Cultural Values Influence on Rural Family Caregivers' Decision-Making for Ill Older Adult Loved Ones.

CONTEXT: Rural older adult Americans receive more intense treatment at end of life. Studies indicate that those who participate in goals of care conversations receive care more concordant with their values. Yet, rates of documented goals of care discussions are lower in rural and Black communities. Although multi-factorial, the role that rural family caregivers (FCGs) play in decision-making for ill loved ones is understudied. OBJECTIVE: This study aimed to explore rural FCGs cultural values, beliefs, and attitudes about serious illness and treatment decision-making and to understand how these factors influence their decision-making around goals of care for their family members. METHODS: This is an embedded qualitative study within a tele-palliative care consult randomized trial that the PEN-3 theoretical model guided. Semi-structured interviews were conducted with FCGs who had completed study participation. Thematic analysis was used to analyze the data. RESULTS: Twelve rural FCGs center their decisions around core values, and the decision-making experience was supported by faith. A model of how the key themes and subthemes interact around the central space of supporting the seriously ill loved to demonstrate the complexity of caregiving when race and rurality intersect is presented. CONCLUSION: This study is a foundational step in understanding how rural FCGs beliefs and values influence decision-making. We recommend incorporating those constructs into the development of culturally responsive decision-support interventions.

Self-compassion reduces posttraumatic stress symptom severity in hurricane survivors via perceived social support.

OBJECTIVE: Following disasters such as hurricanes, self-compassion (e.g., being understanding and showing care toward oneself) can be a valuable personal resource that facilitates social support and reduces posttraumatic symptoms. As a result of their increased connection to other people and interpersonal competence, self-compassionate people may perceive more social support following a traumatic event, which in turn reduces posttraumatic stress symptoms (PTSS). The present study is the first to utilize a longitudinal design and latent variable modeling to test this mediation hypothesis. METHOD: A three-wave longitudinal design was utilized to assess hurricane exposure, self-compassion, perceived social support, and PTSS in hurricane survivors at baseline (T1), 3-month (T2), and 6-month (T3) follow-up. Participants at T1 included 261 hurricane survivors (88.5% women) who were racially diverse and particularly vulnerable to loss of resources (53.2% with an income of less than $30,000). Participants were recruited using online, print, and face-to-face methods, and all survey responses were completed online. RESULTS: Participants reported high hurricane stressor exposure (M = 9.14 serious stressors out of a possible 24). Controlling for hurricane exposure, self-compassion at T1 predicted PTSS at T3, and this was mediated by perceived social support at T2. CONCLUSIONS: Following hurricane exposure, self-compassionate people experience less PTSS over time because they perceive their social support resources to be more robust. Implementation of self-compassion education and training following a disaster could improve perceived social support networks that provide an additional protective factor against PTSS. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Random intercept cross-lagged relations among trauma coping self-Efficacy, trauma coping, and PTSD symptoms among rural hurricane survivors.

BACKGROUND AND OBJECTIVES: The trajectories of recovery and non-recovery following a disaster are well-documented, but the mechanisms of post-disaster adaptation remain poorly understood. Rooted in social cognitive theory and the transactional model of stress and coping, this study longitudinally investigated the reciprocal relations among coping self-efficacy (CSE), coping behaviors (approach and avoidant), and posttraumatic stress symptoms (PTSS) among highly exposed hurricane survivors. DESIGN: 261 Hurricane Florence survivors completed measures of hurricane-related CSE, coping behaviors, and hurricane-related PTSS across three timepoints, beginning 5-8.5 months after Hurricane Florence. METHOD: Random-intercept cross-lagged panel models investigated the relations among study variables. RESULTS: Reciprocal, cross-lagged relations were identified between higher CSE and approach coping from T2 to T3. The lagged relations between approach coping at T1 and T2 were significant, as well as between avoidant coping at T2 and T3. Significant cross-sectional relations were also present for CSE, coping behaviors, and PTSS at T3. CONCLUSIONS: Results provide partial support for the positive feedback loop involving CSE and approach coping, but not for the negative feedback loop involving avoidant coping. CSE may be an important mechanism in longer-term disaster recovery, in part by increasing use of approach coping.

Paraneoplastic Dermatoses and Cutaneous Metastases.

Paraneoplastic syndromes include a variety of cutaneous presentations that have an associated internal malignancy. Some syndromes have a strong correlation to specific internal malignancies, whereas others are associated with a multitude of tumors. There are many cutaneous manifestations that suggest hematologic disorders, which will be reviewed in detail. Cutaneous metastases are commonly from breast and lung cancers and can present as nodules, vascular lesions, eczematous dermatitis, or inflammatory lesions. The most common histologic presentation of cutaneous metastasis is that of a dermal-based or subcutaneous-based nodule with sparing of the epidermis. Determination of origin of tumor requires immunohistochemistry and clinical correlation.

Recovery and adjustment trajectories among Hurricane Florence survivors: Analysis utilizing nonlinear dynamic system modeling.

Self-regulation shift theory (SRST) argues that most individuals are able to successfully recover from trauma via engagement in self-regulation processes as well as the effective utilization of internal and environmental resources. However, a minority of individuals may instead experience a self-determination violation as a result of their self-regulatory capacity being overwhelmed. This self-determination violation is marked by chaotic and shifting adjustment, maladaptive regulation attempts, and, ultimately, a shift to an impaired self-state and the development of persistent psychopathology, such as posttraumatic stress disorder (PTSD). The current study utilized nonlinear dynamic system (NDS) analysis to identify adjustment trajectory dynamics among rural hurricane survivors in North Carolina (N = 131) who completed daily ecological momentary assessments (EMAs) regarding their distress (i.e., negative mood and PTSD symptoms), regulation efforts (e.g., coping), and appraisals (e.g., coping self-efficacy) over a 6-week period. Four adjustment trajectories were identified, including two largely adaptive trajectories (69.0% and 5.7%), a less stable adjustment trajectory (6.9%), and a fourth trajectory (18.4%) marked by shifting adjustment states and more frequent maladaptive regulation and negative appraisals, suggesting possible self-determination violation. Consistent with this possibility, this final trajectory was also associated with more severe PTSD symptoms relative to the other three trajectories at enrollment and 6-month follow-up. Future work should utilize NDS to model posttrauma adjustment dynamics from within a SRST framework to identify patterns of positive and negative adjustment dynamics at different time points in the trauma recovery process.

The Efficacy of the BioFire FilmArray Gastrointestinal Panel to Reduce Hospital Costs Associated With Contact Isolation: A Pragmatic Randomized Controlled Trial.

BACKGROUND: Molecular syndromic panels can rapidly detect common pathogens responsible for acute gastroenteritis in hospitalized patients. Their impact on both patient and healthcare system outcomes is uncertain compared to conventional stool testing. This randomized trial evaluates the impact of molecular testing on in-hospital resource utilization compared to conventional stool testing. METHODS: Hospitalized patients with acute diarrheal illness were randomized 1:1 to either conventional or molecular stool testing with the BioFire FilmArray gastrointestinal panel (FGP). The primary outcome was the duration of contact isolation, and secondary outcomes included other in-hospital resource utilization such as diagnostic imaging and antimicrobial use. RESULTS: A total of 156 patients were randomized. Randomization resulted in a balanced allocation of patients across all three age strata (<18, 18-69, ≥70 years old). The proportion of positive stools was 20.5% vs 29.5% in the control and FGP groups, respectively (p=0.196). The median duration of contact isolation was 51 hours (interquartile range [iqr] 66) and 69 hours (iqr 81) in the conventional and FGP groups, respectively (p=0.0513). There were no significant differences in other in-hospital resource utilization between groups. CONCLUSIONS: There were no differences in in-hospital resource utilization observed between the FGP and conventional stool testing groups.

Long-term Effects of Remote Patient Monitoring in Patients Living with Diabetes: A Retrospective Look at Participants of the Mississippi Diabetes Telehealth Network Study.

Introduction: Remote patient monitoring (RPM) has demonstrated value as a tool to aid patients in management of their chronic illness in the home. Although the Mississippi Diabetes Telehealth Network Study (MSDTNS) was successful in reducing HbgA1c levels for patients participating in RPM in the Mississippi Delta, the long-term effect of RPM on patients and how to support patients to maintain the treatment effect after discharge remain unclear. Objective: This study evaluated the long-term effectiveness of an RPM program after the intervention was withdrawn. Materials and Methods: A retrospective review of medical records of patients who completed all phases of the MSDTNS from 2014 to 2016 was performed over a period of 6 months. Data collected included HbgA1c values, demographics, and changes in social determinants of health. Results: Of the 31 participants, African Americans displayed a significant difference in HbgA1c values compared with Caucasians since the end of the MSDTNS. No significant effect of other variables, such as income, marital status, insurance coverage, or age, on the change in HbgA1c values was detected since the end of the original study. Conclusions and Relevance: This limited study implies that African Americans are at higher risk for an increase in hemoglobin A1C after the program is completed. More investigation is needed to identify ways to reduce their risk and equalize the long-term effects of RPM on clinical outcomes of patients in rural or underserved communities.

Assessing Family Medicine Physicians' Perceptions of Integrated Behavioral Health in a Primary Care Residency.

BACKGROUND AND OBJECTIVES: Physicians are increasingly confronted with patients' interrelated psychosocial and physiological issues. To assist physicians in managing the psychosocial needs of patients, integrated behavioral health (IBH) has become increasingly common. This study was completed in a large, Midwestern family medicine residency program where the authors sought to (1) identify physicians' perceptions of IBH implementation and areas of needed IBH improvement, and (2) recognize educational needs to be addressed when providing behavioral health training to resident physicians. METHODS: The authors utilized a pre/post design to measure physician perception of access and quality of an integrated behavioral health program. For quantitative data, we performed standard descriptive statistics, likelihood ratio χ2 tests, independent sample t test, and linear mixed-model analysis. For qualitative data, we completed phenomenological analysis, derived from a focus group. RESULTS: Physician satisfaction with access and quality of behavioral health services significantly improved after the implementation of the IBH (P<.01). Perception of behavioral health management also improved, including the commitment of the residency program to mental health well-being, benefit from consultations with BHPs, and physician ownership of managing patients' mental health needs. Themes from the focus group indicated a desire for increased communication with BHPs, as well as additional assessment and intervention skills to manage psychiatric disorders. CONCLUSIONS: Family physicians value IBH in supporting patients' behavioral health treatment, and resident physicians hone behavioral health management skills through collaborating with BHPs and completing behavioral health training. Residencies should increase focus on teaching essential skills in behavioral health management.

COVID-19-Associated Coagulopathy in the Peripartum Setting: A Case Report.

Sepsis-induced coagulopathy (SIC) scoring and D-dimer can be used to recognize COVID-19-induced coagulopathy, but the utility of these is largely unknown in the peripartum setting and leaves anticoagulation guidance unclear. We present the case of a critically ill postpartum patient with COVID-19 infection. This patient presented with clinical signs of COVID-19 infection and developed acute respiratory failure requiring invasive mechanical ventilation and subsequent cesarean delivery at 34 weeks. She initially improved postoperatively but deteriorated after postoperative day 5. She was found to have a very elevated D-dimer of 58 µg/mL and anticoagulation was escalated to full dosing. She required prolonged mechanical ventilation and deceased after developing gram-positive cocci bacteremia. This case demonstrates that recognition and management of COVID-19-associated coagulopathy can be confusing in the peripartum period and studies are needed to validate D-dimer and SIC scoring in this population of patients.

Received support in the aftermath of Hurricane Florence: reciprocal relations among perceived support, community solidarity, and PTSD.

Background and Objectives: The social support deterioration model (SSDM) posits that individuals who do not receive adequate support following a disaster are vulnerable to losses in community solidarity and perceived support, as well as the development of persistent distress. However, limited longitudinal research has evaluated the relations among support and these outcomes among disaster-affected individuals. Design: The current study utilized random intercept cross-lagged panel modeling (RI-CLPM) to examine reciprocal relations among received support, community solidarity, perceived support, and posttraumatic stress disorder (PTSD) symptoms among rural Hurricane Florence survivors (n = 261) assessed 5-8 months post-hurricane (T1), and then at two more timepoints at three-month intervals (T2 and T3). Results: Results of the RI-CLPM supported that lower received support at T2 was associated with decreases in community solidarity at T3, and higher perceived support at T1 was associated with increases in received support at T2. In supplemental analyses, higher received support at T2 was associated with lower PTSD symptoms at T3. Conclusions: Consistent with the SSDM, individuals who receive less support post-disaster are vulnerable to losses in community solidarity and potentially persistent PTSD symptoms. Conversely, those with stronger support networks may be better able to access needed support in the longer-term.

Pharmacological effects of ex vivo mesenchymal stem cell immunotherapy in patients with acute kidney injury and underlying systemic inflammation.

Mesenchymal stem cells (MSCs) have natural immunoregulatory functions that have been explored for medicinal use as a cell therapy with limited success. A phase Ib study was conducted to evaluate the safety and immunoregulatory mechanism of action of MSCs using a novel ex vivo product (SBI-101) to preserve cell activity in patients with severe acute kidney injury. Pharmacological data demonstrated MSC-secreted factor activity that was associated with anti-inflammatory signatures in the molecular and cellular profiling of patient blood. Systems biology analysis captured multicompartment effects consistent with immune reprogramming and kidney tissue repair. Although the study was not powered for clinical efficacy, these results are supportive of the therapeutic hypothesis, namely, that treatment with SBI-101 elicits an immunotherapeutic response that triggers an accelerated phenotypic switch from tissue injury to tissue repair. Ex vivo administration of MSCs, with increased power of testing, is a potential new biological delivery paradigm that assures sustained MSC activity and immunomodulation.

Nitrogen form, concentration, and micronutrient availability affect microcystin production in cyanobacterial blooms.

Harmful algal blooms (HABs) are increasing in magnitude, frequency, and duration caused by anthropogenic factors such as eutrophication and altered climatic regimes. While the concentrations and ratios of nitrogen (N) and phosphorus are correlated with bloom biomass and cyanotoxin production, there is less known about how N forms and micronutrients (MN) interact to regulate HABs and cyanotoxin production. Here, we used two separate approaches to examine how N and MN supply affects cyanobacteria biomass and cyanotoxin production. First, we used a Microcystis laboratory culture to examine how N and MN concentration and N form affected the biomass, particulate N, and microcystin-LR concentration and cell quotas. Then, we monitored the N, iron, molybdenum, and total microcystin concentrations from a hypereutrophic reservoir. From this hypereutrophic reservoir, we performed a community HAB bioassay to examine how N and MN addition affected the biomass, particulate N, and microcystin concentration. Microcystis laboratory cultures grown in high urea and MN conditions produced more biomass, particulate N, and had similar C:N stoichiometry, but lower microcystin-LR concentrations and cell quotas when compared to high nitrate and MN conditions. Our community HAB bioassay revealed no interactions between N concentration and MN addition caused by non-limiting MN background concentrations. Biomass, particulate N, and microcystin concentration increased with N addition. The community HAB amended with MN resulted in greater microcystin-LA concentration compared to non-MN amended community HABs. Our results highlight the complexity of how abiotic variables control biomass and cyanotoxin production in both laboratory cultures of Microcystis and community HABs.

A retrospective evaluation of eastern coral snake envenomation and antivenom administration in cats: 30 cases (2012-2019).

Thirty cats were identified to be have been suspected to have a potential coral snake envenomation after searching medical records from 2012 to 2019 at a university teaching hospital. The records were reviewed and evaluated for signalment, date and time of the snake encounter, elapsed time between encounter and hospital examination, presenting complaint, initial physical examination findings, initial laboratory findings, antivenom dose and duration of administration, adverse reactions to antivenom, additional treatments administered, progression of clinical signs, length of hospitalization, and outcome. Thirteen cats presented with clinical signs consistent with envenomation while 17 cats were treated for possible asymptomatic envenomation, as defined by the owner discovering a live or dead coral snake in their home or on their property. Initial physical examination findings included tachypnea with short shallow breaths and use of accessory muscles; tetraparesis with normal or decreased to absent spinal reflexes; cranial nerve deficits including decreased to absent gag, slow pupillary light reflexes, and absent physiologic nystagmus; and normal or altered mentation. Laboratory findings included hypercapnia, hyperglycemia, hypokalemia, increased aspartate aminotransferase activity, increased alanine aminotransferase activity, echinocytosis, leukocytosis, azotemia, and hyperlactatemia. Twenty-eight cats received antivenom; two cats received two vials while twenty-six cats received one vial. Antivenom reaction was suspected in one cat that developed facial swelling during administration of the drug. Average length of hospitalization was 1 day for cats without clinical signs and 3 days for cats with clinical signs. Twenty-nine cats survived to discharge. Due to the inclusion criteria of the study, cats euthanized on presentation or discharged without receiving antivenom may have been unintentionally excluded from the study. Diagnosis of eastern coral snake envenomation should be suspected in the cat that has acute onset of lower motor neuron neuropathy. Prognosis with treatment is considered good with 97% of cats surviving to discharge. Antivenom reaction occurred in 3.5% of administrations with none being fatal. Monitoring of hypercapnia was critical in making the decision to mechanically ventilate patients. Supportive care that includes antivenom administration, recumbency care, and mechanical ventilation if needed are the mainstays of therapy.

A Monolithic Spatial Heterodyne Raman Spectrometer: Initial Tests.

A monolithic spatial heterodyne Raman spectrometer (mSHRS) is described, where the optical components of the spectrometer are bonded to make a small, stable, one-piece structure. This builds on previous work, where we described bench top spatial heterodyne Raman spectrometers (SHRS), developed for planetary spacecraft and rovers. The SHRS is based on a fixed grating spatial heterodyne spectrometer (SHS) that offers high spectral resolution and high light throughput in a small footprint. The resolution of the SHS is not dependent on a slit, and high resolution can be realized without using long focal length dispersing optics since it is not a dispersive device. Thus, the SHS can be used as a component in a compact Raman spectrometer with high spectral resolution and a large spectral range using a standard 1024 element charge-coupled device. Since the resolution of the SHRS is not dependent on a long optical path, it is amenable to the use of monolithic construction techniques to make a compact and robust device. In this paper, we describe the use of two different monolithic SHSs (mSHSs), with Littrow wavelengths of 531.6 nm and 541.05 nm, each about 3.5 × 3.5 × 2.5 cm in size and weighing about 80 g, in a Raman spectrometer that provides ∼3500 cm-1 spectral range with 4-5 cm-1 and 8-9 cm-1 resolution, for 600 grooves/mm and 150 grooves/mm grating-based mSHS devices, respectively. In this proof of concept paper, the stability, spectral resolution, spectral range, and signal-to-noise ratio of the mSHRS spectrometers are compared to our bench top SHRS that uses free-standing optics, and signal to noise comparisons are also made to a Kaiser Holospec f/1.8 Raman spectrometer.

Improving Emotional and Cognitive Outcomes for Domestic Violence Survivors: The Impact of Shelter Stay and Self-Compassion Support Groups.

This study examined the effectiveness of a domestic violence shelter and tested the impact of a self-compassion support group curriculum on outcomes valued by shelters such as autonomy, emotional restoration, and safety. Data were collected from 251 women staying in a domestic violence shelter who had the opportunity to attend a self-compassion support group during their stay. Women completed a pre- and posttest survey assessing self-compassion, empowerment, positive emotion, and perceptions of safety. First, women experienced a positive change (N = 36) from pretest to posttest across all four outcome variables, suggesting the domestic violence shelter was effective at improving survivors' well-being. Second, participants who attended a self-compassion support group at least once reported more positive posttest scores compared with those who did not attend a group (N = 79); however, this effect was limited to participants who stayed in shelter a short time. Women who stayed in shelter a longer amount of time experienced more positive posttest scores regardless of group attendance. Although the sample size was limited, analyses directly comparing the traditional shelter support group with the self-compassion support group show that both were equally effective. These findings provide support for shelter effectiveness in terms of improving well-being. They also suggest women who stay in shelter a short period of time may not experience as many shelter benefits unless they attend a support group. Therefore, shelters should consider offering support groups to women very soon after shelter entry. Furthermore, more research is needed to disentangle the benefits of self-compassion interventions over and above a general support group curriculum.

Self-Compassionate Responses to an Imagined Sexual Assault.

This research assesses the relationship between self-compassion and well-being following an imagined trauma (i.e., sexual assault) and shows positive outcomes from a self-compassion induction. After a pilot study (N = 54) established the believability of a sexual assault scenario, the primary study randomly assigned female participants (N = 141) to a self-compassion or control condition. Participants read educational prompts (self-compassion and verbal learning or verbal learning only), completed comprehension questions, read and wrote about a hypothetical scenario from a compassionate perspective or generally, and completed the trait self-compassion scale. Regression analyses showed trait and induced self-compassion predicted less negative outcomes.

Safety Among Newly Resettled Refugees in the USA.

Within a context of changing political and social perspectives toward refugee resettlement in the USA, this mixed methods study examines experiences of safety among recently resettled refugees. The study was conducted by resettlement agency personnel within two states, Utah and Arizona. We examine risk and protective factors associated with perceptions of safety among a sample of 243 participants, as well as experiences related to safety as described in focus groups with 50 participants. Of the environmental factors examined, attending events related to one's culture, language, or religion and more frequent home visits were associated with higher levels of perceived safety, while experiencing discrimination was associated with lower levels of perceived safety. Some individual and social factors such as nation of origin were also associated with perceptions of safety. Focus groups identified key themes related to safety in the USA which included discrimination, concerns about family safety, and feeling safe in the USA. An increased emphasis on safety as a key resettlement outcome can strengthen resettlement policy and guide community responses.

Resilience, Self-compassion, and Mental Health Outcomes: Rebuilding Eastern North Carolina After Natural Disasters.

Natural disasters have occurred more frequently in Eastern North Carolina in recent years. Evidence supports that repeated exposure to natural disasters may have lasting mental health impacts among vulnerable populations. Greater access to mental health services may aid in ensuring equitable access to needed care and promote resilience.

Author Correction: Mesenchymal Stromal Cell Bioreactor for Ex Vivo Reprogramming of Human Immune Cells.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.