Understanding American Indian tribal college student knowledge, attitudes, beliefs, and behaviors surrounding alternative tobacco products.

OBJECTIVES: To examine knowledge, attitudes, beliefs, and behaviors about alternative tobacco products among American Indian tribal college students. PARTICIPANTS: One hundred and five tribal college students. METHODS: Focus groups, one interview, and demographic surveys. RESULTS: Tobacco use varied across the sample with 35.2% of the participants being users of ENDS products and 29.5% were cigarette smokers. Overall, participants viewed electronic nicotine delivery systems and chewing tobacco as primary examples of alternative tobacco products and described a generational divide between alternative and conventional tobacco product use. Alternative tobacco products were not considered suitable for use in traditional contexts. CONCLUSIONS: Previously successful cessation programs in this population have relied on cultural tailoring related to traditional tobacco use in American Indian communities. Our findings suggest that this strategy may be less effective for addressing alternative tobacco use. Reliance on the importance of family relationships may prove more impactful in future programming.

Nitrous oxide for the treatment of complex regional pain syndrome: a randomized blinded trial.

INTRODUCTION: Complex Regional Pain Syndrome (CRPS) is a debilitating neuropathic condition often refractory to conventional treatments. N-methyl-D-aspartate (NMDA) receptor antagonists have a well-established role in the development and modulation of chronic neuropathic pain. Nitrous oxide is widely used and generally safe anesthetic gas with NMDA receptor antagonist activity. We therefore tested the hypothesis that brief periods of nitrous oxide exposure reduce pain in patients with CRPS. METHODS: Patients with a diagnosis of CRPS were randomized to either 2 hours of nitrous oxide exposure on three alternating days (Nitrous Oxide) versus a placebo air/oxygen mixture (Air-Oxygen). Our primary outcome was patient-reported pain scores at 1 week and 1 month. Secondary and exploratory outcomes were physical and mental health (PRMOIS-29 v2 survey), specific neuropathic pain symptoms (McGill short-form questionnaire), and opioid consumption. RESULTS: 44 patients participated in the study; 20 were randomized to Nitrous Oxide and 24 were assigned to Air-Oxygen. Pain scores did not differ significantly, with the estimated difference in means (Nitrous Oxide-Air-Oxygen) of -0.57 (95% CI: -1.42 to 0.28) points, p=0.19. There were also no differences detected in secondary outcomes, with the estimated difference in mean Z-scores for physical health (Nitrous Oxide-Air-Oxygen) of 0.13 (95% CI: -0.16 to 0.43), mental health 0.087 (95% CI: -0.31 to 0.48), and Patient Global Impression of Change score -0.7 (95% CI: -1.85 to 0.46). CONCLUSIONS: Compared with air/oxygen, 2 hours of nitrous oxide/oxygen exposure for three sessions did not provide meaningful therapeutic potential for patients with chronic CRPS. Our results do not support using nitrous oxide for the treatment of CRPS.

Everyday discrimination for American Indian tribal college students enrolled in the Internet All Nations Breath of Life program.

OBJECTIVE: Identify factors associated with perceived discrimination, including depression, body image satisfaction, body mass index (BMI), social support, stress, and self-reported social status. PARTICIPANTS: A total of 249 American Indian tribal college students. METHODS: Students were recruited for an Internet-based smoking cessation program. A total of 249 students answered the Everyday Discrimination Scale questions to assess perceived discrimination. We conducted bivariate analyses to determine potential significant associations between perceived discrimination and health outcomes at baseline. RESULTS: We found 63% of the sample reported racial discrimination. Among those who reported moderate/severe depression, 87% reported discrimination. Among those who were not satisfied with their body image, 70% reported racial discrimination. CONCLUSION: Reports of racial discrimination are highly prevalent among our participants. We found reports of discrimination are significantly associated with depression and dissatisfaction with body image. Our study highlights a high priority population that perceives racial discrimination, potentially increasing their risk for adverse health outcomes.

In Our Sacred Voice - An Exploration of Tribal and Community Leader Perceptions as Health Communicators of Disease Prevention among American Indians in the Plains.

American Indians (AI) are disproportionately and significantly impacted by disease morbidity, mortalityand poor behavioral health outcomes. Health promotion and health communication programs exist to address these health disparities and health conditions; however, few programs fully integrate holistic approaches when targeting AI populations. The objective of this study was to explore how tribal and community leaders throughout the Central Plains (Kansas, Iowa, Missouri, and South Dakota) viewed themselves as health communicators and health promoters within their communities. Members of the Center for American Indian Community Health (CAICH) conducted 39 in-depth interviews with members of federally recognized tribes living in reservation communities as well as urban tribal communities across the region. Results from the sample show that these individuals do not necessarily see themselves as the "authority" health communicator or health promoter within their tribe or community. They did perceive themselves and others as gatekeepers of pertinent health information. Social and cultural authority within culturally centered messaging and collective delivery of this type of health information from trusted sources within tribes and communities is perceived to bolster health communication programs and positively impact health outcomes among AI populations.

Pilot Testing All Nations Snuff Out Smokeless (ANSOS): A Culturally Tailored Smokeless Tobacco Cessation Program for American Indians.

American Indians have the highest rates of smokeless tobacco (SLT) use of any racial/ethnic group in the United States, yet no proven effective cessation programs exist for them. Because tobacco is a sacred plant to many American Indians, cessation programs must not portray it in a completely negative manner. Based on our successful All Nations Breath of Life smoking cessation program, we developed and pilot-tested the All Nations Snuff Out Smokeless (ANSOS) program. Of 48 participants who began the program, 33 completed to six months (68.8% retention rate). Among participants who completed the program, 11 (34%) self-reported abstinence. When those lost to follow-up are considered current users, the cessation rate is 22.9%. An additional 14 individuals reported decreasing use (29.2% of all participants), with an average of 3.4 days per week decrease. All Nations Snuff Out Smokeless shows promise as a culturally appropriate SLT cessation program and is ready for efficacy testing.

Direct Peripheral Nerve Stimulation for the Treatment of Complex Regional Pain Syndrome: A 30-Year Review.

INTRODUCTION: Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD), is a difficult to treat condition characterized by debilitating pain and limitations in functional ability. Neuromodulation, in the form of spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS), have been traditionally used as a treatment for CRPS with variable success. OBJECTIVE: This chart review describes the use of implantable PNS systems in the treatment of CRPS of the upper and lower extremities spanning nearly three decades. MATERIALS AND METHODS: A retrospective chart review was performed on 240 patients with PNS implanted between 1990 and 2017 at our institution. Of these, 165 patients were identified who had PNS systems implanted for a diagnosis of CRPS. Patient profile, including baseline characteristics, comorbidities, past/current interventions/medications and targeted nerves, was descriptively summarized through standard summary statistics. Patients' pain scores and opioid consumptions at baseline (preimplant), 1 month, 6 months, and 12 months were collected and compared. Device revisions and explants were summarized, and patient functional outcomes were described. RESULTS: Pain scores at baseline and at 12-month follow-up were decreased from a mean of 7.4 ± 1.6 to 5.5 ± 2.4 and estimated to be 1.87 (95% CI: [1.29, 2.46], paired t-test p-value <0.001) lower at 12 months. At baseline, 62% of patients were on chronic opioid therapy, compared with 41% at 12 months. Of 126 patients who reported changes in functional status, 64 (51%) reported improvement, 27 (21%) reported worsening, and 35 (28%) did not report any meaningful change. Excluding end-of-life battery replacements, surgical revision occurred in 56 (34%) of patients. Thirteen patients (8%) underwent implantation of a second PNS because of symptomatic expansion outside of the original painful region. Device explant was performed in 32 (19%) of patients. Median length of follow-up was 74 [14, 147] months. Of the 36 patients who continue to follow-up at our institution, 29 (81%) continue to use their PNS. CONCLUSIONS: We can conclude that PNS is a useful modality to improve function and reduce long-term pain in selected patients suffering from CRPS type I and type II.

Association Between Oral Pain Medications and Intrathecal Opioid Dose Escalation: A Retrospective Analysis.

OBJECTIVES: Patients treated with intrathecal therapy frequently require opioid dose increases to maintain analgesia. The kinetics of intrathecal opioid dose escalation are poorly understood. We hypothesized that antidepressant use, antiepileptic use, and lower baseline oral opioid intake prior to intrathecal pump implantation will be protective against intrathecal opioid dose escalation. MATERIALS AND METHODS: Targeted drug delivery medication doses were collected from patients who had an intrathecal pump implanted between 2007 and 2016. From a sample size of 136 patients, the association between antidepressant, antiepileptic, and oral opioid use with intrathecal dose escalation was assessed using statistical models. RESULTS: Individuals using an antiepileptic had an estimated ratio of means (97.5% CI) of opioid consumption of 0.91 (97.5% CI: [0.48, 1.73], p = 0.74) at six months, 0.83 ([0.43, 1.58], p = 0.51) at 12 months, and 0.77 ([0.40, 1.45], p = 0.36) at 24 months. Patients prescribed antidepressants had an estimated ratio of means (97.5% CI) of 1.43 ([0.77, 2.65], p = 0.19) at six months, 1.41 ([0.76, 2.63], p = 0.22) at 12 months, and 1.33 ([0.70, 2.51], p = 0.31) at 24 months. In our secondary analysis of pre-implant oral opioid use, patients treated with high oral opioid doses had a similar pattern of intrathecal dose escalation when compared to patients using low doses of oral opioids. CONCLUSIONS: Use of antiepileptics, antidepressants, or low oral opioid doses was not associated with attenuation of intrathecal dose escalation. Intrathecal opioid dose escalation was observed to occur similarly, regardless of baseline oral analgesics concomitantly employed.

The Potential of Overlayers on Tin-based Perovskites for Water Splitting.

Photoelectrochemical water splitting is a promising method of clean hydrogen production for green energy uses. Here, we report on a tin-based oxide perovskite combined with an overlayer that shows enhanced bifunctional hydrogen and oxygen evolution. In our first-principles study of tin-based perovskites, based upon density functional theory, we investigate how the formation of a surface affects the electronic properties of these materials. We show that the best candidate, SrSnO3, possesses hydrogen and oxygen overpotentials of 0.75 and 0.72 eV, respectively, which are reduced to 0.35 and 0.54 eV with the inclusion of a ZrO2 overlayer. Furthermore, this overlayer promotes charge extraction, stabilizes the reaction pathways, and improves the band gap such that it straddles the overpotentials between pH 0 and pH 12. This result indicates that SrSnO3 with a ZrO2 overlayer has significant potential as a highly efficient bifunctional water splitter for producing hydrogen and oxygen gas on the same surface.

Spinal Cord Stimulation for Neurogenic Thoracic Outlet Syndrome: A Case Report.

Despite conservative and surgical treatments, patients with neurogenic thoracic outlet syndrome can develop debilitating chronic pain of the shoulder and arm. Here we report a case of a patient who failed medical treatment, surgical resection of the first rib, and subsequent resection of rib regrowth with partial excision of a hypertrophied middle scalene muscle. Ultimately, this patient was successfully treated with spinal cord stimulation with dramatic pain relief and remarkable functional improvement for more than 3 years. This first report provides hope for those who suffer from this debilitating syndrome.

Baseline characteristics of American Indian smokeless tobacco users participating in two pilot cessation studies.

American Indians have higher rates of smokeless tobacco (SLT) use than other racial/ethnic groups in the US, yet no efficacious cessation program exists for them. Because tobacco is a sacred plant to many American Indians, it is imperative that a program respect the scared nature of tobacco while encouraging quitting recreational use. All Nations Snuff Out Smokeless (ANSOS) was designed to help American Indian SLT users quit recreational tobacco use while still using it for traditional purposes. We pilot tested the ANSOS 6-month group-based counseling program (N = 48) and a shortened version consisting of a one-time education session (N = 80). Here, we discuss the tobacco characteristics of participants at baseline in both studies. Participants across studies were more likely to be male (74.2%) and have at least a college education (65%). Participants in the one-time education sessions were younger (age 35 vs age 39) and used SLT fewer days per week (4.9 vs 5.7). Two-thirds of those in the full program reported that they often substitute SLT in locations where smoking is not allowed compared to 26%. Participants in the education sessions were more likely to report daily use of traditional tobacco (20% versus 0%). Results suggest that dual use of SLT and cigarettes needs to be addressed, as does the use of SLT to circumvent public smoking rules. The role of traditional tobacco and its relationship to lower SLT use also warrants further investigation.

One-Time Education Sessions to Help American Indian Smokeless Tobacco Users Quit.

American Indian (AI) smokeless tobacco use rates are the highest of all racial/ethnic groups within the United States. Despite this, no effective cessation program currently exists that acknowledges the cultural significance of tobacco among many American Indian tribal nations. Participants were smokeless tobacco users, over 18 years of age, and were recruited through community partners. We modified the All Nations Snuff Out Smokeless Tobacco group-based program to be delivered as a one-time education session intervention. This was delivered to 80 participants and follow-up data was collected by self-report at 6-months. The mean age of participants was 35 and most were male (70%). A majority (69%) grew up on a AI reservation; the mean age of first smokeless tobacco use was 16 years of age. Of program completers reached for 6-month post baseline, 46% reported 0 days of SLT use; 13.5% of participants reduced; while 36% reported continued daily use. In intention to treat analysis those lost to follow-up are considered current users, the quit rate was 12.5% and among those who were still using, 4.0% reduced their use. In this study, a one-time education session intervention was effective for those who prefer an individual based approach to quitting SLT use. Follow up strategies to increase participant retention at 6-months should be explored.

Lung separation in children: Options and impact on gas exchange and lung compliance.

BACKGROUND: One-lung ventilation is a challenging airway technique in the pediatric population. Multiple airway devices can be employed, but there is no consensus as to the most reliable and physiologically advantageous method. This report is a review of the methods of one-lung ventilation in children in our practice, as well as an analysis of the impact of airway device type, patient age, and duration of lung separation on respiratory mechanics and gas exchange. METHODS: The records of all pediatric patients undergoing procedures requiring one-lung ventilation in a single center over an 18-month period were reviewed. Demographics, time required to achieve lung separation (anesthesia ready-time), and duration of one-lung ventilation were collected. Data from arterial blood gas analysis and ventilator parameters were collected at three time points: 15 minutes prior to one-lung ventilation (pre-OLV), 15 minutes after initiation of one-lung ventilation (during OLV), and 15 minutes after one-lung ventilation was ended (post-OLV). Standard equations for calculating compliance, the ratio of arterial partial pressure of oxygen to the fraction of inspired oxygen, and the alveolar-arterial oxygen gradient were used. RESULTS: Forty-six patients were identified with a mean age of 9.3 (inner quartile range 3-15) years. All patients had significant changes in pulmonary function when comparing pre-OLV with during OLV and when comparing during OLV with post-OLV. There were no significant changes from pre- to post-OLV. On further analysis, there were more pronounced changes in compliance and gas exchange in older patients (P = 0.003; 95% CI: -0.62 to -0.14). There was also a significant decrease in post-OLV compliance with a longer duration of OLV (P = 0.018; 95% CI: -0.02 to <-0.01). Airway device type did not have significant impact on the parameters examined. CONCLUSION: Our report demonstrates significant changes in lung function during one-lung ventilation. One particular device does not seem to be superior. Though pre-OLV measures of pulmonary function correlate closely with post-OLV, older age and a prolonged duration of one-lung ventilation did impact compliance.

Food Security and Diet Among American Indians in the Midwest.

The purpose of this study was to determine levels of food security among American Indians (AI) living in the Midwest and possible correlations between food security levels and various health outcomes, diet, and demographic variables. This study used a cross-sectional design to determine health behaviors among AI. Participants (n = 362) were recruited by AI staff through various cultural community events in the Midwest, such as powwows and health fairs. Inclusion criteria included the following: age 18 years or older, self-identify as an AI, and willing to participate in the survey. Of all participants, 210 (58%) had either low or very low food security, with 96 in the very low category (26.5%). Participants with very low food security tended to have significantly more chronic conditions. Additional significant differences for very low food security existed by demographic variables, including having no insurance (p < 0.0001) or having a regular primary care provider (p = 0.0354). There was also a significant difference between food security levels and the consumption of fast food within the past week (p value = 0.0420), though no differences were found in fruit and vegetable consumption. AI in our sample had higher levels of food insecurity than those reported in the literature for other racial/ethnic groups. AI and non-Native health professionals should be aware of the gravity of food insecurity and the impact it has on overall health. Additional research is needed to determine specific aspects of food insecurity affecting different Native communities to develop appropriate interventions.

Development of a Culturally Appropriate Smokeless Tobacco Cessation Program for American Indians.

This study describes a multiphasic approach to the development of a smokeless tobacco cessation program targeted for American Indians (AI) of different tribal nations. The authors gathered formative data from a series of focus groups and interviews to investigate the knowledge, attitudes, and beliefs of AI and smokeless tobacco (SLT) use. Predominant themes emerged from four major topic areas (SLT use, initiation and barriers, policy, and program development) across both studies. This study further assessed educational materials developed for the cessation program for scientific accuracy, readability, and cultural appropriateness. Program materials were scientifically accurate and culturally appropriate. The average corrected reading grade level was 6.3 using the Fry formula and 7.1 using the SMOG formula. Based on this research, a detailed approach to formative research can be used in combination with input from community members to develop health interventions that address health disparities for a specific population.

American Indian Knowledge, Attitudes, and Beliefs About Smokeless Tobacco: A Comparison of Two Focus Group Studies.

Though smokeless tobacco (SLT) use has decreased in many communities, concern for American Indian (AI) SLT use remains, as this population continues to be disproportionally affected by SLT-related diseases. Tobacco has cultural significance to many AI tribes, therefore tobacco cessation messages portraying tobacco as entirely negative may be ineffective. As a part of our formative research for an SLT cessation intervention, we sought to gain a better understanding of the knowledge, attitudes, and beliefs about SLT among AI community members. We describe two independent focus group studies conducted in Montana (ten focus groups, 54 participants) and Kansas (six focus groups, 27 participants). Predominant themes emerged from three major topic areas (SLT use, program development, and recreational SLT use) during the discussions from both studies. The formative approach and data from these studies will allow us to more appropriately address SLT-related health disparities across multiple AI communities.

Diabetes Self-Management Behaviors among American Indians in the Midwestern United States.

The purpose of this study was to understand if American Indian adults with diabetes in the Midwest are similar to American Indian adults nationally in their self-management behaviors. This cross-sectional survey was conducted from May 2009 to April 2010 at powwows, health fairs, and other community events. The convenience sample self-selected into the study and answered questions via touch screen computer about diabetes self-management. Participants were significantly below the national average for American Indians in their adherence to self-management recommendations in daily foot checks (p=0.0035) and having had a dilated eye exam in the previous year (p=0.0002), despite being significantly more likely to have taken a diabetes self-management class (p<0.0001). They were similar to the national average for daily glucose checks and having had one or more hemoglobin A1C tests in the previous year. Participants were less likely to eat 5 or more servings of fruits or vegetables per day (p=0.0001), but more likely to achieve 150 minutes or more of physical activity per week (p=0.0001). Programs addressing self-care issues should be developed to help improve the self-management habits of American Indian adults with diabetes, with particular attention to activities outside of monitoring blood glucose and hemoglobin A1C levels.

Delayed resolution of lung inflammation in Il-1rn-/- mice reflects elevated IL-17A/granulocyte colony-stimulating factor expression.

IL-1 has been associated with acute lung injury (ALI) in both humans and animal models, but further investigation of the precise mechanisms involved is needed, and may identify novel therapeutic targets. To discover the IL-1 mediators essential to the initiation and resolution phases of acute lung inflammation, knockout mice (with targeted deletions for either the IL-1 receptor-1, i.e., Il-1r1(-/-), or the IL-1 receptor antagonist, i.e., Il-1rn(-/-)) were exposed to aerosolized LPS, and indices of lung and systemic inflammation were examined over the subsequent 48 hours. The resultant cell counts, histology, protein, and RNA expression of key cytokines were measured. Il-1r1(-/-) mice exhibited decreased neutrophil influx, particularly at 4 and 48 hours after exposure to LPS, as well as reduced bronchoalveolar lavage (BAL) expression of chemokines and granulocyte colony-stimulating factor (G-CSF). On the contrary, Il-1rn(-/-) mice demonstrated increased BAL neutrophil counts, increased BAL total protein, and greater evidence of histologic injury, all most notably 2 days after LPS exposure. Il-1rn(-/-) mice also exhibited higher peripheral neutrophil counts and greater numbers of granulocyte receptor-1 cells in their bone marrow, potentially reflecting their elevated plasma G-CSF concentrations. Furthermore, IL-17A expression was increased in the BAL and lungs of Il-1rn(-/-) mice after exposure to LPS, likely because of increased numbers of γδ T cells in the Il-1rn(-/-) lungs. Blockade with IL-17A monoclonal antibody before LPS exposure decreased the resultant BAL neutrophil counts and lung G-CSF expression in Il-1rn(-/-) mice, 48 hours after exposure to LPS. In conclusion, Il-1rn(-/-) mice exhibit delayed resolution in acute lung inflammation after exposure to LPS, a process that appears to be mediated via the G-CSF/IL-17A axis.