Depression influences fatigue in inflammatory bowel disease amongst other factors: a structural modelling approach.

Objectives: Fatigue is common in people with inflammatory bowel disease (IBD) and is associated with IBD activity, sleep disturbance, anxiety and depression. The relative contribution of these factors to fatigue is unclear. This study aimed to investigate the relationship between fatigue and these factors through a novel approach using structural equation modelling. Design: Online questionnaire circulated via three tertiary IBD centres and Crohn's Colitis Australia. Methods: Fatigue was assessed using the Functional assessment of chronic illness measurement system fatigue subscale. Validated measures of sleep, anxiety, depression and IBD activity were included. Following correlation analyses, a structural equation model was developed for the outcome of the fatigue score. Direct and indirect effects were calculated. Results: There were 630 complete responses to the online questionnaire. The median age of respondents was 41 with the majority female and over half (52%) on biologic medication. Structural equation models for Crohn's disease and ulcerative colitis demonstrated a good fit. In Crohn's disease, the relationship between IBD activity and fatigue was mostly mediated indirectly through the influence of IBD activity on sleep, anxiety and primarily depression. Sleep quality mediated the influence of IBD activity and the indirect effects of depression on fatigue, but not anxiety. Unlike in Crohn's disease, the direct influence of IBD activity on fatigue in ulcerative colitis was non-negligible, although remained of lesser magnitude than the indirect effect of IBD activity on fatigue. Depression was the primary indirect mediator of the influence of IBD activity on fatigue in ulcerative colitis. Conclusion: In Crohn's disease, IBD activity leads to fatigue through its influence on sleep quality and mental health. The data suggest treatment of clinically significant depression, in both ulcerative colitis and Crohn's disease, may result in the largest decline in fatigue score compared to other variables. Treatment algorithms for fatigue should consider depression a priority.

Depression influences fatigue in inflammatory bowel disease Fatigue is common in people with inflammatory bowel disease. Studies investigating the causes of fatigue in people with inflammatory bowel disease have consistently identified depression, anxiety, sleep quality and IBD activity as factors associated with fatigue. People with inflammatory bowel disease were asked about their fatigue levels, sleep quality, depression, anxiety and inflammatory bowel disease activity. These responses were used to generate a model to explain the interaction between these factors and how they influence fatigue. The contribution of each of these factors to fatigue was then determined. Depression had the largest overall contribution. The influence of inflammatory bowel disease activity on fatigue occurred mostly through its impact on other factors such as depression and sleep quality. Consideration should be given to screening for and treating depression in people with inflammatory bowel disease and fatigue.

Ethical Implications of Mentor Influence on Career Choices in Dermatology.

Mentorship is a critical aspect of personal and professional development throughout anyone's life. Unlike many other fields, a medical career is a long multistep process that can begin in high school and continue throughout a physician's career. When considering competitive specialties such as dermatology, mentors are increasingly crucial in helping students successfully match to programs of their choice, but the variability and extent of mentorship can raise ethical concerns. We discuss the evolution of mentorship in dermatology and the potential ethical issues involved. We propose possible solutions to the ethical conflict between mentor and mentee.

Noseband type and tightness level affect pressure on the horse's face at trot.

BACKGROUND: Poor noseband adjustment could create high pressures that may risk pain or tissue damage. OBJECTIVES: To quantify sub-noseband pressures dorsally over the nasal bone and ventrally over the mandibular rami for a Cavesson, Swedish (crank), Drop and Flash noseband at five tightness levels (2.0 to 0.0 finger equivalents). STUDY DESIGN: In vivo experiments. METHODS: Eight high-level dressage horses were ridden at the trot in a straight line by their usual riders. Two small pressure mats, attached to the noseband over the nasal bone and the mandibular rami, collected force (N) and pressure (kPa) data from four noseband types (Cavesson/Swedish/Flash/Drop) each adjusted to five tightness levels (2.0/1.5/1.0/0.5/0.0 finger equivalents) based on the use of a taper gauge. Noseband tightness and types were compared using Friedman's analyses with post hoc Wilcoxon tests (p ≤ 0.01). RESULTS: Pressures (median and [25th and 75th percentiles]) and forces increased with tightness for all noseband types with higher mean pressures consistently recorded on the mandibles (Cavesson: 9.1 [5.0, 12.5] kPa, Swedish: 10.5 [6.3, 14.9] kPa, Flash: 8.0 [3.6, 15.2] kPa) than the nasal bones (Cavesson: 2.8 [1.1, 4.7] kPa, Swedish: 4.3 [3.1, 7.4] kPa, Flash: 4.9 [3.0, 7.3] kPa, p ≤ 0.002). None of the measured nasal pressures or forces differed significantly between tightness levels of 2.0 (1.6 [0.6, 3.6] kPa) and 1.5 fingers (2.9 [1.3, 4.1] kPa), but these values significantly increased from 1.0 (3.1 [1.5, 4.9] kPa), 0.5 (4.2 [2.3, 6.2] kPa), and 0.0 finger tightness (6.4 [3.8, 10.3] kPa) for most variables (p ≤ 0.004). No differences were found in mean/maximal nasal and mandibular pressures when fitted with a Cavesson or Swedish noseband. MAIN LIMITATIONS: Behavioural and physiological parameters were not measured. CONCLUSIONS: Nasal and mandibular pressures increased with noseband tightness, with 1.0 finger laxity or less associated with significantly and incrementally higher pressures than 1.5 or 2.0 finger tightness.

Early-life variation in migration is subject to strong fluctuating survival selection in a partially migratory bird.

Population dynamic and eco-evolutionary responses to environmental variation and change fundamentally depend on combinations of within- and among-cohort variation in the phenotypic expression of key life-history traits, and on corresponding variation in selection on those traits. Specifically, in partially migratory populations, spatio-seasonal dynamics depend on the degree of adaptive phenotypic expression of seasonal migration versus residence, where more individuals migrate when selection favours migration. Opportunity for adaptive (or, conversely, maladaptive) expression could be particularly substantial in early life, through the initial development of migration versus residence. However, within- and among-cohort dynamics of early-life migration, and of associated survival selection, have not been quantified in any system, preventing any inference on adaptive early-life expression. Such analyses have been precluded because data on seasonal movements and survival of sufficient young individuals, across multiple cohorts, have not been collected. We undertook extensive year-round field resightings of 9359 colour-ringed juvenile European shags Gulosus aristotelis from 11 successive cohorts in a partially migratory population. We fitted Bayesian multi-state capture-mark-recapture models to quantify early-life variation in migration versus residence and associated survival across short temporal occasions through each cohort's first year from fledging, thereby quantifying the degree of adaptive phenotypic expression of migration within and across years. All cohorts were substantially partially migratory, but the degree and timing of migration varied considerably within and among cohorts. Episodes of strong survival selection on migration versus residence occurred both on short timeframes within years, and cumulatively across entire first years, generating instances of instantaneous and cumulative net selection that would be obscured at coarser temporal resolutions. Further, the magnitude and direction of selection varied among years, generating strong fluctuating survival selection on early-life migration across cohorts, as rarely evidenced in nature. Yet, the degree of migration did not strongly covary with the direction of selection, indicating limited early-life adaptive phenotypic expression. These results reveal how dynamic early-life expression of and selection on a key life-history trait, seasonal migration, can emerge across seasonal, annual, and multi-year timeframes, yet be substantially decoupled. This restricts the potential for adaptive phenotypic, microevolutionary, and population dynamic responses to changing seasonal environments.

Differential impacts of the COVID-19 pandemic on mental health service access among Medicaid-enrolled individuals.

The COVID-19 public health emergency (PHE) caused significant disruptions in the delivery of care, with in-person visits decreasing and telehealth use increasing. We investigated the impact of these changes on mental health services for Medicaid-enrolled adults and youth in Washington State. Among enrollees with existing mental health conditions, the first year of the PHE was associated with a surge in specialty outpatient mental health visits (13% higher for adults and 7% higher for youth), returning to pre-PHE levels in the second year. Conversely, youth with new mental health needs experienced a decline in specialty outpatient visit rates by ∼15% and 37% in the first and second years of the PHE, respectively. These findings indicate that while mental health service use was maintained or improved for established patients, these patterns did not extend to Medicaid-enrolled youth with new mental health needs, potentially due to barriers such as difficulty in finding providers and establishing new patient-provider relationships remotely. To bridge this gap, there is a need for a multi-faceted approach that includes improving service accessibility, enhancing provider availability, and optimizing initial care encounters, whether in-person or virtual, to better support new patients.

Insurance acceptance and cash pay rates for psychotherapy in the US.

Cost and insurance coverage remain important barriers to mental health care, including psychotherapy and mental health counseling services ("psychotherapy"). While data are scant, psychotherapy services are often delivered in private practice settings, where providers frequently do not take insurance and instead rely on direct pay. In this cross-sectional analysis, we use a large national online directory of 175 083 psychotherapy providers to describe characteristics of private practice psychotherapy providers who accept and do not accept insurance, and assess self-reported private pay rates. Overall, about one-third of private practice psychotherapists did not accept insurance, with insurance acceptance varying substantially across states. We also found significant session rate differentials, with Medicaid rates being on average 40% lower than reported cash pay rates, which averaged $143.26 a session. Taken together, low insurance acceptance across a broad swath of mental health provider types means that access to care is disproportionately reliant on patients' ability to afford out-of-pocket payments-even when covered by insurance. While our findings are descriptive and may not be representative of all US psychotherapists, they add to scant existing knowledge about the cash pay market for an important mental health service that has experienced increased use and demand over time.

"A sweating moment": impact of disclosure in cancer care on LGBTQI patient satisfaction.

PURPOSE: Lesbian, gay, bisexual, trans, queer, and intersex (LGBTQI) people face unique challenges in cancer care. This mixed methods study examined LGBTQI patients' satisfaction with cancer care and factors associated with satisfaction, including experiences of LGBTQI disclosure. The study also explored what helps to facilitate safe disclosure and improve satisfaction with care for this population. METHODS: We used a mixed methods approach, involving 430 surveys and 104 semi-structured interviews with LGBTQI people with cancer (16-92 years) with various cancer types, sexuality and gender identities, ages, and people with intersex variations. RESULTS: Most participants reported being satisfied with their cancer care (n = 300, 76.3%) and had disclosed their LGBTQI sexuality or gender identity or intersex variations to at least some of their cancer healthcare professionals (HCPs) (n = 357, 87.1%). Satisfaction with care was higher with more disclosure to HCPs, HCP acknowledgment of partner/s and support people, and the ability to find LGBTQI specific information about cancer; it was lower with reports of discrimination in cancer care. Qualitative analysis identified that some participants were always out to HCPs, but others felt burdened with the responsibility and emotion work of disclosure and feared negative responses. Same-gender intimate partners facilitated disclosure and need to be respected within cancer care. CONCLUSIONS: HCPs need to take the lead in facilitating LGBTQI disclosure in cancer care. Targeted interventions and training for HCPs, including reception and administration staff, are crucial to ensure equitable, affirming cancer care for all LGBTQI patients, ultimately leading to improved satisfaction with cancer care. IMPLICATIONS FOR CANCER SURVIVORS: Creating safe and inclusive environments for LGBTQI cancer patients is essential to encourage disclosure and improve satisfaction with cancer care.

Caught in the crossfire: biodiversity conservation paradox of sociopolitical conflict.

The current state of global biodiversity is confronted with escalating threats arising from human-induced environmental changes and a growing array of unpredictable challenges. However, effective conservation efforts are often hindered by limited knowledge, especially in developing economies such as the Philippines. The limitations imposed by these shortfalls in biodiversity knowledge hamper the capacity to protect biodiversity in light of the continuing extinction crisis. Our study revealed that areas with higher conflict levels exhibited lower species richness, fewer occurrence records, and reduced forest cover. This finding provides initial evidence for the relationship between sociopolitical conflict and biodiversity in the Philippines. We posit that the security risks caused by sociopolitical conflicts could have a negative impact on conservation efforts, particularly in terms of monitoring and implementing measures to protect natural resources. The links that bind armed conflict and biodiversity conservation are multifaceted and complex issues that warrant greater scientific and political attention. Finally, we identified 10 meaningful approaches to address shortfalls in biodiversity knowledge in conflicted areas, particularly incorporating conflict-sensitive approaches, considering the geopolitical context and conflict dynamics to adapt and align their strategies with local realities for more effective conservation efforts.

The Role of Equestrian Professionals in Saddle Fit for Horses and Riders in the United Kingdom.

The horse owner and the multi-disciplinary team (MDT) are responsible for safeguarding horse welfare by ensuring the equipment being used is correctly fitted. The aim of this study was to investigate how saddle fit is assessed, managed, and acted upon by equestrian professionals. Participants (n = 483) completed an online questionnaire, which was split into three major sections: (1) participant demographics; (2) saddle fit for the horse; and (3) saddle fit for the rider. Descriptive statistics, Kruskal-Wallis, and univariable and multivariable analyses were performed (p < 0.05). Inductive content analysis identified themes from open-question responses. From the UK responses (n = 377), 184 saddle fitters, 77 therapists, and 116 coaches completed the survey. Compared to coaches, saddle fitters and therapists asked more frequently when their clients last had their saddle fitted (p = 0.0004). Saddle fitters typically assessed the saddle statically and dynamically vs. therapists, where it was dependent on the circumstances of the assessment (p = 0.0004). Saddle fitters experienced the saddle being out of balance more than therapists (p = 0.032) and made more alterations to the saddle than therapists and coaches (p = 0.0004). This study highlights opportunities for professions within the MDT to better support each other and horseowners to achieve improvements in overall fit for horses and riders.

Pharmacogenomics and pediatric drug development: science and political power. A narrative review.

INTRODUCTION: Pharmacogenomics (PGx) investigates how genomes control enzyme expression. Developmental pharmacology (DP) describes the temporal sequence of enzymes impacting absorption, distribution, metabolism, and excretion (ADME) of food and drugs. AREAS COVERED: US and European Union (EU) legislation facilitate and/or enforce pediatric studies for all new drugs, called overall 'pediatric drug development' (PDD). DP and PDD look at patients' chronological age, but oscillate between legal and physiological meanings of the term 'child.' Children's bodies become mature with puberty. EXPERT OPINION: Decades after first DP observations in babies, PGx offers a better understanding of the variability of safety and efficacy of drugs, of the process of aging, and of shifting enzyme patterns across aging. We should rethink and revise outdated interpretations of ADME changes in minors. The Declaration of Helsinki forbids pointless studies that some pediatric researchers and regulatory agencies, more so the EMA than the FDA, demand pointless pediatric studies is regrettable. Medicine needs to differentiate between legal and physiological meanings of the term 'child' and should use objective measures of maturity.

Call to action: Blueprint for change in acute and critical care nursing.

Herein, we propose a blueprint for action to completely measure and recognize the care provided by acute and critical care nurses to be incorporated into policy that shapes and supports practice. We address the nature of nurses' work by identifying nine practice domains, hospital practice environment assumptions, and expected outcomes. Nurses' work, as a cross-system process, needs to be included in hospital-based core measures to fully reflect nurses' impact on patient care. We call for a balanced measurement portfolio focused on patient/family-, unit-, and systems-level outcomes. We focus on what nurses do and what patients and their families can expect rather than only on the elimination of select adverse events. We provide a way forward to allow measure development and implementation with incentives for their use. This approach to making nurses' contributions and impact on outcomes visible will enhance acute and critical care nursing practice and benefit patients and their families.

Assembled genome of an Ethiopian Plasmodium vivax isolate generated using GridION long-read technology.

Plasmodium vivax causes ~20% of malaria cases in Ethiopia. Here, we report a long-read genome assembly generated from an individual collected in 2022. P. vivax is genetically diverse across endemic regions; thus, the genome assembly of an African isolate is an important resource for the malaria research community.

Ethics of Dynamic and Differential Pricing for Cosmetic Procedures.

Patient demand for procedures has increased in the evolving landscape of cosmetic dermatology. This has been fueled, in part, by social media and the growing normalization of cosmetic enhancements; however, this has led some patients to have potentially unrealistic expectations, placing undue pressure on dermatologists to meet these often unrealizable demands. This pressure is further exacerbated by patients who are seen as difficult, demanding, and time-consuming and who may require extensive counseling. Physicians may adopt dynamic or differential pricing strategies to offset the additional time and effort these patients require. We discuss the ethical concerns surrounding these pricing strategies in the cosmetic sphere, highlight the importance of transparency in pricing, and offer suggestions to promote clarity and fairness in cosmetic dermatology practices.