Working With Rural Producers to Expand EBT in Farmers' Markets: A Case Study in Hardeman County, Tennessee.

Rural residents tend to eat less fruits and vegetables, placing them at higher risk of chronic diseases compared with urban residents. Farmers' markets can provide increased access to fresh produce for rural communities. Encouraging markets to accept Supplemental Nutrition Assistance Program (SNAP) benefits through Electronic Benefit Transfer (EBT) can expand access to healthy foods to low-income residents. Rural markets are less likely to accept SNAP compared with urban markets. Rural producers have identified lack of knowledge and limited support about the application process as barriers for accepting SNAP. This case study details how our Extension program helped a rural producer through the SNAP application process. We started with a workshop to inform rural producers about the benefits of accepting SNAP. After the workshop, we provided hands-on support and assistance to help one producer navigate the EBT application process as well as how to implement and advertise SNAP at the market. Implications for practitioners about tips to help producers overcome challenges and barriers for EBT acceptance are discussed.

Why digital health trials can fail: Lessons learned from a randomized trial of health coaching and virtual cardiac rehabilitation.

Background: We performed a trial to evaluate the efficacy of a blended intervention with personalized health coaching and virtual cardiac rehabilitation to improve medication adherence and risk factors. The trial was terminated early. Here, we describe findings from a root cause analysis and lessons learned. Methods: SmartGUIDE was an open-label, single-center trial that randomized participants with coronary artery disease who were prescribed a statin and/or P2Y12 inhibitor 1:1 to either usual care or the added use of a mobile app with components of cardiac rehabilitation paired with personal virtual coaching. The primary outcome was medication adherence: proportion of days covered (PDC). The planned sample size was 132. We performed a root cause analysis to evaluate processes from study development to closure. Results: During trial conduct, the technology start-up withdrew the intervention. The study was terminated early with 63 participants randomized and data from 26 available for analysis. The median PDC was high in both groups (intervention group 94%, interquartile range [IQR] 88%-96%; control group: 99%, IQR 95%-100%). Root cause analysis identified factors for not achieving trial objectives: key factors that limited enrollment (inclusion criteria, low penetration of compatible smartphones), participant retention or engagement (poor app product, insufficient technology support), and suboptimal choice of a technology partner (technology start-up's inexperience in health care, poor product design, inadequate fundraising). Conclusion: We identified important and preventable factors leading to trial failure. These factors may be common across digital health trials and may explain prior observations that many such trials are never completed. Careful vetting of technology partners and more pragmatic study designs may prevent these missteps.

Predictors of Daily Pain Medication Use in Individuals with Recurrent Back Pain.

PURPOSE: A key component to chronic pain management regimens is the use of analgesic medications. Psychological factors, such as mood states, may also affect the use of pain medications for individuals with chronic pain, but few observational studies have examined how these factors may predict pain medication use at the daily level. METHODS: Daily assessments from 104 individuals with back pain were used to examine fluctuations in daily pain intensity, mood, sleep quality, and physical activity as predictors of the likelihood of pain medication (opioid and non-opioid) use and levels of medication use on the same day. RESULTS: Pain intensity and mood ratings significantly predicted whether participants used pain medication on the same day, while only pain intensity predicted whether participants used more medication than usual. Further, current opioid users were more likely to increase the amount of their medication use on days of higher pain. DISCUSSION: This article identifies fluctuations in daily pain intensity and mood as salient predictors of daily pain medication use in individuals with recurrent back pain. The current study is among the first to highlight both pain and mood states as predictors of daily pain medication use in individuals with back pain, though future studies may expand on these findings through the use of higher-resolution daily medication use variables.

Examining influential factors in providers' chronic pain treatment decisions: a comparison of physicians and medical students.

BACKGROUND: Chronic pain treatment guidelines are unclear and conflicting, which contributes to inconsistent pain care. In order to improve pain care, it is important to understand the various factors that providers rely on to make treatment decisions. The purpose of this study was to examine factors that reportedly influence providers' chronic pain treatment decisions. A secondary aim was to examine differences across participant training level. METHODS: Eighty-five participants (35 medical students, 50 physicians) made treatment decisions for 16 computer-simulated patients with chronic pain. Participants then selected from provided lists the information they used and the information they would have used (had it been available) to make their chronic pain treatment decisions for the patient vignettes. RESULTS: Frequency analyses indicated that most participants reported using patients' pain histories (97.6 %) and pain description (95.3 %) when making treatment decisions, and they would have used information about patients' previous treatments (97.6 %) and average and current pain ratings (96.5 %) had this information been available. Compared to physicians, medical students endorsed more frequently that they would have used patients' employment and/or disability status (p < 0.05). A greater proportion of medical students wanted information on patients' use of illicit drugs and alcohol to make treatment decisions; while a greater proportion of physicians reported using personal experience to inform their decisions. DISCUSSION: This study found providers use patients' information and their own experiences and intuition to make chronic pain treatment decisions. Also, participants of different training levels report using different patient and personal factors to guide their treatment decisions. CONCLUSIONS: These results highlight the complexity of chronic pain care and suggest a need for more chronic pain education aimed at medical students and practicing providers.

Evidence for abnormal cytokine expression in Gulf War Illness: A preliminary analysis of daily immune monitoring data.

BACKGROUND: Gulf War Illness (GWI) is a clinically heterogeneous chronic condition that affects many veterans of the 1990-1991 Persian Gulf War. One of the most prevalent and debilitating symptoms of GWI is abnormal fatigue. The mechanisms underlying GWI generally, and fatigue symptoms specifically, have yet to be conclusively identified, although immune system abnormalities are suspected to be involved. The first goal of this immune monitoring study was to determine if GWI is associated with higher absolute levels and daily variability of pro-inflammatory immune factors. The second goal was to explore the relationship between day-to-day immune marker fluctuations and daily self-reported fatigue severity. METHODS: We recruited veterans with GWI and healthy veteran control (HV) participants to provide self-reported fatigue severity data and blood samples, over 25 consecutive days. We profiled inflammatory processes by using a longitudinal, daily immune-monitoring approach. For each day, serum cytokine and chemokine concentrations were determined using multiplex assays. RESULTS: Seven veterans with GWI and eight healthy veteran control (HV) participants completed the study protocol. We found that GWI was associated with higher variability in the expression of eotaxin-1 (p < 0.001). For GWI participants, higher fatigue severity days were associated with greater IL-1ß (p = 0.008) and IL-15 (p < 0.001). CONCLUSIONS: Our findings provide preliminary evidence that the immune system is involved in the pathophysiology of GWI. Longitudinal immune profiling approaches may be helpful in discovering targets for novel therapies in conditions such as GWI.

Feline mediastinal lymphoma: a retrospective study of signalment, retroviral status, response to chemotherapy and prognostic indicators.

Historically, feline mediastinal lymphoma has been associated with young age, positive feline leukaemia virus (FeLV) status, Siamese breed and short survival times. Recent studies following widespread FeLV vaccination in the UK are lacking. The aim of this retrospective multi-institutional study was to re-evaluate the signalment, retroviral status, response to chemotherapy, survival and prognostic indicators in feline mediastinal lymphoma cases in the post-vaccination era. Records of cats with clinical signs associated with a mediastinal mass and cytologically/histologically confirmed lymphoma were reviewed from five UK referral centres (1998-2010). Treatment response, survival and prognostic indicators were assessed in treated cats with follow-up data. Fifty-five cases were reviewed. The median age was 3 years (range, 0.5-12 years); 12 cats (21.8%) were Siamese; and the male to female ratio was 3.2:1.0. Five cats were FeLV-positive and two were feline immunodeficiency-positive. Chemotherapy response and survival was evaluated in 38 cats. Overall response was 94.7%; complete (CR) and partial response (PR) rates did not differ significantly between protocols: COP (cyclophosphamide, vincristine, prednisone) (n = 26, CR 61.5%, PR 34.0%); Madison-Wisconsin (MW) (n = 12, CR 66.7%, PR 25.0%). Overall median survival was 373 days (range, 20-2015 days) (COP 484 days [range, 20-980 days]; MW 211 days [range, 24-2015 days] [P = 0.892]). Cats achieving CR survived longer (980 days vs 42 days for PR; P = 0.032). Age, breed, sex, location (mediastinal vs mediastinal plus other sites), retroviral status and glucocorticoid pretreatment did not affect response or survival. Feline mediastinal lymphoma cases frequently responded to chemotherapy with durable survival times, particularly in cats achieving CR. The prevalence of FeLV-antigenaemic cats was low; males and young Siamese cats appeared to be over-represented.

Subjective assessment of a new moisturizing mouthwash for the symptomatic management of dry mouth.

OBJECTIVE: A randomized clinical trial and consumer usage test were conducted to evaluate the acceptability and benefits of OASIS Moisturizing Mouthwash in subjects experiencing symptoms of dry mouth. METHODOLOGY: Study 1: A randomized, double blind, two-period crossover clinical trial was conducted in 49 subjects to evaluate OASIS Moisturizing Mouthwash and an experimental mouthwash formulation. Following a three-day acclimatization phase, subjects used both products at home for three days. Each treatment phase was separated by a three-day washout period. Study 2: Subjects participated in a one- to two-week home usage consumer test using OASIS Moisturizing Mouthwash, after which they completed a 52-question online survey exploring sensory benefits and resultant quality of life attributes of the product. RESULTS: Study 1: A total of 46 adults with a mean age of 64 years completed the study. On average, subjects used the test products three times per day. OASIS Moisturizing Mouthwash was found to be beneficial in managing dry mouth, and was well-liked by the study population, as evidenced by a statistically significant improvement over subjects' normal remedies for managing dry mouth for strength of flavor, taste, freshening breath, immediate and long lasting lubrication, and moisturization. Both products were well-tolerated. Study 2: Three-hundred and twenty-three subjects completed a one- to two-week consumer home usage test followed by an online questionnaire. On a five-point scale, over 80% of respondents perceived the OASIS Moisturizing Mouthwash as "excellent" or "very good" on sensory attributes such as taste and texture, and 70-80% gave the product an "excellent" or "very good" rating on benefit attributes. CONCLUSION: These studies showed that OASIS Moisturizing Mouthwash was beneficial in managing dry mouth, and was well-liked by the study population.