients with documented medical cannabis use. Objectives: To estimate the prevalence of past-year medical cannabis use documented in electronic health records (EHRs) and to describe patients with EHR-documented medical cannabis use, EHR-documented cannabis use without evidence of medical use (other cannabis use), and no EHR-documented cannabis use. Design, Setting, and Participants: This cross-sectional study assessed adult primary care patients who completed a cannabis screen during a visit between November 1, 2017, and October 31, 2018, at a large health system that conducts routine cannabis screening in a US state with legal medical and recreational cannabis use. Exposures: Three mutually exclusive categories of EHR-documented cannabis use (medical, other, and no use) based on practitioner documentation of medical cannabis use in the EHR and patient report of past-year cannabis use at screening. Main Outcomes and Measures: Health conditions for which cannabis use has potential benefits or risks were defined based on National Academies of Sciences, Engineering, and Medicine's review. The adjusted prevalence of conditions diagnosed in the prior year were estimated across 3 categories of EHR-documented cannabis use with logistic regression. Results: A total of 185 565 patients (mean [SD] age, 52.0 [18.1] years; 59% female, 73% White, 94% non-Hispanic, and 61% commercially insured) were screened for cannabis use in a primary care visit during the study period. Among these patients, 3551 (2%) had EHR-documented medical cannabis use, 36 599 (20%) had EHR-documented other cannabis use, and 145 415 (78%) had no documented cannabis use. Patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential benefits (49.8%; 95% CI, 48.3%-51.3%) compared with patients with other cannabis use (39.9%; 95% CI, 39.4%-40.3%) or no cannabis use (40.0%; 95% CI, 39.8%-40.2%). In addition, patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential risks (60.7%; 95% CI, 59.0%-62.3%) compared with patients with other cannabis use (50.5%; 95% CI, 50.0%-51.0%) or no cannabis use (42.7%; 95% CI, 42.4%-42.9%). Conclusions and Relevance: In this cross-sectional study, primary care patients with documented medical cannabis use had a high prevalence of health conditions for which cannabis use has potential benefits, yet a higher prevalence of conditions with potential risks from cannabis use. These findings suggest that practitioners should be prepared to discuss potential risks and benefits of cannabis use with patients.

Qualitative study exploring the barriers to menstrual hygiene management faced by adolescents and young people with a disability, and their carers in the Kavrepalanchok district, Nepal.

BACKGROUND: Menstrual hygiene management (MHM) is a recognised public health, social and educational issue, which must be achieved to allow the realisation of human rights. People with disabilities are likely to experience layers of discrimination when they are menstruating, but little evidence exists. METHODS: The study aims to investigate barriers to MHM that people with disabilities and their carers face in the Kavrepalanchok, Nepal, using qualitative methods. Twenty people with disabilities, aged 15-24, who menstruate and experience 'a lot of difficulty' or more across one or more of the Washington Group functional domains were included, as well as 13 carers who provide menstrual support to these individuals. Purposeful sampling was applied to select participants. Different approaches were used to investigating barriers to MHM and triangulate data: in-depth interviews, observation, PhotoVoice and ranking. We analysed data thematically, using Nvivo 11. RESULTS: Barriers to MHM experienced by people with disabilities differ according to the impairment. Inaccessible WASH facilities were a major challenge for people with mobility, self-care and visual impairments. People with intellectual impairments had difficulty accessing MHM information and their carers despaired when they showed their menstrual blood to others, which could result in abuse. No support mechanisms existed for carers for MHM, and they felt overwhelmed and isolated. Menstrual discomfort was a major challenge; these were managed with home remedies, or not at all. Most participants followed menstrual restrictions, which were widespread and expected; many feared they would be cursed if they did not. As disability is often viewed as a curse, this demonstrates the layers of discrimination faced. CONCLUSION: Issues related to MHM for people with disabilities is more complex than for others in the population due to the additional disability discrimination and impairment experienced. Research exploring these issues must be conducted in different settings, and MHM interventions, tailored for impairment type and carers requirements,should be developed. Attention to, and resourcing for disability inclusive MHM must be prioritised to ensure 'no one is left behind'.