Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions. DESIGN: Two-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up. SETTING: Department of Veterans Affairs medical facility. PARTICIPANTS: 103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions. INTERVENTIONS: Experimental arm-a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm-usual care in a large Department of Veterans Affairs medical facility. MAIN OUTCOME MEASURES: Oswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect. RESULTS: Veterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms). CONCLUSION: These findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population.

Achieving STEM diversity: Fix the classrooms.

Outdated teaching methods amount to discrimination.

Bruins-in-Genomics: Evaluation of the impact of a UCLA undergraduate summer program in computational biology on participating students.

Recruiting, training and retaining scientists in computational biology is necessary to develop a workforce that can lead the quantitative biology revolution. Yet, African-American/Black, Hispanic/Latinx, Native Americans, and women are severely underrepresented in computational biosciences. We established the UCLA Bruins-in-Genomics Summer Research Program to provide training and research experiences in quantitative biology and bioinformatics to undergraduate students with an emphasis on students from backgrounds underrepresented in computational biology. Program assessment was based on number of applicants, alumni surveys and comparison of post-graduate educational choices for participants and a control group of students who were accepted but declined to participate. We hypothesized that participation in the Bruins-in-Genomics program would increase the likelihood that students would pursue post-graduate education in a related field. Our surveys revealed that 75% of Bruins-in-Genomics Summer participants were enrolled in graduate school. Logistic regression analysis revealed that women who participated in the program were significantly more likely to pursue a Ph.D. than a matched control group (group x woman interaction term of p = 0.005). The Bruins-in-Genomics Summer program represents an example of how a combined didactic-research program structure can make computational biology accessible to a wide range of undergraduates and increase participation in quantitative biosciences.

How Were Wait Times for Priority Procedures in Canada Impacted during the First Six Months of the COVID-19 Pandemic?

In 2020, health systems across Canada responded to the COVID-19 pandemic by making rapid changes to reduce the risk of exposure for patients and staff and to allocate resources toward the treatment of COVID-19 patients. This included postponing surgical and diagnostic procedures. Data collected by the Canadian Institute for Health Information show that these interventions resulted in longer wait times across all provinces in April-September 2020 for scheduled surgical procedures, such as hip and knee replacements and cataract surgeries. The impact on wait times for cancer surgeries and diagnostic imaging varied by type of procedure and jurisdiction, while the wait times for hip fracture repair and radiation therapy were not impacted. Subsequent waves of the COVID-19 pandemic added to the initial backlog of procedures, and it will take time to assess the long-term impact of surgical and diagnostic imaging delays on patient outcomes and wait times.

Leverage the power of ritual to improve community health worker efficacy and public health outcomes: Lessons from Bihar, India.

Biomedical health interventions now have global reach and interact in complex and often poorly understood ways with traditional medical rituals that precede biomedicine. People often experience biomedical practices and treatments as rituals because they are very similar from an experiential perspective.1 Yet the global public health community often views ritual practices of communities as obstacles to adopting new health-promoting behaviors. The lack of engagement with the biomedical and traditional medical rituals of local populations has obscured understanding the critical functions of these behaviors, limited the potential to leverage ritualization to increase behavioral uptake, and stymied social and behavioral change efforts. Our large-scale, mixed methods research with Community Health Workers (CHW) in Bihar, India, has shown that understanding the rituals of a community provides critical insight into their identities, norms, values, and goals. We propose that health interventions should be informed by, and build upon, knowledge of health rituals. A deep understanding of existing beliefs and behaviors will allow local health "influencers" such as CHW to encourage new and modified rituals that integrate the best of biomedical and traditional health practices in ways that preserve their meaning and shared purpose. Funding: Grants INV-008582 and INV-016014 to C.L. from The Bill & Melinda Gates Foundation funded this manuscript.

Facilitating behavioral change: A comparative assessment of ASHA efficacy in rural Bihar.

Community health worker (CHW) programs are essential for expanding health services to many areas of the world and improving uptake of recommended behaviors. One of these programs, called Accredited Social Health Activists (ASHA), was initiated by the government of India in 2005 and now has a workforce of about 1 million. ASHAs primarily focus on improving maternal and child health but also support other health initiatives. Evaluations of ASHA efficacy have found a range of results, from negative, to mixed, to positive. Clarity in forming a general impression of ASHA efficacy is hindered by the use of a wide range of evaluation criteria across studies, a lack of comparison to other sources of behavioral influence, and a focus on a small number of behaviors per study. We analyze survey data for 1,166 mothers from Bihar, India, to assess the influence of ASHAs and eight other health influencers on the uptake of 12 perinatal health behaviors. We find that ASHAs are highly effective at increasing the probability that women self-report having practiced biomedically-recommended behaviors. The ASHA's overall positive effect is larger than any of the nine health influencer categories in our study (covering public, private, and community sources), but their reach needs to be more widely extended to mothers who lack sufficient contact with ASHAs. We conclude that interactions between ASHAs and mothers positively impact the uptake of recommended perinatal health behaviors. ASHA training and program evaluation need to distinguish between individual-level and program-level factors in seeking ways to remove barriers that affect the reach of ASHA services.

Tradition, taste and taboo: the gastroecology of maternal perinatal diet.

BACKGROUND: Maternal malnutrition is a major source of regional health inequity and contributes to maternal and infant morbidity and mortality. Bihar, a state in eastern India adjacent to Jharkhand and West Bengal, has relatively high neonatal mortality rates because a large portion of infants are born to young mothers. Bihar has the second-highest proportion of underweight children under 3 in India, with infant mortality rates of 48 per 1000 live births. Maternal malnutrition remains a major threat to perinatal health in Bihar, where 58.3% of pregnant women are anaemic. METHODS: We examined dietary beliefs and practices among mothers, mothers-in-law and community members, including Accredited Social Health Activists (ASHAs), using focus group discussions (n=40 groups, 213 participants), key informant interviews (n=50 participants) and quantitative surveys (n=1200 recent mothers and 400 community health workers). We report foods that are added/avoided during the perinatal period, along with stated reasons underlying food choice. We summarise the content of the diet based on responses to the quantitative survey and identify influencers of food choice and stated explanations for adding and avoiding foods. KEY FINDINGS: Analyses for all methodologies included gathering frequency counts and running descriptive statistics by food item, recommendation to eat or avoid, pregnancy or post partum, food group and health promoting or risk avoiding. During pregnancy, commonly added foods were generally nutritious (milk, pulses) with explanations for consuming these foods related to promoting health. Commonly avoided foods during pregnancy were also nutritious (wood apples, eggplant) with explanations for avoiding these foods related to miscarriage, newborn appearance and issues with digestion. Post partum, commonly added foods included sweets because they ease digestion whereas commonly avoided foods included eggplants and oily or spicy foods. Family, friends, relatives or neighbours influenced food choice for both mothers and ASHAs more than ASHAs and other health workers.Perinatal dietary beliefs and behaviours are shaped by local gastroecologies or systems of knowledge and practice that surround and inform dietary choices, as well as how those choices are explained and influenced. Our data provide novel insight into how health influencers operating within traditional and biomedical health systems shape the perinatal dietary beliefs of both mothers and community health workers.

The impact of care management for high-risk pediatric asthmatics on healthcare utilization.

INTRODUCTION: From 2011 to 2015, a series of quality improvement interventions were developed that targeted pediatric persistent asthmatics that included recalls for those overdue for care and access to specialist care. The objective of this study was to assess the impact on urgent care and emergency department visits and hospitalizations from enrollment into at least one intervention during the time period. METHODS: Persistent asthmatics were identified through electronic medical records, with patients having an asthma designation containing "persistent," asthma control containing "poor", and asthma risk being "high risk." Asthma utilization events were identified for these patients between January 1, 2011, and June 30, 2015 using ICD-9 diagnosis codes. Evaluation focused on differences in utilization for patients before and after receiving interventions through the use of logistic regression for each utilization outcome. RESULTS: The interventions were delivered to 1060 children out of a total of 2046 identified as having the persistent asthmatic criteria. The intervention group consisted of 389 (36.7%) moderate persistent asthmatics and 643 (60.7%) mild persistent asthmatics, with 976 (92.1%) identifying as a minority. Analysis of 60692 months of data showed patients who received the intervention were less likely to visit the urgent care (OR [0.80, 0.96]) or be hospitalized (OR [0.37, 0.75]) than those who did not receive any interventions. Adjustment for provider referral into the interventions resulted in slight changes for both hospitalizations (OR [0.38, 0.79]) and urgent care (OR [0.68, 0.94]). CONCLUSION: Children receiving interventions were less likely to be hospitalized or visit urgent care clinics.

Differential dopamine modulation of spinal reflex amplitudes is associated with the presence or absence of the autonomic nervous system.

The spinal cord contains a highly collateralized network of descending dopamine (DA) fibers that stem from the dorso-posterior hypothalamic A11 region in the brain, however, the modulatory actions of DA have generally only been assessed in lumbar segments L2-L5. In contrast to these exclusively sensorimotor segments, spinal cords segments T1-L2 and, in mouse, L6-S2, additionally contain the intermediolateral (IML) nucleus, the origin of autonomic nervous system (ANS). Here, we tested if the different spinal circuits in sensorimotor and IML-containing segments react differently to the modulation of the monosynaptic reflex (MSR) by DA. Bath-application of DA (1 µM) led to a decrease of MSR amplitude in L3-L5 segments; however, in IML-containing segments (T10-L2, and S1/2) the MSR response was facilitated. We did not observe any difference in the response between thoracic (sympathetic) and lumbosacral (parasympathetic) segments. Application of the D2-receptor agonists bromocriptine or quinpirole mimicked the effects of DA, while blocking D2 receptor pathways with raclopride or application with the D1-receptor agonist SKF 38393 led to an increase of the MSR in L3-L5 segments and a decrease of the MSR in IML-containing segments. In contrast, in the presence of the gap-junction blockers, carbenoloxone and quinine, DA modulatory actions in IML-containing segments were similar to those of sensorimotor L3-L5 segments. We suggest that DA modulates MSR amplitudes in the spinal cord in a segment-specific manner, and that the differential outcome observed in ANS segments may be a result of gap junctions in the IML.

Coordination of Care Could Improve: Canadian Results from the Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Care coordination is a critical component of a strong primary care system. The Commonwealth Fund (CMWF) 2019 International Health Policy Survey of Primary Care Physicians polled physicians in 11 countries, allowing international and pan-Canadian comparisons of physicians' perspectives in this area. Canadian physicians indicated that there was room for improvement in coordinating care with those outside their practice, particularly specialists, home-based care providers and social services. Opportunities may arise in learning from higher-performing CMWF countries and in adopting new information technologies that are growing methods of facilitating communication across care settings.

Creating inclusive classrooms by engaging STEM faculty in culturally responsive teaching workshops.

BACKGROUND: As higher education institutions strive to effectively support an increasingly diverse student body, they will be called upon to provide their faculty with tools to teach more inclusively, especially in science, technology, engineering, and mathematics (STEM) classrooms where recruitment and retention of students from underrepresented and disadvantaged groups present long-standing challenges. Pedagogical training approaches to creating inclusive classrooms involve interventions that raise awareness of student and instructor social identities and explore barriers to learning, such as implicit bias, microaggressions, stereotype threat, and fixed mindset. Such efforts should focus on embracing diversity as an asset leveraged to benefit all students in their learning. In this paper, we describe the impact of multiday, off-campus immersion workshops designed to impart faculty with these tools. Based on analysis of workshop participant data, we report the resulting changes in faculty knowledge of factors affecting classroom climate and student success in STEM, attitudes about students, and motivation to adopt new teaching practices aimed at fostering equitable and culturally responsive learning environments. RESULTS: Key findings indicate that attendees (1) increased their knowledge of social identities and the barriers to learning in STEM classrooms, particularly those faced by students from underrepresented groups in STEM or socioeconomically challenged backgrounds; (2) changed their attitudes about students' abilities as science majors, shifting away from a fixed-mindset perspective in which characteristics, such as intelligence, are perceived as innate and unalterable; and (3) modified their teaching approaches to promote inclusivity and cultural responsiveness. CONCLUSION: Faculty members, who are linchpins in the evolution of college classrooms into settings that provide students with equitable opportunities to succeed academically in STEM, can benefit from participating in immersion workshops structured to support their awareness of issues affecting classroom culture related to race/ethnicity, LGBTQ status, religious affiliation, ability, socioeconomic status, and other social identities that contribute to disparities in STEM achievement and persistence.

Perinatal risk and the cultural ecology of health in Bihar, India.

The objective of the current study is to examine the cultural ecology of health associated with mitigating perinatal risk in Bihar, India. We describe the occurrences, objectives and explanations of health-related beliefs and behaviours during pregnancy and postpartum using focus group discussions with younger and older mothers. First, we document perceived physical and supernatural threats and the constellation of traditional and biomedical practises including taboos, superstitions and rituals used to mitigate them. Second, we describe the extent to which these practises are explained as risk-preventing versus health-promoting behaviour. Third, we discuss the extent to which these practises are consistent, inconsistent or unrelated to biomedical health practises and describe the extent to which traditional and biomedical health practises compete, conflict and coexist. Finally, we conclude with a discussion of the relationships between traditional and biomedical practises in the context of the cultural ecology of health and reflect on how a comprehensive understanding of perinatal health practises can improve the efficacy of health interventions and improve outcomes. This article is part of the theme issue 'Ritual renaissance: new insights into the most human of behaviours'.

BTBD9 and dopaminergic dysfunction in the pathogenesis of restless legs syndrome.

Restless legs syndrome (RLS) is characterized by an urge to move legs, usually accompanied by uncomfortable sensations. RLS symptoms generally happen at night and can be relieved by movements. Genetic studies have linked polymorphisms in BTBD9 to a higher risk of RLS. Knockout of BTBD9 homolog in mice (Btbd9) and fly results in RLS-like phenotypes. A dysfunctional dopaminergic system is associated with RLS. However, the function of BTBD9 in the dopaminergic system and RLS is not clear. Here, we made use of the simple Caenorhabditis elegans nervous system. Loss of hpo-9, the worm homolog of BTBD9, resulted in hyperactive egg-laying behavior. Analysis of genetic interactions between hpo-9 and genes for dopamine receptors (dop-1, dop-3) indicated that hpo-9 and dop-1 worked similarly. Reporter assays of dop-1 and dop-3 revealed that hpo-9 knockout led to a significant increase of DOP-3 expression. This appears to be evolutionarily conserved in mice with an increased D2 receptor (D2R) mRNA in the striatum of the Btbd9 knockout mice. Furthermore, the striatal D2R protein was significantly decreased and Dynamin I was increased. Overall, activities of DA neurons in the substantia nigra were not altered, but the peripheral D1R pathway was potentiated in the Btbd9 knockout mice. Finally, we generated and characterized the dopamine neuron-specific Btbd9 knockout mice and detected an active-phase sleepiness, suggesting that dopamine neuron-specific loss of Btbd9 is sufficient to disturb the sleep. Our results suggest that increased activities in the D1R pathway, decreased activities in the D2R pathway, or both may contribute to RLS.

The Experience of Primary Caregivers of Undocumented Immigrants with End-Stage Kidney Disease that Rely on Emergency-Only Hemodialysis.

BACKGROUND: Undocumented immigrants with end-stage kidney disease (ESKD) who rely on emergency-only hemodialysis (dialysis only after an emergency department evaluation) face psychosocial distress. Emergency-only hemodialysis (EOHD) is likely burdensome for primary caregivers as well. OBJECTIVE: To understand the experience of primary caregivers of undocumented immigrants with ESKD who rely on emergency-only hemodialysis. DESIGN, SETTING, AND PARTICIPANTS: A qualitative, semi-structured interview study to assess the experiences of primary caregivers of undocumented immigrants with ESKD at a safety-net hospital in Denver, Colorado from June 28 to November 15, 2018. Applied thematic analysis was used to analyze interviews. MAIN OUTCOMES AND MEASURES: Themes and subthemes. RESULTS: Twenty primary caregiver participants had a mean (SD) age of 46 (17), 13 (65%) were female, 7 (35%) were in an adult child caregiver role, and 13 (65%) were spouses. Five themes and 17 subthemes (in parentheses) were identified: (1) Caregiver role (providing emotional, physical, and economic support, advocacy and care navigation), (2) Caregiver burden (anxiety related to patient and personal death, emotional exhaustion and personal illness, struggle with finances, self-care and redefining relationship), (3) Unpredictable EOHD (acute episodes of illness that trigger emergency, stress when patient is denied dialysis, impact on work and sleep, and emotional relief after a session of EOHD), (4) Effect on children (dropping out or missing school, psychosocial distress, children assuming caregiver responsibilities, and juggling multi-generational caregiving of children), (5) Faith and appreciation (comfort in God and appreciation of healthcare). CONCLUSIONS AND RELEVANCE: Caregivers of undocumented immigrants with ESKD who rely upon EOHD experience caregiver burden and distress. The impact of EOHD on caregivers should be considered when assessing the consequences of excluding undocumented immigrants from public insurance programs.

Virtual Reality Use for Symptom Management in Palliative Care: A Pilot Study to Assess User Perceptions.

In the past two decades, virtual reality (VR) technology has found use in a variety of clinical settings including pain management, physical medicine and rehabilitation, psychiatry, and neurology. However, little is known about the utility of VR in the palliative care setting. Moreover, previous investigations have not explored user perceptions of the VR experience in this population. Understanding user perceptions of the VR intervention will be critical for the development and delivery of effective VR therapies. To examine the utility of VR for palliative care patients, a pilot study of VR use was conducted with 12 adult patients diagnosed with life-limiting illness who were residents at a free-standing hospice facility. The intervention consisted of a one-time 30-minute VR experience. User perceptions were assessed through both quantitative and qualitative means, including participant responses to open-ended questions after the VR intervention. Acute changes in symptom burden were assessed using the revised Edmonton Symptom Assessment Scale. Participants found the VR experience to be both enjoyable and useful, and the intervention was well-tolerated overall. This study provides support for VR as a promising new therapeutic modality for patients undergoing palliative care.