Recent stressful life events and identity development in emerging adults: An examination of within-person effects.

OBJECTIVE: To examine longitudinal associations among stressful life events and identity processess in emerging adults while accounting for within-person and between-person effects. BACKGROUND: Theoretical perspectives suggest that stressful life events may impact one's identity (i.e., coherent sense of self), but few studies have considered how changes in stressful life events are associated with changes within an individual's identity development over time (within-person effects). METHODS:  Recent stressful life events (i.e., academic problems, friendship problems, romantic problems, and time pressure) and the processes through which identity develops (e.g., exploring in breadth and depth) were examined longitudinally (T1-T3) in a sample of emerging adults (N = 1125, Mage = 17.96 years). RESULTS: Random-intercept cross-lagged modeling demonstrated that at the between-person level, emerging adults with greater academic and friendship problems, as well as more time pressures (relative to their counterparts), tended to engage in greater ruminative exploration. Further, those with more academic problems tended to demonstrate weaker commitment-making and exploration in breadth and depth (relative to their counterparts). Within-person increases in romantic problems predicted lower commitment-making and higher ruminative exploration over time. CONCLUSION: Findings suggest that romantic problems may predict within-person changes in identity processes, whereas academic problems, friendship problems, and time pressure may be more concurrently related to identity development.

Perioperative Management of Paraneoplastic Necrotizing Myopathy in Thyroidectomy: A Case Report.

Perioperative management of patients with myopathies can be challenging due to the increased risk of malignant hyperthermia (MH) and anesthesia-induced rhabdomyolysis (AIR). However, currently, there is no evidence regarding the optimal anesthetic management for paraneoplastic necrotizing myopathy (PNM) (total intravenous anesthetic vs. volatile anesthetics). Here, I report a case where anesthesia was administered safely using volatile anesthetics. A 63-year-old female presented with PNM associated with papillary thyroid carcinoma, necessitating urgent thyroidectomy. The patient, previously diagnosed with anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) antibody-associated myopathy, exhibited progressive weakness and dysphagia, prompting suspicion of PNM. The patient's compromised respiratory status, attributed to tracheal compression by a large goiter, necessitated an urgent thyroidectomy. Anesthetic management considerations included the potential effect of HMGCR-M on respiratory muscles and the need for careful planning to mitigate postoperative complications. The patient underwent total thyroidectomy, left central compartment clearance, and tracheostomy. The surgery proceeded uneventfully, with meticulous monitoring and adjustment of anesthetic agents to maintain hemodynamic stability. Postoperatively, the patient recovered well, demonstrating complete resolution of neurological symptoms during a three-month follow-up. The case underscores the importance of recognizing paraneoplastic syndromes in the context of thyroid surgery and highlights potential challenges faced by anesthesiologists. Despite the lack of established safety data for anesthetic drugs in HMGCR-M necrotizing myopathy, the case demonstrates the successful use of sevoflurane and rocuronium.

Harmonization of clinical practice guidelines for primary prevention and screening: actionable recommendations and resources for primary care.

BACKGROUND: Clinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program. METHODS: A review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40-69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations. RESULTS: We identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40-69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program. CONCLUSIONS: Comprehensive care requires the ability to address a person's overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care.

Chronic disease prevention and screening outcomes for patients with and without financial difficulty: a secondary analysis of the BETTER WISE cluster randomised controlled trial.

OBJECTIVE: Building on Existing Tools To improvE chronic disease pRevention and screening in primary care Wellness of cancer survIvorS and patiEnts (BETTER WISE) was designed to assess the effectiveness of a cancer and chronic disease prevention and screening (CCDPS) programme. Here, we compare outcomes in participants living with and without financial difficulty. DESIGN: Secondary analysis of a cluster-randomised controlled trial. SETTING: Patients of 59 physicians from 13 clinics enrolled between September 2018 and August 2019. PARTICIPANTS: 596 of 1005 trial participants who responded to a financial difficulty screening question at enrolment. INTERVENTION: 1-hour CCDPS visit versus usual care. OUTCOME MEASURES: Eligibility for a possible 24 CCDPS actions was assessed at baseline and the primary outcome was the percentage of eligible items that were completed at 12-month follow-up. We also compared the change in response to the financial difficulty screening question between baseline and follow-up. RESULTS: 55 of 265 participants (20.7%) in the control group and 69 of 331 participants (20.8%) in the intervention group reported living with financial difficulty. The primary outcome was 29% (95% CI 26% to 33%) for intervention and 23% (95% CI 21% to 26%) for control participants without financial difficulty (p=0.01). Intervention and control participants with financial difficulty scored 28% (95% CI 24% to 32%) and 32% (95% CI 27% to 38%), respectively (p=0.14). In participants who responded to the financial difficulty question at both time points (n=302), there was a net decrease in the percentage of participants who reported financial difficulty between baseline (21%) and follow-up (12%, p<0.001) which was similar in the control and intervention groups. The response rate to this question was only 51% at follow-up. CONCLUSION: The BETTER intervention improved uptake of CCDPS manoeuvres in participants without financial difficulty, but not in those living with financial difficulty. Improving CCDPS for people living with financial difficulty may require a different clinical approach or that social determinants be addressed concurrently with clinical and lifestyle needs or both. TRIAL REGISTRATION NUMBER: ISRCTN21333761.

Inequity in US Racial/Ethnic Infant Health and Birth Outcomes: The Role of the Adult Sex Ratio as a Potential Indicator of Structural Anti-Black Racism.

BACKGROUND: Structural racism accounts for inequity in health outcomes in ways that are difficult to measure. To conduct more actionable research and measure the impact of intervention programs, there is a need to develop indicator measures of structural racism. One potential candidate is the Adult Sex Ratio (ASR), which was identified by Du Bois as an important indicator of social life functioning over 100 years ago and has remained significant up to the present day. This study investigated the utility of this measure. METHODS: We compared birth/infant health outcomes using the US 2000 Linked Birth/Infant Death Cohort Data Set matched with 2000 Census data on adult sex ratios in multilevel logistic regression models, stratified by the racial/ethnic category of the mothers. RESULTS: In an adjusted model, the odds of infant death was 21% higher among non-Hispanic Black (NHB) women living in counties in the lowest ASR tertile category when compared to their counterparts in counties in the highest ASR tertile. Similarly, the odds of giving birth to a preterm or a low birth weight infant were each 20% higher among NHB women living in counties in the lowest ASR tertile compared to their counterparts in counties in the highest ASR tertile. CONCLUSION: ASRs may serve as a useful indicator of anti-Black structural racism at the local level. More research is needed to determine the circumstances under which this factor may serve to improve assessment of structural racism and facilitate health equity research.

Longitudinal Associations among Identity Processes and Mental Health in Young Adulthood: The Mediating Role of Social Support.

Emerging adulthood (ages 18-25) is a period of identity exploration, particularly for young adults navigating the transition to post-secondary school. Little is known about how changes in identity exploration may be related to emerging adults' mental health, or the role of social support plays in identity-related processes. In the present study, associations among identity exploration, internalizing symptoms, and perceived social support were examined. Participants included a diverse group of emerging adults (N = 1,125, Mage = 17.96 years) studying at a Canadian university. Random-intercept cross-lagged modeling demonstrated that within-person increases in exploration in breadth predicted fewer depressive symptoms over time, whereas within-person increases in exploration in depth predicted more depressive and anxious symptoms over time. A mediation effect from perceived support from significant other to depressive symptoms via exploration in breadth was also evident. Findings suggest that identity exploratory processes may be developmentally relevant in emerging adulthood, but their implications for mental health may differ. Perceived social support is also meaningfully related to identity exploration and mental health.

A longitudinal examination of school-related and mental health mediators linking emotion regulation to academic achievement.

Emotion regulation is assumed to underlie academic achievement through different mechanisms (e.g., a positive orientation toward school and schoolwork, better mental health). However, few studies have contrasted these mediating mechanisms within a longitudinal analytic framework, which is necessary to determine which mechanism(s) are most likely to translate emotion regulation into academic success over time. The present study addressed this gap by examining whether children's emotion regulation capacities were associated with later academic achievement through school-related (i.e., school bonding and academic motivation) and mental health mediators (i.e., internalizing and externalizing symptoms). Participants included 300 4- and 8-year-old children (n = 150 in each age cohort; 50% female) and their caregivers from Canada. Measures were collected over 4 years. Path analyses indicated that higher emotion regulation (T1; age 4/8 years) was associated with better academic achievement 3 years later (T4; age 7/11 years) through stronger school bonding and lower internalizing symptoms in the interim (T2; age 5/9 years; the indirect effect through internalizing symptoms held after controlling for initial levels of internalizing symptoms). Significant effects were derived from both caregiver and child informants when applicable and indirect effects held across age cohorts and genders. Findings highlight the interplay of social-emotional, academic, and mental health development across childhood, as well as the potential benefits of extending academic interventions to the social-emotional and mental health domains.

Results from the BETTER WISE trial: a pragmatic cluster two arm parallel randomized controlled trial for primary prevention and screening in primary care during the COVID-19 pandemic.

BACKGROUND: Cancer and chronic diseases are a major cost to the healthcare system and multidisciplinary models with access to prevention and screening resources have demonstrated improvements in chronic disease management and prevention. Research demonstrated that a trained Prevention Practitioner (PP) in multidisciplinary team settings can improve achievement of patient level prevention and screening actions seven months after the intervention. METHODS: We tested the effectiveness of the PP intervention in a pragmatic two-arm cluster randomized controlled trial. Patients aged 40-65 were randomized at the physician level to an intervention group or to a wait-list control group. The intervention consisted of a patient visit with a PP. The PP received training in prevention and screening and use of the BETTER WISE tool kit. The effectiveness of the intervention was assessed using a composite outcome of the proportion of the eligible prevention and screening actions achieved between intervention and control groups at 12-months. RESULTS: Fifty-nine physicians were recruited in Alberta, Ontario, and Newfoundland and Labrador. Of the 1,005 patients enrolled, 733 (72.9%) completed the 12-month analysis. The COVID-19 pandemic occurred during the study time frame at which time nonessential prevention and screening services were not available and in-person visits with the PP were not allowed. Many patients and sites did not receive the intervention as planned. The mean composite score was not significantly higher in patients receiving the PP intervention as compared to the control group. To understand the impact of COVID on the project, we also considered a subset of patients who had received the intervention and who attended the 12-month follow-up visit before COVID-19. This assessment demonstrated the effectiveness of the BETTER visits, similar to the findings in previous BETTER studies. CONCLUSIONS: We did not observe an improvement in cancer and chronic disease prevention and screening (CCDPS) outcomes at 12 months after a BETTER WISE prevention visit: due to the COVID-19 pandemic, the study was not implemented as planned. Though benefits were described in those who received the intervention before COVID-19, the sample size was too small to make conclusions. This study may be a harbinger of a substantial decrease and delay in CCDPS activities under COVID restrictions. TRIAL REGISTRATION: ISRCTN21333761. Registered on 19/12/2016. http://www.isrctn.com/ISRCTN21333761 .

Nurturing child social-emotional development: evaluation of a pre-post and 2-month follow-up uncontrolled pilot training for caregivers and educators.

BACKGROUND: Social-emotional capacities contribute to children's mental health by helping them navigate their own and others' emotional states and forge healthy relationships. Caregivers and educators are critical socialization agents in early and middle childhood, but gaps remain in the systematic integration of social-emotional research into caregiver and educator trainings. The aim of this pilot study was to test the feasibility and preliminary efficacy of a social-emotional training designed to promote caregivers' and educators' capacities to support social-emotional development in children ages 3-8 years. METHODS: Fifty adults (n = 24 caregivers of children ages 3-8 years, n = 26 educators working with children ages 3-8 years) participated in a virtual training over 3 weeks. Participants completed pre-training, post-training, and 2-month follow-up questionnaires evaluating their knowledge of social-emotional concepts, use of training strategies, mental health, and satisfaction with the training. Caregivers also reported children's social-emotional capacities and mental health. RESULTS: On average, caregivers and educators completed 83% of the virtual training sessions and reported high satisfaction with the training. Further, preliminary evidence indicated that caregivers' and educators' knowledge of social-emotional concepts increased pre- to post-training and was maintained at the 2-month follow-up. Increases in caregivers' and educators' knowledge and greater use of training strategies were associated with improvements in children's social-emotional capacities and caregivers' and educators' own mental health. CONCLUSIONS: These pilot results support the feasibility of infusing evidence-based social-emotional content into caregiver and educator training initiatives aimed at nurturing child social-emotional development and mental health. The results inform future evaluation of the short- and long-term benefits of this training with a full-scale randomized controlled trial design.

Facilitators and Barriers to the Implementation of BETTER WISE, a Chronic Disease and Prevention Intervention in Canada: A Qualitative Study.

The aim of the BETTER WISE intervention is to address cancer and chronic disease prevention and screening (CCDPS) and lifestyle risks in patients aged 40-65. The purpose of this qualitative study is to better understand facilitators and barriers to the implementation of the intervention. Patients were invited for a 1-h visit with a prevention practitioner (PP), a member of a primary care team, with specific skills in prevention, screening, and cancer survivorship. We collected and analyzed data from 48 key informant interviews and 17 focus groups conducted with 132 primary care providers and from 585 patient feedback forms. We analyzed all qualitative data using a constant comparative method informed by grounded theory and then employed the Consolidated Framework for Implementation Research (CFIR) in a second round of coding. The following key elements were identified: (1) Intervention characteristics-relative advantage and adaptability; (2) Outer setting-PPs compensating for increased patient needs and decreased resources; (3) Characteristics of individuals-PPs (patients and physicians described PPs as compassionate, knowledgeable, and helpful); (4) Inner setting-network and communication (collaboration and support in teams or lack thereof); and (5) Process-executing the implementation (pandemic-related issues hindered execution, but PPs adapted to challenges). This study identified key elements that facilitated or hindered the implementation of BETTER WISE. Despite the interruption caused by the COVID-19 pandemic, the BETTER WISE intervention continued, driven by the PPs and their strong relationships with their patients, other primary care providers, and the BETTER WISE team.

Conceptualizing maternal and paternal autonomy support and control among adolescents in Hong Kong.

This study examined how parental autonomy support and control are conceptualized by adolescents in Hong Kong (Grades 7-11) using the Perceived Parental Autonomy Support Scale. Competitive models were evaluated using confirmatory factor analyses. Although the 6-factor model demonstrated the best fit, further analyses indicated that a second-order structure was more appropriate. Provision of choice, acknowledgment of child's feelings, rationale for rules, and demands subsumed under autonomy support. Guilt-inducing criticisms and the use of threats subsumed under control. Performance pressure emerged as a first-order construct on its own. Measurement invariance was evident across adolescent gender and age. All subscales had adequate to strong reliability. Discriminate validity was evident. Findings offer insights into the conceptualization of autonomy support and control in Hong Kong.

Daily COVID-19 Stressor Effects on Children's Mental Health Depend on Pre-pandemic Peer Victimization and Resting Respiratory Sinus Arrhythmia.

Children's risk of poorer mental health due to the COVID-19 pandemic may depend on risk and protective factors heading into the pandemic. This study examined same-day associations between COVID-19 stressors and children's mental health using a daily diary design across 14 days, and considered the moderating roles of pre-pandemic peer victimization experiences and resting respiratory sinus arrhythmia (RSA; an indicator of cardiac regulatory capacity). Forty-nine Canadian children aged 8-13 years (Mage = 10.69, 29 girls) participated in the final wave of a longitudinal study just prior to the pandemic and a daily diary extension during the pandemic (N = 686 pandemic measurement occasions). Multilevel modeling indicated that children had poorer mental health on days when they experienced a COVID-19 stressor (e.g., virtual academic difficulties, social isolation). A three-way interaction indicated that this association was stronger for those with higher pre-pandemic peer victimization experiences and lower pre-pandemic resting RSA; however, highly victimized children with higher resting RSA did not experience poorer mental health on days with COVID-19 stressors. Findings offer preliminary insights into the preceding risk and protective factors for children's mental health amidst major subsequent stress.

Adoption of Patient-Generated Health Data in Oncology: A Report From the NCCN EHR Oncology Advisory Group.

BACKGROUND: Collecting, monitoring, and responding to patient-generated health data (PGHD) are associated with improved quality of life and patient satisfaction, and possibly with improved patient survival in oncology. However, the current state of adoption, types of PGHD collected, and degree of integration into electronic health records (EHRs) is unknown. METHODS: The NCCN EHR Oncology Advisory Group formed a Patient-Reported Outcomes (PRO) Workgroup to perform an assessment and provide recommendations for cancer centers, researchers, and EHR vendors to advance the collection and use of PGHD in oncology. The issues were evaluated via a survey of NCCN Member Institutions. Questions were designed to assess the current state of PGHD collection, including how, what, and where PGHD are collected. Additionally, detailed questions about governance and data integration into EHRs were asked. RESULTS: Of 28 Member Institutions surveyed, 23 responded. The collection and use of PGHD is widespread among NCCN Members Institutions (96%). Most centers (90%) embed at least some PGHD into the EHR, although challenges remain, as evidenced by 88% of respondents reporting the use of instruments not integrated. Forty-seven percent of respondents are leveraging PGHD for process automation and adherence to best evidence. Content type and integration touchpoints vary among the members, as well as governance maturity. CONCLUSIONS: The reported variability regarding PGHD suggests that it may not yet have reached its full potential for oncology care delivery. As the adoption of PGHD in oncology continues to expand, opportunities exist to enhance their utility. Among the recommendations for cancer centers is establishment of a governance process that includes patients. Researchers should consider determining which PGHD instruments confer the highest value. It is recommended that EHR vendors collaborate with cancer centers to develop solutions for the collection, interpretation, visualization, and use of PGHD.

Exploring Beliefs and Attitudes Toward Female Genital Mutilation/Cutting Among Healthcare Providers in New York City.

Given the increase of African immigrants from countries with high female genital cutting (FGC) prevalence, this study explored U.S. healthcare providers' beliefs and attitudes regarding FGC. A total of 31 professionals who have provided services to FGC-experienced women in New York City were interviewed; data were analyzed using grounded theory. Results indicated that, although a majority of respondents emphasized maintaining a nonjudgmental and open-minded attitude toward clients' experiences, some only focused on the negative aspects of FGC. Also, multifaceted efforts by providers to understand the cultural meanings of FGC and resolve their own cultural dissonance were identified. The implications for practice were discussed.

Development and Validation of the Teen Dating Aggression Measure Among Canadian Youth.

Teen dating violence (TDV) victimization is a traumatic experience that can have adverse consequences for adolescents. Current measures that assess TDV do not fully distinguish between psychological and relational forms of aggression, nor do they capture aggressive acts that are common within adolescent relationships. The purpose of this study was to evaluate the psychometric properties of the Teen Dating Aggression Measure (TeDAM) using a sample of 730 Canadian adolescents (M = 15.88 years, SD = 1.23). The measure is an expansion of the Conflict in Adolescent Dating Relationships Inventory and includes items that describe other forms of violence such as coercion and control, along with more traditional indicators of dating violence (e.g., sexual aggression). Factor analyses yielded three factors, namely psychological aggression, sexual and physical aggression, and relational aggression, which were correlated with more frequent cannabis and alcohol use as well as rape myth acceptance. These results provide initial support for the utility of the TeDAM for assessing TDV with adolescents.

NCCN Policy Summit: Defining, Measuring, and Applying Quality in an Evolving Health Policy Landscape and the Implications for Cancer Care.

Quality measurement is a critical component of advancing a health system that pays for performance over volume. Although there has been significant attention paid to quality measurement within health systems in recent years, significant challenges to meaningful measurement of quality care outcomes remain. Defining cost can be challenging, but is arguably not as elusive as quality, which lacks standard measurement methods and units. To identify industry standards and recommendations for the future, NCCN recently hosted the NCCN Oncology Policy Summit: Defining, Measuring, and Applying Quality in an Evolving Health Policy Landscape and the Implications for Cancer Care. Key stakeholders including physicians, payers, policymakers, patient advocates, and technology partners reviewed current quality measurement programs to identify success and challenges, including the Oncology Care Model. Speakers and panelists identified gaps in quality measurement and provided insights and suggestions for further advancing quality measurement in oncology. This article provides insights and recommendations; however, the goal of this program was to highlight key issues and not to obtain consensus.

Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal.

The first confirmed case of coronavirus disease 2019 (COVID-19) in the United States was reported on January 20, 2020, in Snohomish County, Washington. At the epicenter of COVID-19 in the United States, the Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, and University of Washington are at the forefront of delivering care to patients with cancer during this public health crisis. This Special Feature highlights the unique circumstances and challenges of cancer treatment amidst this global pandemic, and the importance of organizational structure, preparation, agility, and a shared vision for continuing to provide cancer treatment to patients in the face of uncertainty and rapid change.

Sleep macro-architecture and micro-architecture in children born preterm with sleep disordered breathing.

BACKGROUND: Both preterm birth and sleep disordered breathing (SDB) affect sleep in children. We compared the effects of SDB on sleep macro-architecture and micro-architecture in children born preterm (N = 50) and children born at term (N = 50). We hypothesized that sleep would be more disrupted in children born preterm. METHODS: Polysomnographic studies matched for age (3-12 years) and SDB severity were analyzed. Sleep macro-architecture was assessed using standard criteria and micro-architecture was evaluated using spectral analysis of the electroencephalogram and slow wave activity (SWA) calculated for each sleep stage across the night. RESULTS: Ex-preterm children (gestational age 29.3 ± 3.6 weeks, mean ± standard error of the mean) were not different from controls for demographic or respiratory parameters or sleep macro-architecture. Theta power in N2 tended to be higher for F4 (p < 0.05) and C4 (p < 0.07). In the second non-rapid eye movement period, SWA was significantly higher in the preterm group compared to the term group for both F4 and C4 (p < 0.05 for both). CONCLUSIONS: Sleep micro-architecture in children born preterm showed increased theta power and SWA. These differences provide evidence of increased sleep debt and reduced dissipation of sleep debt across the night. Further studies are required to identify if these findings are related to impaired neurocognition and behavior.