Digitally Enabled Peer Support Intervention to Address Loneliness and Mental Health: Prospective Cohort Analysis.

BACKGROUND: Social isolation and loneliness affect 61% of US adults and are associated with significant increases in excessive mental and physical morbidity and mortality. Annual health care spending is US $1643 higher for socially isolated individuals than for those not socially isolated. OBJECTIVE: We prospectively evaluated the effects of participation with a digitally enabled peer support intervention on loneliness, depression, anxiety, and health-related quality of life among adults with loneliness. METHODS: Adults aged 18 years and older living in Colorado were recruited to participate in a peer support program via social media campaigns. The intervention included peer support, group coaching, the ability to become a peer helper, and referral to other behavioral health resources. Participants were asked to complete surveys at baseline, 30, 60, and 90 days, which included questions from the validated University of California, Los Angeles Loneliness Scale, Patient Health Questionnaire 2-Item Scale, General Anxiety Disorder 7-Item Scale, and a 2-item measure assessing unhealthy days due to physical condition and mental condition. A growth curve modeling procedure using multilevel regression analyses was conducted to test for linear changes in the outcome variables from baseline to the end of the intervention. RESULTS: In total, 815 ethnically and socially diverse participants completed registration (mean age 38, SD 12.7; range 18-70 years; female: n=310, 38%; White: n=438, 53.7%; Hispanic: n=133, 16.3%; Black: n=51, 6.3%; n=263, 56.1% had a high social vulnerability score). Participants most commonly joined the following peer communities: loneliness (n=220, 27%), building self-esteem (n=187, 23%), coping with depression (n=179, 22%), and anxiety (n=114, 14%). Program engagement was high, with 90% (n=733) engaged with the platform at 60 days and 86% (n=701) at 90 days. There was a statistically (P<.001 for all outcomes) and clinically significant improvement in all clinical outcomes of interest: a 14.6% (mean 6.47) decrease in loneliness at 90 days; a 50.1% (mean 1.89) decline in depression symptoms at 90 days; a 29% (mean 1.42) reduction in anxiety symptoms at 90 days; and a 13% (mean 21.35) improvement in health-related quality of life at 90 days. Based on changes in health-related quality of life, we estimated a reduction in annual medical costs of US $615 per participant. The program was successful in referring participants to behavioral health educational resources, with 27% (n=217) of participants accessing a resource about how to best support those experiencing psychological distress and 15% (n=45) of women accessing a program about the risks of excessive alcohol use. CONCLUSIONS: Our results suggest that a digitally enabled peer support program can be effective in addressing loneliness, depression, anxiety, and health-related quality of life among a diverse population of adults with loneliness. Moreover, it holds promise as a tool for identifying and referring members to relevant behavioral health resources.

Hyperbaric oxygen therapy in children with post-concussion syndrome improves cognitive and behavioral function: a randomized controlled trial.

Persistent post-concussion syndrome (PPCS) is a common and significant morbidity among children following traumatic brain injury (TBI) and the evidence for effective PPCS treatments remains limited. Recent studies have shown the beneficial effects of hyperbaric oxygen therapy (HBOT) in PPCS adult patients. This randomized, sham-control, double blind trial evaluated the effect of hyperbaric oxygen therapy (HBOT) on children (age 8-15) suffering from PPCS from mild-moderate TBI events six months to 10 years prior. Twenty-five children were randomized to receive 60 daily sessions of HBOT (n = 15) or sham (n = 10) treatments. Following HBOT, there was a significant increase in cognitive function including the general cognitive score (d = 0.598, p = 0.01), memory (d = 0.480, p = 0.02), executive function (d = 0.739, p = 0.003), PPCS symptoms including emotional score (p = 0.04, d = - 0.676), behavioral symptoms including hyperactivity (d = 0.244, p = 0.03), global executive composite score (d = 0.528, p = 0.001), planning/organizing score (d = 1.09, p = 0.007). Clinical outcomes correlated with significant improvements in brain MRI microstructural changes in the insula, supramarginal, lingual, inferior frontal and fusiform gyri. The study suggests that HBOT improves both cognitive and behavioral function, PPCS symptoms, and quality of life in pediatric PPCS patients at the chronic stage, even years after injury. Additional data is needed to optimize the protocol and to characterize the children who can benefit the most.

Effectiveness of a minimal virtual motivational interviewing training for first years medical students: differentiating between pre-test and then-test.

BACKGROUND: Shifting towards patient-centeredness, medical doctors need patient-centered communication skills. Motivational Interviewing (MI) is an evidence-based, collaborative, goal-oriented communication technique to strengthen a person's own motivation and commitment to change. The purpose of this study is to evaluate the effectiveness of a brief virtual role-play MI-training program on MI-knowledge and skills in first-year undergraduate medical students, making use of both a pre-test and a then-test (retrospective pre-test) to check for response shift in evaluating the educational intervention. METHODS: Four 10-15 min MI-game-based training conversations embedded in the Kognito Conversation Platform™ were offered to the students using a single-group Interrupted Time Series design. RESULTS: Participants included 339 undergraduate medical students (RR= 83.1%). The one-hour MI virtual training proved effective in two ways: participants gained knowledge and skills, and increased awareness of the existing intrinsic knowledge and skill they already possess to communicate with future patients in a patient-centered way. CONCLUSION: A brief one-hour MI-training simulation can be effective even if offered at an early stage during medical education. Furthermore, response shift varied and was not present in all students. PRACTICE IMPLICATION: The addition of a then-test to the study design reveals results that otherwise would not have been found.

Limits of Sums for Binomial and Eulerian Numbers and their Associated Distributions.

We provide a probabilistic approach using renewal theory to derive some novel identities involving Eulerian numbers and uniform B-splines. The renewal perspective leads to a unified treatment for the normalized binomial coefficients and the normalized Eulerian numbers when studying their limits of sums, as well as their associated distributions - the binomial distributions (Bernstein polynomials) and the Irwin-Hall distributions (uniform B-splines). We further extend the probabilistic perspective to h-Bernstein polynomials (Pólya-Eggenberger distributions) through conditional renewal processes, and derive new limits of various ways of summing for the two special numbers and associated distributions. The proposed probabilistic unification dramatically simplifies the proofs of some identities, which are far from obvious (such as for h-Bernstein polynomials) or do not otherwise even appear promising (such as for Eulerian numbers).

Adherence to Monitoring Guidelines of Amiodarone Adverse Reactions.

BACKGROUND: Amiodarone treatment frequently causes adverse reactions. Clinical guidelines warrant a comprehensive assessment prior to chronic treatment with amiodarone and repeated monitoring for the appearance of adverse reactions. OBJECTIVE: To evaluate adherence to these guidelines. METHODS: A retrospective chart review of electronic medical records of adult patients treated with oral amiodarone for at least 12 months. RESULTS: One hundred patient records were analyzed; 97% of patients were evaluated for thyroid and liver functions prior to treatment. Liver functions were properly monitored every 6 months in 96% of patients and thyroid function in only 59%. Most (84%) patients completed a chest X-ray before treatment; only 2% completed a respiratory function test. None have performed a chest X-ray annually. Sixty-four percent of the patients were examined by an ophthalmologist prior to treatment; periodic ophthalmic surveillance was not consistent. Neurological and dermatological evaluations were not recorded for any of the patients, unless symptoms appeared. Only 50% were adherent to annual cardiac reassessment. CONCLUSIONS: Adherence to recommended clinical guidelines for monitoring amiodarone adverse reactions is poor. Interventions to improve compliance with these guidelines are needed.

Simulated Conversations With Virtual Humans to Improve Patient-Provider Communication and Reduce Unnecessary Prescriptions for Antibiotics: A Repeated Measure Pilot Study.

BACKGROUND: Despite clear evidence that antibiotics do not cure viral infections, the problem of unnecessary prescribing of antibiotics in ambulatory care persists, and in some cases, prescribing patterns have increased. The overuse of antibiotics for treating viral infections has created numerous economic and clinical consequences including increased medical costs due to unnecessary hospitalizations, antibiotic resistance, disruption of gut bacteria, and obesity. Recent research has underscored the importance of collaborative patient-provider communication as a means to reduce the high rates of unnecessary prescriptions for antibiotics. However, most patients and providers do not feel prepared to engage in such challenging conversations. OBJECTIVES: The aim of this pilot study was to assess the ability of a brief 15-min simulated role-play conversation with virtual humans to serve as a preliminary step to help health care providers and patients practice, and learn how to engage in effective conversations about antibiotics overuse. METHODS: A total of 69 participants (35 providers and 34 patients) completed the simulation once in one sitting. A pre-post repeated measures design was used to assess changes in patients' and providers' self-reported communication behaviors, activation, and preparedness, intention, and confidence to effectively communicate in the patient-provider encounter. Changes in patients' knowledge and beliefs regarding antibiotic use were also evaluated. RESULTS: Patients experienced a short-term positive improvement in beliefs about appropriate antibiotic use for infection (F1,30=14.10, P=.001). Knowledge scores regarding the correct uses of antibiotics improved immediately postsimulation, but decreased at the 1-month follow-up (F1,30=31.16, P<.001). There was no change in patient activation and shared decision-making (SDM) scores in the total sample of patients (P>.10) Patients with lower levels of activation exhibited positive, short-term benefits in increased intent and confidence to discuss their needs and ask questions in the clinic visit, positive attitudes regarding participation in SDM with their provider, and accurate beliefs about the use of antibiotics (P<.10). The results also suggest small immediate gains in providers' attitudes about SDM (mean change 0.20; F1,33= 8.03, P=.01). CONCLUSIONS: This pilot study provided preliminary evidence on the efficacy of the use of simulated conversations with virtual humans as a tool to improve patient-provider communication (ie, through increasing patient confidence to actively participate in the visit and physician attitudes about SDM) for engaging in conversations about antibiotic use. Future research should explore if repeated opportunities to use the 15-min simulation as well as providing users with several different conversations to practice with would result in sustained improvements in antibiotics beliefs and knowledge and communication behaviors over time. The results of this pilot study offered several opportunities to improve on the simulation in order to bolster communication skills and knowledge retention.

Detecting When an Implicit Equation or a Rational Parametrization Defines a Conical or Cylindrical Surface, or a Surface of Revolution.

Given an implicit polynomial equation or a rational parametrization, we develop algorithms to determine whether the set of real and complex points defined by the equation, i.e., the surface defined by the equation, in the sense of Algebraic Geometry, is a cylindrical surface, a conical surface, or a surface of revolution. The algorithms are directly applicable to, and formulated in terms of, the implicit equation or the rational parametrization. When the surface is cylindrical, we show how to compute the direction of its rulings; when the surface is conical, we show how to compute its vertex; and when the surface is a surface of revolution, we show how to compute its axis of rotation directly from the defining equations.

Development and Validation of the Gatekeeper Behavior Scale.

BACKGROUND: Community-based gatekeeper trainings are effective tools in increasing gatekeeper skills but few validated measures assess impact. AIMS: This study aimed at determining the validity of an 11-item Gatekeeper Behavior Scale (GBS) to assess gatekeeper skills that predict behavior. METHOD: To validate the scale, 8,931 users were administered GBS surveys at pretraining, posttraining, and follow-up periods. The training was one of five from the suite of online At-Risk mental health learning simulations for university faculty/staff or students or high/middle school educators. RESULTS: A confirmatory factor analysis revealed the three-factor model based on the subscales of preparedness, likelihood, and self-efficacy fit the data best. Factor loadings showed all items correlated highly with theoretical constructs (r ≥ .84, p < .001). The GBS had high internal consistency (α = 0.93). Criterion-related validity for likelihood to discuss concerns at posttraining was significantly related to approaching students believed to be in psychological distress (r = .219, p < .001). Likelihood to refer significantly correlated with the number of students referred (r = .235, p < .001). Convergent validity was established via a correlation between self-efficacy in motivating someone to seek help and general self-efficacy (r = .519, p < .001). CONCLUSION: The GBS appears to be a valid tool in measuring the impact of online gatekeeper training simulations and holds promise for assessing other delivery methods.

Finding the Axis of Revolution of an Algebraic Surface of Revolution.

We present an algorithm for extracting the axis of revolution from the implicit equation of an algebraic surface of revolution based on three distinct computational methods: factoring the highest order form into quadrics, contracting the tensor of the highest order form, and using univariate resultants and gcds. We compare and contrast the advantages and disadvantages of each of these three techniques and we derive conditions under which each technique is most appropriate. In addition, we provide several necessary conditions for an implicit algebraic equation to represent a surface of revolution.

Harnessing the power of conversations with virtual humans to change health behaviors.

Skillful, collaborative conversations are powerful tools to improve physical and mental health. Whether you are a parent talking with your child about the dangers of substance abuse, an educator concerned about a student's signs of psychological distress, a veteran worried about a buddy who is contemplating suicide, or a healthcare professional wanting to better engage patients to increase treatment compliance, having the skill, confidence and motivation to engage in conversations can truly transform the health and well-being of those you interact with. Kognito develops role-play simulations that prepare individuals to effectively lead real-life conversations that measurably improve social, emotional, and physical health. The behavior change model that drives the simulations draws upon components of game mechanics, virtual human simulation technology and integrates evidence-based instructional design components as well as principles of social-cognitive theory and neuroscience such as motivational interviewing, emotional regulation, empathy and mindfulness. In the simulations, users or enter a risk-free practice environment and engage in a conversation with intelligent, fully animated, and emotionally responsive virtual characters that model human behavior. It is in practicing these conversations, and receiving feedback from a virtual coach, that users learn to better lead conversations in real life. Numerous longitudinal studies have shown that users who complete Kognito simulations demonstrate statistically significant and sustained increases in attitudinal variables that predict behavior change including preparedness, likelihood, and self-efficacy to better manage conversations. Pending the target population, each online or mobile simulation resulted in desired behavior changes ranging from increased referrals of students, patients or veterans in psychological distress to mental health support services, or increasing physician patient-centered communication or patient self-confidence and active involved in the decision-making processes. These simulations have demonstrated a capability to address major health and public health concerns where effective conversations are necessary to bring about changes in attitudes and behaviors.

Oil spill contamination probability in the southeastern Levantine basin.

Recent gas discoveries in the eastern Mediterranean Sea led to multiple operations with substantial economic interest, and with them there is a risk of oil spills and their potential environmental impacts. To examine the potential spatial distribution of this threat, we created seasonal maps of the probability of oil spill pollution reaching an area in the Israeli coastal and exclusive economic zones, given knowledge of its initial sources. We performed simulations of virtual oil spills using realistic atmospheric and oceanic conditions. The resulting maps show dominance of the alongshore northerly current, which causes the high probability areas to be stretched parallel to the coast, increasing contamination probability downstream of source points. The seasonal westerly wind forcing determines how wide the high probability areas are, and may also restrict these to a small coastal region near source points. Seasonal variability in probability distribution, oil state, and pollution time is also discussed.

Business Models for Successfully Maintaining Games for Health.

Videogames for health provide innovative, exciting, and possibly highly effective new media for helping players change their behaviors or otherwise benefit their health. Getting the right videogames into the hands of players who can benefit most in a way that pays for the continued innovation and creation of such games is a current challenge. Entertainment videogame companies, which create games primarily to enhance players' enjoyment, have used the general business marketplace (e.g., online stores, walk-in stores, app stores) to deliver their products directly to consumers and earn enough capital to invest in making new products. No one believes, however, that enough kids or adults would use the general business marketplace to purchase games for health in sufficient volume to provide the down payment for the innovation and creation of new games for health. A successful business model is critical to the financial future of games for health. We asked members of our Editorial Board who are in health-related companies (Fikry Isaac, MD, MPH), in several game development companies (Chris Ashford, Ron Goldman, David J. Lenihan, Brent Poole, and Richard Buday, FAIA), and the head of the Games for Health Europe Foundation (Jurriaan van Rijswijk, MSc) to address questions in a roundtable about the current and possible future business models for games for health.

A Game-Based Simulation Utilizing Virtual Humans to Train Physicians to Screen and Manage the Care of Patients with Mental Health Disorders.

Every year, one in four American adults suffers from a diagnosable mental disorder, yet most of them go untreated, creating a significant public health challenge. This challenge is compounded by large-scale disasters, which can cause an influx of primary care patients presenting with physical symptoms that mask mental health disorders. Primary care providers (PCPs) are usually the first point of contact for those patients; thus there exist crucial opportunities to detect and address nonphysical disorders in primary care settings that would improve patient outcomes and quality of care. Unfortunately, many PCPs view mental health as separate from the services that they provide, and the majority of them have received little training during or after medical or nursing school about risk factors, symptoms, and treatment options. To help integrate behavioral health into primary care, Kognito Interactive developed "At-Risk in Primary Care," an online game-based simulation that integrates role-play conversations with virtual humans to train PCPs to screen patients for mental health disorders, perform brief behavioral interventions using motivational interviewing (MI), refer patients, and integrate behavioral health into their treatment while building patients' intrinsic motivation to adhere to it. Preliminary findings on the implementation of this game in New York City show significant increases in skill and motivation to screen patients, conduct behavioral interventions, and refer patients to specialized care. These results show the promise of innovative technology-based solutions to integrate mental health training in primary care.

Are Pediatricians "Game"? Reducing Childhood Obesity by Training Clinicians to Use Motivational Interviewing Through Role-Play Simulations with Avatars.

The results of a feasibility study funded by a National Institutes of Health Small Business Innovation Research Phase 1 grant to assess the potential of using online, avatar-based simulation technology to increase pediatricians' use of motivational interviewing techniques to reduce childhood obesity are promising, with potentially positive implications for individual and public health outcomes.

Using an Avatar-Based Simulation to Train Families to Motivate Veterans with Post-Deployment Stress to Seek Help at the VA.

OBJECTIVE: This study examines the effectiveness of "Family of Heroes," an online avatar-based post-deployment stress and resiliency training simulation, in increasing families' engagement in motivating their veterans who exhibit signs of post-deployment stress, including post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), depression, and suicide ideation, to seek help at the Veterans Administration (VA). MATERIALS AND METHODS: Participants were randomly assigned to an experimental group (n=50) that completed the online training and pre- and post-intervention and 1-month follow-up surveys or a control group (n=44) who only completed a pre-test and a 1-month follow-up survey. RESULTS: The experimental group exhibited significantly greater changes in its preparedness and likelihood to recognize signs of post-deployment stress and in approaching their veteran to discuss their concern and motivate them to seek help at the VA. This group also reported significant change in actual behavior in terms of discussing their concern with their veteran (79 percent approached to discuss vs. 56 percent for the control group). Finally, seven (22 percent) of the veterans who were approached by the experimental group started to receive mental health treatment (five at the VA). All seven were previously diagnosed with PTSD and/or depression but never before started treatment at the VA. CONCLUSION: Results strongly suggest that "Family of Heroes" is an effective tool to engage families in taking an active role in motivating their veterans who exhibit signs of post-deployment stress to seek help at the VA. Results also suggest that the training can increase the actual number of veterans experiencing post-deployment stress who begin to receive treatment at the VA.