Ten-Year Outcomes: Community Health Center/Academic Medicine Partnership for Rural Family Medicine Training.

BACKGROUND AND OBJECTIVES: The widening gap between urban and rural health outcomes is exacerbated by physician shortages that disproportionately affect rural communities. Rural residencies are an effective mechanism to increase physician placement in rural and medically underserved areas yet are limited in number due to funding. Community health center/academic medicine partnerships (CHAMPs) can serve as a collaborative framework for expansion of academic primary care residencies outside of traditional funding models. This report describes 10-year outcomes of a rural training pathway developed as part of a CHAMP collaboration. METHODS: Using data from internal registries and public sources, our retrospective study examined demographic and postgraduation practice characteristics for rural pathway graduates. We identified the rates of postgraduation placement in rural (Federal Office of Rural Health Policy grant-eligible) and federally designated Medically Underserved Areas/Populations (MUA/Ps). We assessed current placement for graduates >3 years from program completion. RESULTS: Over a 10-year period, 25 trainees graduated from the two residency expansion sites. Immediately postgraduation, 84% (21) were in primary care Health Professional Shortage Areas (HPSAs), 80% (20) in MUA/Ps, and 60% (15) in rural locations. Sixteen graduates were >3 years from program completion, including 69% (11) in primary care HPSAs, 69% (11) in MUA/Ps, and 50% (5) in rural locations. CONCLUSIONS: This CHAMP collaboration supported development of a rural pathway that embedded family medicine residents in community health centers and effectively increased placement in rural and MUA/Ps. This report adds to national research on rural workforce development, highlighting the role of academic-community partnerships in expanding rural residency training outside of traditional funding models.

Identification of Novel, Selective Ataxia-Telangiectasia Mutated Kinase Inhibitors with the Ability to Penetrate the Blood-Brain Barrier: The Discovery of AZD1390.

The inhibition of ataxia-telangiectasia mutated (ATM) has been shown to chemo- and radio-sensitize human glioma cells in vitro and therefore might provide an exciting new paradigm in the treatment of glioblastoma multiforme (GBM). The effective treatment of GBM will likely require a compound with the potential to efficiently cross the blood-brain barrier (BBB). Starting from clinical candidate AZD0156, 4, we investigated the imidazoquinolin-2-one scaffold with the goal of improving likely CNS exposure in humans. Strategies aimed at reducing hydrogen bonding, basicity, and flexibility of the molecule were explored alongside modulating lipophilicity. These studies identified compound 24 (AZD1390) as an exceptionally potent and selective inhibitor of ATM with a good preclinical pharmacokinetic profile. 24 showed an absence of human transporter efflux in MDCKII-MDR1-BCRP studies (efflux ratio <2), significant BBB penetrance in nonhuman primate PET studies (Kp,uu 0.33) and was deemed suitable for development as a clinical candidate to explore the radiosensitizing effects of ATM in intracranial malignancies.

The contributions of clinical disease activity, functional disability, and illness intrusiveness to depressive symptoms in pediatric inflammatory bowel disease.

BACKGROUND: Clinical disease activity associated with inflammatory bowel disease (IBD) can place physical limitations on youths' activities of daily living. In turn, functional limitations potentially contribute to youths' heightened experience of IBD-induced intrusions on a wide range of routine and valued activities (i.e., illness intrusiveness), which can increase their risk for depressive symptoms. The present study examined the contributions of clinical disease activity, functional disability, and illness intrusiveness to depressive symptoms in youth with IBD. METHODS: Youth (N = 180) completed the Functional Disability Inventory (FDI), Illness Intrusiveness Scale-Child (IIS-C), and Children's Depression Inventory-2 (CDI-2). Physicians completed the Physicians Global Assessment of disease activity (PGA). RESULTS: Results revealed a mediating effect for functional disability in the association between disease activity and depressive symptoms (PGA → FDI → CDI-2); illness intrusiveness mediated the association between functional disability and depressive symptoms (i.e., FDI → IIS-C → CDI-2). Serial mediation revealed that clinical disease activity conferred an indirect effect on youth depressive symptoms through the sequential effects of functional disability and illness intrusiveness (i.e., PGA → FDI → IIS-C → CDI-2). CONCLUSIONS: Taken together, these findings indicate that youth who encounter more physical limitations as a function of clinical disease activity are more likely to experience an amplified sense of IBD-related intrusions on their ability to participate in meaningful activities. In turn, heightened illness intrusiveness increases the likelihood of depressive symptoms. Clinical interventions that help youth maintain adequate functional ability in the face of IBD disease activity and encourage involvement in positively valued activities could decrease the negative impact of IBD on youths' emotional adjustment.

Use of Behavior Change Techniques and Quality of Commercially Available Inflammatory Bowel Disease Apps.

BACKGROUND: Inclusion of evidence-based behavior change techniques (e.g., self-monitoring) in mobile health apps has the potential to promote adherence to inflammatory bowel disease treatment. While inflammatory bowel disease management apps exist, the extent to which they incorporate behavior change techniques remains unknown. AIMS: The present study systematically evaluated the content and quality of free, commercially available inflammatory bowel disease management apps. METHODS: Apps were identified using a systematic search of the Apple App and Google Play stores. Apps were evaluated using Abraham and Michie's taxonomy of 26 behavior change techniques. A literature search was conducted to identify behavior change techniques specific and relevant for people with inflammatory bowel disease. App quality was assessed using the Mobile App Rating Scale with scores ranging from 1 (Inadequate) to 5 (Excellent). RESULTS: A total of 51 inflammatory bowel disease management apps were evaluated. Apps included 0-16 behavior change techniques (Mean = 4.55) and 0-10 inflammatory bowel disease management behavior change techniques (Mean = 3.43). App quality ranged from 2.03 to 4.62 (Mean = 3.39) out of 5.00. Two apps, My IBD Care: Crohn's & Colitis and MyGiHealth GI Symptom Tracker, included the highest number of overall and inflammatory bowel disease management behavior change techniques along with high-quality scores. Bezzy IBD was the only app with a high number of overall and inflammatory bowel disease management behavior change techniques with a primary focus on social support/change. CONCLUSION: Most inflammatory bowel disease management apps reviewed included evidence-based inflammatory bowel disease management behavior change techniques.

Content Validity and Cognitive Debriefing of a Patient-Reported Outcome Instrument Evaluating Symptoms and Disease Impact in Patients with Geographic Atrophy.

INTRODUCTION: Geographic atrophy (GA) occurs in the later stages of dry age-related macular degeneration (AMD) and impairs visual acuity, eventually causing permanent blindness in some patients and impacting patient quality of life. Patient-reported outcome (PRO) measures that assess the experience of patients with visual impairment do not sufficiently capture all concepts salient to patients with GA. In this study the experience of patients with GA secondary to dry AMD was evaluated, and items from the novel 10-item Visual Impairment Symptom Severity Assessment (VISSA-10) PRO instrument were mapped to salient symptoms to assess its content validity, ease of use, and relevance. METHODS: Concept elicitation interviews were conducted with patients with GA to determine salient symptoms and impacts of GA, and a conceptual model was developed to reflect these. The items in the VISSA-10 instrument were then mapped onto the salient symptoms included in this conceptual model. Cognitive debriefing interviews were also conducted with the same cohort to determine the comprehensiveness and comprehensibility of the instrument, and to qualitatively assess levels of change considered meaningful by patients. RESULTS: In total, 25 symptoms and 36 impacts were reported by 19 patients with GA, with seven symptoms and 11 impacts identified as salient. Of these, 12 symptoms and 15 impacts reported were not included in a previously published conceptual model for patients with dry AMD. Overall, eight of the ten items from the VISSA-10 instrument mapped to salient symptoms reported by patients with GA. All patients reported that the instrument was clear and easy to understand. CONCLUSIONS: The VISSA-10 instrument was shown to be content valid, clear, and comprehensible, with sufficient concept coverage to measure the experience of patients with GA. Although further quantitative validation is required, this instrument has demonstrated potential for implementation in future clinical trials to evaluate the efficacy of new treatments for GA.

Sleep mHealth Applications and Behavior Change Techniques Evaluation.

OBJECTIVES: Mobile health apps may be an effective way to increase sleep management skills. Although little has been documented about the content and quality of available sleep management apps, providers often make app recommendations to help with sleep self-management. The objective of this study was to systematically evaluate the content and quality of commercially available sleep apps. METHODS: Following a systematic search of the Apple App and Google Play stores, 56 sleep management apps were evaluated. App content was evaluated using the taxonomy of behavior change techniques (BCTs), and app quality was assessed using the Mobile App Rating Scale. RESULTS: Sleep management apps included 0-15 BCTs (M = 6.89) and 0-9 sleep BCTs (M = 4.87). App quality ranged from 2.51 to 4.80 (M = 3.78) out of 5.00. Sleepiest Sleep Sounds Stories, ShutEye: Sleep Tracker, and Mintal Tracker: Sleep Recorder included the highest number of sleep BCTs and highest quality scores. CONCLUSIONS: While the content and quality of sleep management apps is variable, the findings are promising as many apps included a high number of BCTs and high quality. Although evidence of efficacy through randomized controlled trials is necessary to establish efficacy, this review can aid in app selection in the interim.

The Combined Effects of Youth and Parent Illness Intrusiveness on Depressive Symptoms in Adolescents with Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) presents physical and emotional challenges for families and imposes significant lifestyle intrusions on both youth and parents. The present study examined the effects of IBD disease activity and youth illness intrusiveness on depressive symptoms in adolescents, and the moderating influence of parent illness intrusiveness on these associations. Adolescents and parents completed measures of illness intrusiveness; youth completed a measure of depressive symptoms. Physicians provided estimates of IBD disease activity. Mediation analysis revealed an IBD disease activity → youth intrusiveness → youth depressive symptoms indirect effect. Moderated mediation analyses revealed this indirect effect to be greater among youth whose parents endorsed more IBD-related intrusions. Youth encountering greater activity disruptions related to IBD are vulnerable to depressive symptoms. When parents also experience IBD-induced intrusions, youth are at even greater risk for depressive symptoms. Clinical implications are discussed within the context of youths' and parents' experiences of IBD.

Quality of Life in Adolescents and Young Adults With a Chronic Medical Condition: The Role of Perceived Maturity and Transition Readiness.

INTRODUCTION: Adolescents and young adults (AYA) with a chronic medical condition (CMC) attending college must learn to manage their own healthcare (i.e., transition readiness). Maturity has been linked to positive outcomes in AYAs. Research has established a positive relationship between transition readiness and quality of life. The current study aimed to examine a model of perceived maturityàtransition readinessàmental and physical quality of life. METHOD: AYA (N = 153) with a CMC completed self-report questionnaires. RESULTS: The perceived maturity→transition readiness→mental quality of life indirect path was significant (ab = 1.96, 95% CI = 0.53 to 3.62). The perceived maturity→transition readiness→physical quality of life direct and indirect paths were not significant. DISCUSSION: Results showed that maturity and transition readiness are positively associated. Transition readiness may be one mechanism by which maturity results in enhanced quality of life. PRACTICE IMPLICATIONS: Findings highlight the value of enhancing strengths such as maturity to promote AYA independence/autonomy.

Factor analysis of the stigma scale-child in pediatric inflammatory bowel disease.

OBJECTIVE: Illness stigma, or perceived stigma related to a chronic health condition, is pervasive among youth with inflammatory bowel disease (IBD). However, no studies exist examining the psychometric properties of illness stigma measures in this population. Using a modified version of the Child Stigma Scale originally developed for youth with epilepsy, the current study investigated the factor structure and validity of this adapted measure (i.e., Stigma Scale - Child; SS-C) in youth with IBD. METHODS: Factor analyses were conducted to determine the most parsimonious factor structure for the adapted 8-item Stigma Scale - Child in a sample of 180 youth with IBD. Correlations were conducted to assess convergent validity, and a multiple regression was conducted to further evaluate the measure's predictive validity of child depressive symptoms. RESULTS: The most parsimonious model for the SS-C is a one-factor solution with an error covariance between the two items assessing concealment/disclosure of IBD diagnosis. CONCLUSIONS: The SS-C is a psychometrically sound illness stigma measure in pediatric IBD that demonstrates strong convergent validity with psychosocial adjustment factors such as thwarted belongingness, illness uncertainty, and illness intrusiveness, as well as strong predictive validity with youth depressive symptoms. The SS-C is a viable option for use as a brief screener in youth with IBD across clinical and research settings.

Interprofessional team based learning to enhance behavioral health care for Latinx patients: Results of a teleconsultation program.

Culturally sensitive behavioral health services are scarce, particularly in rural and underserved areas. To expand integrated behavioral health care training for providers, specifically those working in rural communities and federally qualified health centers, an interprofessional teleconsultation program was developed. Given the desire to focus on culturally informed care training, this was done in partnership with a nonprofit community mental health agency which focuses on behavioral health within Latinx populations. The teleconsultation sessions were provided bimonthly using Zoom and included didactic components and case-based discussion using the Multidimensional Ecosystemic Comparative Approach (MECA; Falicov, 1995; Falicov, 2017). Participants represented a diverse, interprofessional group composed of behavioral health professionals (45.2%), primary care physicians (26.8%), family medicine residents (15.3%), and others (medical students and administrative staff [12.7%]). The program evaluation demonstrates that participants valued the teleconsultation sessions and articulated specific skills that they subsequently planned to integrate into their clinical practice to enhance care. This teleconsultation model allows interprofessional training across multiple types of organizations to enhance knowledge in providing integrated behavioral health care for Latinx populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

ß-Amyloid and Tau Imaging in Chronic Traumatic Brain Injury: A Cross-sectional Study.

BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) has been promoted as a risk factor for Alzheimer disease (AD). There is evidence of elevated ß-amyloid (Aß) and tau, the pathologic hallmarks of AD, immediately following TBI. It is not clear whether Aß and tau remain elevated in the chronic period. To address this issue, we assessed Aß and tau burden in long-term TBI survivors and healthy controls using PET imaging. METHODS: Using a cross-sectional design, we recruited individuals following a single moderate to severe TBI at least 10 years previously from an inpatient rehabilitation program. A demographically similar healthy control group was recruited from the community. PET data were acquired using 18F-NAV4694 (Aß) and 18F-MK6240 (tau) tracers. Aß deposition was quantified using the Centiloid scale. Tau deposition was quantified using the standardized uptake value ratio (SUVR) in 4 regions of interest (ROIs). As a secondary measure, PET scans were also visually read as positive or negative. We examined PET data in relation to time since injury and age at injury. PET data were analyzed in a series of regression analyses. RESULTS: The sample comprised 87 individuals with TBI (71.3% male; 28.7% female; mean 57.53 years, SD 11.53) and 59 controls (59.3% male; 40.7% female; mean 60.34 years, SD 11.97). Individuals with TBI did not have significantly higher 18F-NAV4694 Centiloid values (p = 0.067) or 18F-MK6240 tau SUVRs in any ROI (p ≤ 0.001; SUVR greater for controls). Visual assessment was consistent with the quantification; individuals with TBI were not more likely than controls to have a positive Aß (p = 0.505) or tau scan (p = 0.221). No associations were identified for Aß or tau burden with time since injury (p = 0.057 to 0.332) or age at injury. DISCUSSION: A single moderate to severe TBI was not associated with higher burden of Aß or tau pathologies in the chronic period relative to healthy controls. Aß and tau burden did not show a significant increase with years since injury, and burden did not appear to be greater for those who were older at the time of injury.

Illness stigma, body image dissatisfaction, thwarted belongingness and depressive symptoms in youth with inflammatory bowel disease.

BACKGROUND: Elevated depressive symptoms are observed in a significant number of youth with inflammatory bowel disease (IBD) and have been linked to illness stigma and social isolation. Body image dissatisfaction is an understudied variable in the pediatric IBD literature that may be related to both stigma and social difficulties. It is suspected that, due to the stigmatizing nature of IBD, some youth may feel self-conscious about their body image, which contributes to decreased feelings of social belongingness and ultimately depressive symptoms. The current study tested an illness stigma→ body image dissatisfaction→ thwarted belongingness→ depressive symptoms serial mediation model, in which IBD stigma was hypothesized to indirectly influence youth depressive symptoms through the sequential effects of stigma on body image dissatisfaction and thwarted social belongingness. METHODS: Youth with IBD (N = 75) between 10 and 18 years old were recruited from a pediatric gastroenterology clinic and completed psychosocial measures. Disease severity was assessed by a physician global assessment. Current medications and BMI data were collected. RESULTS: Analyses revealed significant direct effects among the modeled variables and a significant serial indirect path for illness stigma→ body image dissatisfaction→ thwarted belongingness→ depressive symptoms, controlling for sex, BMI and prednisone medication. CONCLUSIONS: Youth who perceive greater IBD stigma are more likely to experience increased body image dissatisfaction due to their IBD, which may engender feelings of social estrangement and ultimately elevated depressive symptoms. Depressive symptoms and the psychosocial challenges faced by youth should be routinely monitored as part of comprehensive IBD management.

Under the influence of nature: The contribution of natural capital to tourism spend.

Tourism and outdoor leisure is an important economic sector for many countries, and has a substantial reliance on natural capital. Natural capital may be the primary purpose for tourism, or it may be a secondary factor, where the choice of location for a leisure activity is influenced by natural capital. Typically, when valuing tourism and outdoor leisure, all expenditure associated with the activity is assigned to the ecosystem it occurs in. However, this value illustrates the dependency on natural capital, rather than the contribution of natural capital. In natural capital accounting, a major challenge is to separately identify the contribution of natural capital from that of other forms of capital. In this study we develop a transparent and repeatable method that is able to attribute the contribution of natural capital (here defined as ecosystems) to the output of multiple tourism and outdoor leisure activities. Using national statistics from Great Britain, we calculate the natural capital contribution to tourism spend by activity at a national and regional scale, and for a case study map and value the contributing ecosystems. We estimated that, out of a total £36 billion spent on tourism and leisure activities in 2017, £22.5 billion was attributable to natural capital. This equates to 0.9% of the UK GDP. The Gross Value Added component of this attributable was £10.5 billion, equivalent to 0.4% of the UK GDP. Regions with the highest natural capital contribution in Great Britain were Scotland and Wales, with the lowest being Greater London and the West Midlands in England. For the case study, the ecosystems with the greatest contribution to terrestrial activities were marine and enclosed farmland. These methods can be applied worldwide for anywhere with aggregate economic statistics on expenditure associated with tourism and outdoor leisure, with the aid of open source GIS datasets.

Brain age in chronic traumatic brain injury.

Traumatic brain injury (TBI) is associated with greater 'brain age' that may be caused by atrophy in grey and white matter. Here, we investigated 'brain age' in a chronic TBI (≥10 years) sample. We examined whether 'brain age' increases with years post injury, and whether it is associated with injury severity, cognition and functional outcome. We recruited 102 participants with moderate to severe TBI aged between 40 and 85 years. TBI participants were assessed on average 22 years post-injury. Seventy-seven healthy controls were also recruited. Participants' 'brain age' was determined using T1-weighted MRI images. TBI participants were estimated to have greater 'brain age' compared to healthy controls. 'Brain age' gap was unrelated to time since injury or long-term functional outcome on the Glasgow Outcome Scale-Extended. Greater brain age was associated with greater injury severity measured by post traumatic amnesia duration and Glasgow Coma Scale. 'Brain age' was significantly and inversely associated with verbal memory, but unrelated to visual memory/ability and cognitive flexibility and processing speed. A longitudinal study is required to determine whether TBI leads to a 'one-off' change in 'brain age' or progressive ageing of the brain over time.

Stigma, Intrusiveness, and Distress in Parents of Children with a Disorder/Difference of Sex Development.

OBJECTIVE: The impact of parent-reported stigma due to their child's disorder/difference of sex development (DSD) on parent psychosocial adjustment is poorly understood. In other pediatric populations, perceived interference of medical conditions into daily activities (i.e., illness intrusiveness ) mediates the relationship of stigma to adjustment. This study assessed relationships between parent-focused and child-focused stigma → illness intrusiveness → depressive and anxious symptoms . Exploratory analyses sought to identify patient characteristics associated with stigma. METHOD: Caregivers (59 women and 43 men) of 63 children diagnosed with a DSD up to age 4 years completed measures of demographics, parent-focused and child-focused stigma, illness intrusiveness, and depressive and anxious symptoms. RESULTS: Increased parent-focused and child-focused stigma were associated with increased illness intrusiveness, which, in turn, was associated with increased depressive and anxious symptoms for parents nested within dyads. Among children with DSD family histories, parents reported greater child-focused stigma. CONCLUSION: Parents who experience DSD-related stigma report greater interference of their child's DSD into their daily activities, which is associated with poorer psychosocial adjustment. Findings support developing clinical interventions related to parents' perceptions of stigma and illness intrusiveness to improve parent adjustment.

Reduced COVID-19 severity elicited by weight loss from a medically supervised ketogenic diet in a geographically diverse ambulatory population with type 2 diabetes and obesity.

Objective: To investigate factors associated with COVID-19 severity in ambulatory individuals with type 2 diabetes mellitus (T2DM) and obesity treated with a medically supervised ketogenic diet (MSKD). Research design and methods: In this real-world, retrospective, exploratory analysis, multivariate modelling was used to assess clinical factors associated with hospitalisation for COVID-19 in a geographically diverse outpatient population with T2DM treated virtually. Results: Leading up to COVID-19 onset, non-hospitalised patients had higher average ketones (0.64 vs 0.52 mmol/L; p=0.016) and greater weight loss (6.8% vs 4.2%; p=0.009) compared with those hospitalised. Greater weight loss was significantly associated with lower likelihood of hospitalisation (adjusted OR=0.91, p=0.005), controlling for enrolment demographics and medical characteristics. Conclusions: Therapies such as MSKD, which elicit rapid, significant weight loss, may favourably impact COVID-19 hospitalisation rate and severity in individuals with T2DM and obesity.