Evaluating the sustainability of patient navigation programs in oncology by length of existence, funding, and payment model participation.

BACKGROUND: For this study, the authors examined whether specific programmatic factors were associated with the sustainability of patient navigation programs. METHODS: This cross-sectional survey explored navigation programmatic factors associated with 3 measures of sustainability: 1) length of program existence, 2) reliance on sustainable funding, and 3) participation in alternative payment models. In total, 750 patient navigators or program administrators affiliated with oncology navigation programs in clinical-based and community-based settings completed the survey between April and July 2019. RESULTS: Associations were observed between both accreditation and work setting and measures of program sustainability. Accredited programs and larger, more resourced clinical institutions were particularly likely to exhibit multiple measures of sustainability. The results also identified significant gaps at the programmatic level in data collection and reporting among navigation programs, but no association was observed between programmatic data collection/reporting and sustainability. CONCLUSIONS: Navigation is not currently a reimbursable service and has historically been viewed as value-added in oncology settings. Therefore, factors associated with sustainability are critical to understand how to build a framework for successful navigation programs within the current system and also to develop the case for potential reimbursement in the future.

Solidifying roles, responsibilities, and the process of navigation across the continuum of cancer care: The Professional Oncology Navigation Task Force.

Since its founding in 1990, the profession of oncology navigation has grown and evolved. Although core concepts serve as a unifying thread throughout the profession, there has not been formal agreement on standardization of definitions, scopes, and roles for the various types of navigators. This has created challenges for sustainability, including reimbursement for navigation services. Emerging from the Biden Cancer Initiative's patient navigation working group, the Professional Oncology Navigation Task Force was created to serve as the voice of professional oncology organizations with an ultimate goal of solidifying definitions, scopes, and roles of navigators across the care continuum. Task group members are committed to cross-disciplinary partnership (including nursing, social work, and nonclinically licensed navigation). As the Task Force worked to define, refine, and disseminate professional standards (with input from the navigation community), the work done by the National Navigation Roundtable was vital to our evolving understanding of the profession. This article outlines the importance of that partnership and highlights the relevant findings of each article in this supplement of Cancer to the standardization work. LAY SUMMARY: Within the profession of oncology navigation, definitions, scopes, and roles of navigators have not been solidified. Standardization of the profession is critical to allow for continued growth and evolution as well as policy direction. This article introduces the work of the Professional Oncology Navigation Task Force, which created the Oncology Navigation Standards of Professional Practice with input from professional leaders and community stakeholders. The article also links the work of the National Navigation Roundtable and the critical need to coordinate and amplify efforts across groups.

Comparing clinical and nonclinical cancer patient navigators: A national study in the United States.

BACKGROUND: A nationwide survey was conducted to examine differences between clinical and nonclinical oncology navigators in their service provision, engagement in the cancer care continuum, personal characteristics, and program characteristics. METHODS: Using convenience sampling, 527 oncology navigators participated and completed an online survey. Descriptive statistics, χ2 statistics, and t tests were used to compare nonclinical (eg, community health worker) and clinical (eg, nurse navigators) navigators on the provision of various navigation services, personal characteristics, engagement in the cancer care continuum, and program characteristics. RESULTS: Most participants were clinical navigators (76.1%). Compared to nonclinical navigators, clinical navigators were more likely to have a bachelor's degree or higher (88.6% vs 69.6%, P < .001), be funded by operational budgets (84.4% vs 35.7%, P < .001), and less likely to work at a community-based organization or nonprofit (2.0% vs 36.5%, P < .001). Clinical navigators were more likely to perform basic navigation (P < .001), care coordination (P < .001), treatment support (P < .001), and clinical trial/peer support (P = .005). Clinical navigators were more likely to engage in treatment (P < .001), end-of-life (P < .001), and palliative care (P = .001) navigation. CONCLUSIONS: There is growing indication that clinical and nonclinical oncology navigators perform different functions and work in different settings. Nonclinical navigators may be more likely to face job insecurity because they work in nonprofit organizations and are primarily funded by grants.

Hunger for sex: Abundant, heterogeneous resources select for sexual reproduction in the field.

Major hypotheses on sex evolution predict that resource abundance and heterogeneity should either select for or against sexual reproduction. However, seldom have these predictions been explicitly tested in the field. Here, we investigated this question using soil oribatid mites, a diverse and abundant group of soil arthropods whose local communities can be dominated by either sexual or asexual species. First, we refined theoretical predictions by addressing how the effects of resource abundance, heterogeneity and abiotic conditions could modify each other. Then, we estimated the strength of selection for sexual species in local communities while controlling for phylogeny and neutral processes (ecological drift and dispersal), and tested its relation to resource and abiotic gradients. We show that sexual species tended to be favoured with increasing litter amount, a measure of basal resource abundance. Further, there was some evidence that this response occurred mainly under higher tree species richness, a measure of basal resource heterogeneity. This response to resources is unlikely to reflect niche partitioning between reproductive modes, as sexual and asexual species overlapped in trophic niche according to a comparative analysis using literature data on stable isotope ratios. Rather, these findings are consistent with the hypothesis that sex facilitates adaptation by breaking unfavourable genetic associations, an advantage that should increase with effective population size when many loci are under selection and, thus, with resource abundance.

Direct and indirect effects of geographic and environmental factors on ant beta diversity across Amazon basin.

Understanding the direct and indirect effects of niche and neutral processes in structuring species diversity is particularly challenging because environmental factors are often geographically structured. Here, we used Structural Equation Modeling to quantify direct and indirect effects of geographic distance, the Amazon River's opposite margins, and environmental differences in temperature, precipitation, and vegetation density (Normalized Difference Vegetation Index-NDVI) on ant beta diversity (Jaccard's dissimilarity) across Amazon basin. We used a comprehensive survey of ground-dwelling ant species from 126 plots distributed across eight sampling sites along a broad environmental gradient. We found that geographic distance and NDVI differences were the major direct predictors of ant composition dissimilarity. The major indirect effect was that of temperature through NDVI, whereas precipitation neither had direct or indirect detectable effects on beta diversity. Thus, ant compositional dissimilarity seems to be mainly driven by a combination of isolation by distance (through dispersal limitation) and selection imposed by vegetation density, and indirectly, by temperature. Our results suggest that neutral and niche processes have been similarly crucial in driving the current beta diversity patterns of Amazonian ground-dwelling ants.

Association Between Fear of Pain and Sports-Related Concussion Recovery in a Pediatric Population.

OBJECTIVE: To determine whether an association exists between fear of pain and recovery time from sports-related concussion in a pediatric population. DESIGN: Prospective observational study. SETTING: Primary outpatient sports medicine clinic of a large pediatric hospital. PATIENTS: One hundred twenty-eight pediatric patients aged 8 to 18 years who presented to clinic with a primary diagnosis of concussion from September 2018 to March 2020. Inclusion criteria included presentation within 2 weeks of injury and symptomatic on initial visit. Patients who sustained a concussion because of motor vehicle collisions or assault were excluded. INDEPENDENT VARIABLES: There was no intervention. Study participants who met inclusion criteria were administered the Fear of Pain Questionnaire (FOPQ) at their initial visit. MAIN OUTCOME MEASURES: Time to clinical recovery was the main outcome measure and was determined by the fellowship-trained sports medicine physician based on resolution of concussion symptoms, resumption of normal physical and cognitive daily activities, no use of accommodations or medications, and normalization of physical exam. RESULTS: There was a significant difference in FOPQ scores for those with prolonged recovery (M = 33.12, SD = 18.36) compared with those recovering in fewer than 28 days (M = 26.16, SD = 18.44; t [126] = -2.18, P = 0.036). CONCLUSIONS: Consistent with the adult literature, we found that pediatric patients are more likely to have a prolonged recovery from concussion when they have higher fear of pain.

Medicare Decision-making, Understanding, and Satisfaction Among Cancer Survivors.

With increased age as a leading risk factor for cancer, many patients depend on Medicare benefits to manage their disease. As such, this study explores (1) Medicare decision-making, (2) Medicare satisfaction, and (3) understanding of Medicare coverage among cancer patients. This cross-sectional study used focus group and survey methodology to explore patient decision-making regarding Medicare benefit selection and patient understanding and satisfaction of Medicare. Focus group findings informed a subsequent survey which was completed by 172 Medicare beneficiaries between December 2018 and January 2019. Quantitative and qualitative analyses were conducted. Findings suggest that although Medicare beneficiaries believe they understand their coverage and are largely satisfied with benefits, many cannot accurately identify the appropriate components of the program particularly regarding how drug benefits are structured. In-depth qualitative analyses from the focus group indicated not only a lack of understanding but a fear of unexpected out-of-pocket costs or coverage challenges. This study illustrates the ongoing challenges with educating Medicare beneficiaries regarding benefits, coverage, and financial obligations of the program. For cancer patients, in-depth and meaningful educational opportunities are critical as is access to multiple components of the Medicare program that can prove vital to the treatment and management of their disease.

Modelling selection, drift, dispersal and their interactions in the community assembly of Amazonian soil mites.

Three processes can explain contemporary community assembly: natural selection, ecological drift and dispersal. However, quantifying their effects has been complicated by confusion between different processes and neglect of expected interactions among them. One possible solution is to simultaneously model the expected effects of each process within species, across communities and across species, thus providing more integrative tests of ecological theory. Here, we used generalized linear mixed models to assess the effects of selection, drift and dispersal on the occurrence probability of 135 soil oribatid mite species across 55 sites over an Amazonian rainforest landscape (64 km2). We tested for interactions between process-related factors and partitioned the explained variation among them. We found that occurrence probability (1) responded to soil P content and litter mass depending on body size and reproductive mode (sexual or parthenogenetic), respectively (selection); (2) increased with community size (drift); and (3) decreased with distance to the nearest source population, and more so in rare species (dispersal limitation). Processes did not interact significantly, and our best model explained 67% of the overall variation in species occurrence probability. However, most of the variation was attributable to dispersal limitation (55%). Our results challenge the seldom-tested theoretical prediction that ecological processes should interact. Rather, they suggest that dispersal limitation overrides the signatures of drift and selection at the landscape level, thus rendering soil microarthropod species ecologically equivalent and possibly contributing to the maintenance of metacommunity diversity.

Longitudinal Outcomes in Adolescents After Referral for Metabolic and Bariatric Surgery.

BACKGROUND: Metabolic and bariatric surgery (MBS) can be a well tolerated and effective treatment option for severe obesity in adolescents. We compared outcomes for adolescents that did and did not proceed to surgery. METHODS: A single-center longitudinal study (2015-2020). Patients were identified as LSG if they completed laparoscopic sleeve gastrectomy within 6 months of initial visit and NoLSG if they did not. Chi-square, Fisher exact, nonparametric Kruskal-Wallis tests, and Linear Mixed Models (LMM) were used to compare outcomes over 2 years. RESULTS: Three hundred fifty-two adolescents were referred with a mean age of 15.6 ±â€Š1.4, 69% girls, 38% Hispanic, and 78% had noncommercial insurance. The median baseline weight was 135 kg and body mass index (BMI) was 48 kg/m2; 42% had a BMI >50. Seventy-nine (22%) underwent LSG whereas 273 (78%) did not complete MBS primarily because of lack of interest. LSG patients had 21% total weight loss and 22% total BMI loss at 24 months whereas NoLSG patients had 4% total weight gain and 3% BMI gain (P < 0.01). Obesity-associated conditions improved in the LSG group (P < 0.01). Follow-up in both groups was poor (≤30% at 24 months). Patients with public insurance and those with BMI from 50 to 59.9 kg/m2 were high performing LSG patients. CONCLUSIONS: A minority (22%) of adolescents referred for MBS proceeded to surgery, despite its demonstrated efficacy and safety in adolescence. Those that did not undergo surgery continued to gain weight. Further research is needed to understand patient preferences or concerns related to MBS utilization during adolescence.

NCCN Patient Advocacy Summit: Delivering Value for Patients Across the Oncology Ecosystem.

As the oncology ecosystem shifts from service-based care to outcomes and value-based care, stakeholders cite concerns regarding the lack of patient experience data that are important to the patient community. To address the patient perspective and highlight the challenges and opportunities within policy and clinical decision-making to improve patient-centered care, NCCN hosted the NCCN Patient Advocacy Summit: Delivering Value for Patients Across the Oncology Ecosystem on December 11, 2019, in Washington, DC. The summit featured multidisciplinary panel discussions, keynote speakers, and patient advocate presentations exploring the implications for patient-centered care within a shifting health policy landscape. This article encapsulates and expounds upon the discussions and presentations from the summit.

An oviposition trap to collect immatures of coprophagous moth flies (Diptera: Psychodidae).

Larvae of Psychodidae develop in a variety of breeding sites, including vertebrate feces. As searching for the larvae can be an extremely difficult task, immatures of many species are little known, with descriptions of coprophagous moth flies all from outside the Neotropics. In an attempt to mitigate this challenge, we tested an oviposition trap using cattle dung as attractant, measured the efficiency and specificity of the traps and the most efficient period of exposition in the field. With 60 traps installed in one fragment of ombrophilous forest, 344 immatures were collected, distributed in four species of Psychoda and one of Feuerborniella. Psychodidae accounted for 75% of the collected Diptera. The high specificity of the trap to Psychodidae contrasts with other studies on coprophagous fauna where they appear in low abundance. Based on the metrics in this study, the most efficient period of trapping exposition was between five to eight days, but the difference was not significant probably due to the high number of zero observations among the traps. Many questions pertaining to coprophagous moth flies remain unanswered. Further research is needed to improve trapping efficiency, elucidate the effects of attractants and determine how environmental factors influence the attractiveness of bait.

Perspectives of Patients With Cancer on the Quality-Adjusted Life Year as a Measure of Value in Healthcare.

OBJECTIVES: Healthcare expenditures in the United States continue to grow; to control costs, there has been a shift away from volume-focused care to value-based care. The incorporation of patient perspectives in the development of value-based healthcare is critical, yet research addressing this issue is limited. This study explores awareness and understanding of patients with cancer about the quality-adjusted life year (QALY), as well as their perspectives regarding the use of the QALY to measure value in healthcare. METHODS: This cross-sectional study used survey methodology to explore patient awareness, understanding, and perspectives on the QALY. A total of 774 patients with cancer and survivors completed this survey in June and July of 2017. Quantitative and qualitative analyses were conducted. RESULTS: Results showed that there is limited awareness of the QALY among patients with cancer and survivors and minimal understanding of how the QALY is used. Only one quarter of respondents believed that the QALY was a good way to measure value in healthcare. Some participants (5%) stated that the QALY could be personally helpful to them in their own decision making, indicating the possible usefulness of the QALY as a decision aid in cancer care. Nevertheless, participants expressed concern about other decision makers using the QALY to allocate cancer care and resources and maintained a strong desire for autonomy over personal healthcare choices. CONCLUSIONS: Although participants believed that the QALY could help them make more informed decisions, there was concern about how it would be used by payers, policymakers, and other decision makers in determining access to care. Implications for policy and research are discussed.

A tropical arthropod unravels local and global environmental dependence of seasonal temperature-size response.

In most ectotherms, adult body size decreases with warming, the so-called 'temperature-size rule' (TSR). However, the extent to which the strength of the TSR varies naturally within species is little known, and the significance of this phenomenon for tropical biota has been largely neglected. Here, we show that the adult body mass of the soil mite Rostrozetes ovulum declined as maximum temperature increased over seasons in a central Amazonian rainforest. Further, per cent decline per °C was fourfold higher in riparian than in upland forests, possibly reflecting differences in oxygen and/or resource supply. Adding our results to a global dataset revealed that, across terrestrial arthropods, the seasonal TSR is generally stronger in hotter environments. Our study suggests that size thermal dependence varies predictably with the environment both locally and globally.

Advance Care Planning Communication: Oncology Patients and Providers Voice their Perspectives.

Advance care planning helps to ensure that patients' end-of-life preferences are understood and discussed with providers. It is an important component of patient-centered care, particularly when patients are facing life-limiting illness. It also has ethical implications for providers, yet evidence suggests that these conversations are not always occurring, particularly in underserved populations. The aim of this study was to understand the challenges and personal beliefs regarding ACP through interviews with patients undergoing active cancer treatment and their oncology providers. This study took place at an urban, multispecialty cancer center in the mid-Atlantic region where approximately 1400 patients are treated each year. Findings revealed differences among both patients and providers in terms of their ACP knowledge, preferences, and practices. Overall, 70% of patients were familiar with advance directives (100% of White patients and 45.5% of Black patients), yet only 35% of them reported having completed one (55.6% of White patients and 18.2% of Black patients, although not statistically significant). Most providers (70%) held ACP conversations with patients with advanced illness only. They tended to make assumptions about the amount of information that patients desired and noted the significant challenges that were inherent with these types of conversations. Overall, ethical implications are inherent in ACP as patients are making medical decisions without always having necessary information. There are various reasons why providers may not supply information regarding potential outcomes and end-of-life planning and why patients may not request (or know to request) more medical information.

What drives the dynamics of a soil mite population under seasonal flooding? A null model analysis.

Floods can inflict high mortality on terrestrial organisms, but may also promote adaptive evolution. In seasonal floodplains, several taxa show flood-related traits that may be important for their long-term persistence, but the available evidence is conflicting. Here, we used a simulation approach to investigate the interplay between seasonal floods and submersion resistance in driving the population dynamics of the parthenogenetic soil mite Rostrozetes ovulum in an Amazonian blackwater floodplain. First, we gathered data from two flood cycles to estimate field survival rate. Next, we used further data from a submersion survival laboratory experiment and a historical flood record to build a null model for R. ovulum's survival rate under seasonal flooding, and then tested it against field survival estimates. Floods caused marked density declines, but the two estimates of field survival rate were statistically equivalent, suggesting relatively constant survival across years. Submersion survival time varied tenfold among individuals, but its variability was within the range known for life history traits of other asexual invertebrates. Both field survival rates were consistent with the null model, supporting seasonal flooding as the main mortality factor. Surprisingly, though, average flood duration was actually larger than the average mite could survive, suggesting that population persistence relies on relatively rare, super-resistant phenotypes. Overall, the studied R. ovulum population appears to have a mainly density-independent dynamics across years, with its viability depending on mechanisms that buffer flood survival rate against temporal oscillations.

Economic investment by ant colonies in searches for better homes.

Organisms should invest more in gathering information when the pay-off from finding a profitable resource is likely to be greater. Here, we ask whether animal societies put more effort in scouting for a new nest when their current one is of low quality. We measured the scouting behaviour of Temnothorax albipennis ant colonies when they inhabit nest-sites with different combinations of desirable attributes. We show that the average probability of an ant scouting decreases significantly with an increase in the quality of the nest in which the colony currently resides. This means that the greater the potential gain from finding a new nest, the more effort a colony puts into gathering information regarding new nest-sites. Our results show, for the first time to our knowledge, the ability of animal societies to respond collectively to the quality of a resource they currently have at their disposal (e.g. current nest-site) and regulate appropriately their information gathering efforts for finding an alternative (e.g. a potentially better nest-site).

Do ants need to be old and experienced to teach?

Learning is widespread in invertebrates. However, whether social insects improve their recruitment skills with experience is only beginning to be investigated. Tandem running is a one-to-one form of recruitment used by certain species of ant. It is a remarkable communication system that meets widely accepted criteria for teaching in non-human animals. Here, we determined experimentally to what extent participation in, and efficient execution of, tandem running depends on either the age or the experience of worker ants. To investigate these issues, we constructed colonies of the ant Temnothorax albipennis with different compositions of inexperienced and experienced workers from different age cohorts and then examined which ants participated in tandem runs when they emigrated. Our results show that the ability to participate actively in recruitment by tandem running is present in all worker age groups but the propensity to participate varies with experience rather than age per se. Experienced individuals were more likely to engage in tandem runs, either as leaders or as followers, than young inexperienced individuals, and older experienced ants were more likely to lead tandems than older inexperienced ants. Young inexperienced ants led faster, more rapidly dispersing and less accurately orientated tandem runs than the older experienced ants. Our study suggests that experience (rather than age per se) coupled to stimulus threshold responses might interact to promote a division of labour so that a suitable number of workers actively participate in tandem runs.

The Identity of the Constriction Region of the Ribosomal Exit Tunnel Is Important to Maintain Gene Expression in Escherichia coli.

Mutational changes in bacterial ribosomes often affect gene expression and consequently cellular fitness. Understanding how mutant ribosomes disrupt global gene expression is critical to determining key genetic factors that affect bacterial survival. Here, we describe gene expression and phenotypic changes presented in Escherichia coli cells carrying an uL22(K90D) mutant ribosomal protein, which displayed alterations during growth. Ribosome profiling analyses revealed reduced expression of operons involved in catabolism, indole production, and lysine-dependent acid resistance. In general, translation initiation of proximal genes in several of these affected operons was substantially reduced. These reductions in expression were accompanied by increases in the expression of acid-induced membrane proteins and chaperones, the glutamate-decarboxylase regulon, and the autoinducer-2 metabolic regulon. In agreement with these changes, uL22(K90D) mutant cells had higher glutamate decarboxylase activity, survived better in extremely acidic conditions, and generated more biofilm in static cultures compared to their parental strain. Our work demonstrates that a single mutation in a non-conserved residue of a ribosomal protein affects a substantial number of genes to alter pH resistance and the formation of biofilms. IMPORTANCE All newly synthesized proteins must pass through a channel in the ribosome named the exit tunnel before emerging into the cytoplasm, membrane, and other compartments. The structural characteristics of the tunnel could govern protein folding and gene expression in a species-specific manner but how the identity of tunnel elements influences gene expression is less well-understood. Our global transcriptomics and translatome profiling demonstrate that a single substitution in a non-conserved amino acid of the E. coli tunnel protein uL22 has a profound impact on catabolism, cellular signaling, and acid resistance systems. Consequently, cells bearing the uL22 mutant ribosomes had an increased ability to survive acidic conditions and form biofilms. This work reveals a previously unrecognized link between tunnel identity and bacterial stress adaptation involving pH response and biofilm formation.

Species diversity of edaphic mites (Acari: Oribatida) and effects of topography, soil properties and litter gradients on their qualitative and quantitative composition in 64 km² of forest in Amazonia.

Small-scale spatial distribution of oribatid mites has been investigated in Amazonia. In addition, medium- and large-scale studies are needed to establish the utility of these mites in detecting natural environmental variability, and to distinguish this variability from anthropogenic impacts. We are expanding the knowledge about oribatid mites in a wet upland forest reserve, and investigate whether a standardized and integrated protocol is an efficient way to assess the effects of environmental variables on their qualitative and quantitative composition on a large spatial scale inside an ecological reserve in Central Amazonia, Brazil. Samples for Berlese-Tullgren extraction were taken in 72 plots of 250 × 6 m distributed over 64 km(2). In total 3,182 adult individuals, from 82 species and 79 morphospecies were recorded, expanding the number of species known in the reserve from 149 to 254. Galumna, Rostrozetes and Scheloribates were the most speciose genera, and 57 species were rare. Rostrozetes ovulum, Pergalumna passimpuctata and Archegozetes longisetosus were the most abundant species, and the first two were the most frequent. Species number and abundance were not correlated with clay content, slope, pH and litter quantity. However, Principal Coordinate Analysis indicated that as the percentage of clay content, litter quantity and pH changed, the oribatid mite qualitative and quantitative composition also changed. The standardized protocol effectively captured the diversity, as we collected one of the largest registers of oribatid mites' species for Amazonia. Moreover, biological and ecological data were integrated to capture the effects of environmental variables accounting for their diversity and abundance.

Mental health factors associated with progression to adolescent metabolic and bariatric surgery.

BACKGROUND: While bariatric surgery has demonstrated significant weight loss for adolescents with severe obesity, only a limited number of adolescents referred to surgery successfully complete the surgical program. Better identification of pre-surgical factors, especially mental health factors, associated with completing bariatric surgery may determine successful referrals to surgical programs versus alternative behavioral health interventions. OBJECTIVES: The primary objective of this article was to investigate the relationship between presurgical mental health factors and whether or not a patient received bariatric surgery within the first six months of entering the program. SETTING: Pediatric Children's Hospital, Bariatric Surgery Program within Pediatric Surgery Department. METHODS: A retrospective medical record review of all patients referred from 2016 to 2019 to an adolescent surgical weight loss program was conducted. Patients were determined as completers if they received a laparoscopic sleeve gastrectomy within 6 months of entering the program. Demographic and preoperative mental health factors among completers (n = 30) were compared with surgery noncompleters (n = 44) using enter method logistic regression. RESULTS: Regression analyses revealed that younger patients, White patients, patients with lower internalizing symptoms on a standardized measure, and patients with greater self-reported motivation for surgery at their initial surgery visit were more likely to obtain surgery within 6 months of starting the program. CONCLUSION: The findings underscore the importance of assessing patients' motivation early in the bariatric surgery referral process. This study highlights potential treatment implications in how best to mitigate patient barriers, such as internalizing symptoms and low motivation, to pursue bariatric surgery and remain committed to weight loss goals through techniques such as motivational interviewing.