Posttraumatic Stress and Opioid Use and Pain among Individuals with Probable Posttraumatic Stress Disorder and Self-Reported Chronic Pain: The Role of Health Literacy.

BACKGROUND: Chronic pain and opioid misuse are a prevalent comorbidity with deleterious health outcomes. Growing work indicates that posttraumatic stress disorder (PTSD) can increase the risk for chronic pain and opioid misuse and dependence. However, there is little understanding of social determinants of health (SDoH) that may account for interrelations of PTSD with chronic pain and opioid misuse and dependence. Health literacy is one relevant SDoH construct, reflecting the ability to gather, process, and comprehend health-related information required to engage in a healthcare setting. OBJECTIVE: The purpose of the present cross-sectional study was to examine the indirect effect of health literacy in the association between PTSD and opioid misuse, opioid dependence, pain intensity, and pain disability. METHOD: The sample included 142 adults (Mage = 35.2, SD = 9.9; 67.4% female; 70.1% White/Caucasian) with self-reported chronic pain and probable PTSD who were using opioid medication. RESULTS: Results demonstrated that PTSD symptom severity had a small indirect effect on opioid misuse and opioid dependence via health literacy; no indirect effects were evident for pain intensity and disability. CONCLUSION: The present investigation provides evidence that health literacy may serve as an important explanatory factor in associations between PTSD symptom severity and opioid misuse and dependence among adults with co-occurring probable PTSD and chronic pain.

Chinese medical students' disposition for critical thinking: a mixed methods exploration.

BACKGROUND: Critical thinking (CT) is an essential competency for medical students. This study's aim was to evaluate Chinese medical students' disposition for CT and to explore the impact of current trends in medical education on students' CT development. METHODS: We used multistage stratified cluster sampling to recruit a total of 1241 medical students among five different years of training and from three medical institutions in China. The Critical Thinking Disposition Inventory-Chinese Version (CTDI-CV) and self-reported information were used to collect cross-sectional data. Based on the data from the CTDI-CV, 112 medical students in clinical course training from a single institution continued one-year follow-up. Their one-year CTDI-CV score changes were collected regarding various medical education variables. RESULTS: The mean CTDI-CV score of the 1241 medical students was 287.04 with 729 (58.7%) students receiving a score of 280 or higher. There were statistically significant differences in schools attended(F = 3.84, P < 0.05), year of school attended(F = 10.32, P < 0.001), GPA(F = 6.32, P < 0.01), weekly time spent learning after class(F = 14.14, P < 0.001), attitude toward medicine(F = 28.93, P < 0.001), desire to be a doctor after graduation(t = - 3.35, P < 0.001), familiarity with CT(F = 20.40, P < 0.001), and perception of importance of CT(F = 22.25, P < 0.001). The participants scored the highest on the CTDI-CV subscales of "inquisitiveness" and the lowest on "truth seeking." The 112 students in the longitudinal study had significantly lower total CT scores after one academic year follow-up. CONCLUSIONS: Chinese medical students generally exhibited positive CT dispositions. The cross-sectional survey and one-year longitudinal study indicated that students' CT disposition diminished as they progressed through traditional medical training. Our study contributes to understanding the status of Chinese medical education of and influential factors on medical students' CT disposition.

Risk and protective factors for burnout among physicians from standardized residency training programs in Shanghai: a cross-sectional study.

BACKGROUND: High burnout has been reported in physician populations. Although the standardized residency training (SRT) in China includes components that might put residents at a higher risk for burnout, the burnout of Chinese medical residents is unknown. This study aimed to evaluate the prevalence of burnout and the associated risk and protective factors for medical residents in the SRT program in Shanghai, China. METHODS: This study was a prospective cross-sectional design. A random sampling strategy was used to recruit 330 resident physicians from four SRT sites in Shanghai, and 318 completed questionnaires were returned. Respondents completed a self-made questionnaire including demographic and work characteristics, four burnout and wellness-specific surveys. Bivariate analyses and hierarchical multiple regression models were used to analyze factors associated with three sub-scales of burn out separately. RESULTS: The overall burnout rate was 71.4%. Low level rate of personal accomplishment (PA) was extremely high at 69.5%. Night shift experience, high occupational stress, and low social support were significant predictors, which explained 49.1% variance of emotional exhaustion (EE) (F = 26.528, P < 0.01). Factors that significantly predicted depersonalization (DP) included male gender, senior residents, night shift experience, high occupational stress, and low psychological empathy, which explained 51.5% variance totally (F = 29.004, P < 0.01). Senior residents, high income, low occupational stress, and high empathy were also significant predictors of decreased personal achievement (PA), which explained 18.4% variance totally (F = 12.897, P < 0.01). CONCLUSIONS: There was a high burnout rate among SRT residents in Shanghai. Occupational stress and several work-related factors were significant and strong risk factors for burnout, while empathy and social support were mild protective factors. Decreased work-related demands and increased access to resources could assist residents in reducing their work stress and improving their well-being.

The effects of job satisfaction and psychological resilience on job performance among residents of the standardized residency training: a nationwide study in China.

High resident job performance is essential for effective medical professionalism. To date, few studies have investigated the potential predictors of job performance among residents in standardized residency training (SRT) program in China. Therefore, a nationwide survey among Chinese residents in SRT program was conducted to evaluate the impact of job satisfaction and psychological resilience on job performance. A total of 1146 residents from 9 hospitals were recruited in this study. Demographic and work-related information, job satisfaction, psychological resilience and job performance were collected through questionnaires. Hierarchical regression analyses indicated that, "work pressure", "doctor-patient conflict", "intrinsic job satisfaction" and "psychological resilience" were significant predictors of job performance for residents in SRT programs and explained 61.3% of variance, while the three dimensions of psychological resilience (tenacity, strength and optimism) accounted for 27.2% of variance. The area under curve (AUC) of the receiver operating characteristic (ROC) curve showed that resilience had the highest predictive accuracy than another three subscales. This study indicated that intrinsic job satisfaction and psychological resilience had a significant influence on job performance. Strategies and measures to improve residents' intrinsic job satisfaction and psychological resilience may be efficacious ways to enhance their job performance.

Esthetic perception of clear aligner therapy attachments using eye-tracking technology.

INTRODUCTION: The purpose of this research was to assess and compare esthetic perceptions of clear aligner therapy with attachments and esthetic brackets by measuring differences in eye fixations using eye-tracking technology. METHODS: The sample involved 250 adult subjects. The subjects gave verbal consent, then viewed photographs showing 4 variations of orthodontic appliances: clear aligner control with minimal attachments, clear aligner with anterior and posterior attachments, esthetic brackets, and clear aligner with posterior attachments. Images were displayed for 6 seconds each on a computer monitor. Location and time to first fixation, total fixation duration, and total visit count and duration for each type of appliance were measured. Subjects were then asked to complete an online survey. RESULTS: Participants spent the least amount of time looking at the photograph of the control, followed by those of the ceramic brackets, posterior attachments, and anterior and/or posterior attachments. The anterior and/or posterior image had the least number of visits but garnered the longest visit duration (1.32 visits averaging 0.74 seconds per visit). This was followed by the images of the posterior attachments (1.40 visits, 0.70 seconds per visit), ceramic brackets (1.43 visits, 0.65 seconds per visit), and minimal attachments control (1.45 visits, 0.61 seconds per visit). The hierarchy of most preferred appliances across all 250 respondents was as follows: minimal attachments control, ceramic brackets, posterior attachments, and anterior and/or posterior attachments. Overall, 88.4% of subjects would compromise appliance esthetics during treatment for a better outcome (n = 221). CONCLUSIONS: Eye-tracking data show that time to the first fixation was negatively correlated with its survey ranking and that an increase in attachments led to an increase in total fixation duration. There is a general desire for clear aligners without attachments and ceramic brackets over clear aligners with multiple attachments. Survey data suggest that although respondents viewed appliance esthetics as highly important, nearly all would compromise appliance esthetics during treatment if it resulted in a better outcome.

A Community Assessment of Psychological Distress in Pacific Islanders Across San Francisco Bay Area Churches During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has exacerbated health and social disparities among US Pacific Islanders (PI). Historically, PIs have experienced a high burden of mental illness yet have underutilized mental health services. These already large treatment gaps in mental health care among PIs may worsen during the COVID-19 pandemic. In the face of pre-existing challenges, little is known about the impacts of the COVID-19 pandemic on mental health outcomes among PIs. METHODS: A community-based, cross-sectional survey was administered to members of 13 PI churches across the San Francisco Bay Area. We assessed the burden of psychological distress among PIs and its associations with demographic, sociocultural, and health factors. KEY RESULTS: Among 439 PI respondents, nearly half reported moderate or severe psychological distress. Only about one-tenth took prescription medication for mental health and less than half utilized a mental health provider in the past year. Most trusted PI churches to provide health and social services. Respondents reporting moderate or severe psychological distress were less likely to utilize a mental health provider in the past year and more likely to feel marginalized, excluded, isolated, or alienated from society "most of the time" or "always." Psychological distress was also associated with "fair" or "poor" health status, female gender, older adults, low trust in PI churches to provide health and social services, and concern over household finances. CONCLUSION: Partnerships with faith-based and community-based organizations are essential to address unmet mental health needs and promote support-seeking behaviors among PIs during this ongoing pandemic and beyond.

An Integrated mHealth App for Smoking Cessation in Black Smokers With HIV: Protocol for a Randomized Controlled Trial.

BACKGROUND: Black adults who smoke and have HIV experience immense stressors (eg, racial discrimination and HIV stigma) that impede smoking cessation success and perpetuate smoking-related health disparities. These stressors also place Black adults who smoke and have HIV at an increased risk of elevated interoceptive stress (eg, anxiety and uncomfortable bodily sensations) and smoking to manage symptoms. In turn, this population is more likely to smoke to manage interoceptive stress, which contributes to worse HIV-related outcomes in this group. However, no specialized treatment exists to address smoking cessation, interoceptive stress, and HIV management for Black smokers with HIV. OBJECTIVE: This study aims to test a culturally adapted and novel mobile intervention that targets combustible cigarette smoking, HIV treatment engagement and adherence, and anxiety sensitivity (a proxy for difficulty and responsivity to interoceptive stress) among Black smokers with HIV (ie, Mobile Anxiety Sensitivity Program for Smoking and HIV [MASP+]). Various culturally tailored components of the app are being evaluated for their ability to help users quit smoking, manage physiological stress, and improve health care management. METHODS: This study is a pilot randomized controlled trial in which Black combustible cigarette smokers with HIV (N=72) are being recruited and randomly assigned to use either (1) the National Cancer Institute's QuitGuide app or (2) MASP+. Study procedures include a web-based prescreener; active intervention period for 6 weeks; smartphone-based assessments, including daily app-based ecological momentary assessments for 6 weeks (4 ecological momentary assessments each day); a video-based qualitative interview using Zoom Video Communications software at week 6 for participants in all study conditions; and smartphone-based follow-up assessments at 0, 1, 2 (quit date), 3, 4, 5, 6, and 28 weeks postbaseline (26 weeks postquitting date). RESULTS: Primary outcomes include biochemically verified 7-day point prevalence of abstinence, HIV-related quality of life, use of antiretroviral therapy, and HIV care appointment adherence at 26 weeks postquitting date. Qualitative data are also being collected and assessed to obtain feedback that will guide further tailoring of app content and evaluation of efficacy. CONCLUSIONS: The results of this study will determine whether the MASP+ app serves as a successful aid for combustible cigarette smoking cessation, HIV treatment engagement, and physiological stress outcomes among Black people with HIV infection. If successful, this study will provide evidence for the efficacy of a new means of addressing major mental and physical health difficulties for this high-risk population. If the results are promising, the data from this study will be used to update and tailor the MASP+ app for testing in a fully powered randomized controlled trial that will evaluate its efficacy in real-world behavioral health and social service settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05709002; https://clinicaltrials.gov/study/NCT05709002. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/52090.

The Positive Association Between Empathy and Self-Esteem in Chinese Medical Students: A Multi-Institutional Study.

BACKGROUND: Empathy is an important element of the physician-patient relationship and is a critical personality trait for medical students. However, research has shown that it declines during undergraduate medical education. It is still unclear how empathy interrelates with the psychological elements of medical students, in particular, self-esteem. This study examined the relationship between empathy and self-esteem to explore other possible methods to improve medical students' empathy. METHODS: A stratified sampling strategy was used to select 1690 medical students from 3 medical institutions in Shanghai as study participants. The questionnaires used to collect data included the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), the Rosenberg Self-esteem Scale (RSES), and a self-made inventory on personal information. Descriptive analysis, independent t-test, One-Way ANOVA, and linear regression were used to analyze the data. RESULTS: The mean empathy score among medical students was 102.73 with SD = 12.64. Multiple regression analysis revealed that, "age," "perception of the importance of empathy," "academic pressure," "desire to be a doctor after graduation," and "self-esteem" were significant predictors of empathy (P < 0.05) and the adjusted R 2 was 0.462. The correlation matrix between empathy and self-esteem was significant (r = 0.510, P < 0.01). Self-esteem explained 15.5% of the variation of empathy in the final regression model. CONCLUSION: There was a positive association between self-esteem and empathy. Self-esteem is one of many factors which contribute to medical students' empathy. Age, academic pressure, attitude toward empathy and future career also play a critical role in medical student empathy. Enhancing medical students' self-esteem may be an efficacious way to improve medical students' empathy.

A Randomized Controlled Trial of Balint Groups to Prevent Burnout Among Residents in China.

INTRODUCTION: Burnout is highly prevalent among residents and is associated with negative outcomes for patients, organizations, and physicians. Balint groups have been shown to be an effective strategy to alleviate physicians' burnout. The purpose of this study was to examine the effectiveness and feasibility of Balint groups in preventing burnout among residents in training programs in China. METHODS: 36 resident physicians in their first year of residency at a comprehensive hospital in China were randomly assigned to two groups. Physicians in the intervention group participated in 2 lectures and 10 Balint sessions for 6 months, while participants in the control group were placed on a waitlist for future Balint sessions. All 36 participants completed burnout and job satisfaction measures pre and post-intervention. RESULTS: The mean burnout subscale scores for EE and DP decreased, and the scores for PA and job satisfaction increased after Balint group participation. However, paired t-test results revealed there were no statistically significant differences between pre and post-test scores for EE (t = -1.323, p = 0.203), DP (t = -0.727, p = 0.477), PA (t = 0.716, p = 0.484, and job satisfaction (t = 0.282, p = 0.781) for the intervention group. For the control group, the burnout subscale scores for EE (t = 2.312, p = 0.034) and DP (t = 2.898, p = 0.019) increased, and there were statistically significant differences between pre and post-test. PA (t = -0.717, p = 0.483) and job satisfaction (t = -0.241, p = 0.812) scores decreased although there were no significant differences seen between the pre and post-test. Independent t-test results demonstrated statistically significant differences in scores for EE (t = -2.662, p = 0.013) and DP (t = -2.433, p = 0.020) between intervention and control group. However, there were not statistically significant differences between groups for scores in PA (t = 1.013, p = 0.318) and job satisfaction (t = 0.367, p = 0.716). All 18 participants in the intervention group reported that Balint groups were helpful and that they would be willing to attend future sessions. Overall satisfaction with the Balint group program was over 80%. CONCLUSION: Balint groups are an efficacious, feasible, standardized method of preventing resident burnout. Residents in China may benefit from Balint group implementation in residency training programs.

General Self-Efficacy Mediates the Effect of Family Socioeconomic Status on Critical Thinking in Chinese Medical Students.

Background: Critical thinking (CT) is an essential competence for medical students. Family socioeconomic status (family SES) and general self-efficacy (GSE) play crucial roles in the development of CT. However, the association among family SES, GSE, and CT in Chinese medical students has yet to be fully investigated. Objectives: To investigate the role of family SES and GSE in the development of CT in Chinese medical students. Methods: 1,338 medical students were recruited using multistage stratified cluster sampling from three institutions in China. The Chinese critical thinking disposition inventory (CTDI-CV), General Self-Efficacy Scale (GSES), and a self-made inventory assessing family SES were administered to collect data. The relationship between CT and family SES as well as GSE was evaluated by structural equation modeling. Results: Students of higher family SES obtained higher CTDI-CV and GSES scores. A positive correlation was found between family SES and CT (r = 0.101-0.141, p < 0.05 or p < 0.01), as well as between family SES and GSE (r = 0.111-0.129, p < 0.01). Moreover, GSE was moderately correlated with CT (r = 0.418, p < 0.01). The model of partial mediate effect of GSE showed the best fit index with X 2 = 29.698, df = 9 and X2/df = 3.300, NFI = 0.990, IFI = 0.993, TLI = 0.984, CFI = 0.993, RMSEA = 0.041. Conclusion: Family SES has a positive albeit limited influence on GSE and CT in Chinese medical students. GSE mediates the effect of family SES on CT and plays a larger role. Enhancing medical student' GSE maybe an efficacious way to improve medical students' CT.

Autoantibodies From Single Circulating Plasmablasts React With Citrullinated Antigens and Porphyromonas gingivalis in Rheumatoid Arthritis.

OBJECTIVE: Anti-citrullinated protein antibodies (ACPAs) are highly specific for rheumatoid arthritis (RA). However, the molecular basis for ACPA production is still unclear. The purpose of this study was to determine if circulating plasmablasts from RA patients produce ACPAs and whether Porphyromonas gingivalis facilitates the generation of ACPAs. METHODS: Using a single-cell antibody cloning approach, we generated 217 and 110 monoclonal recombinant antibodies from circulating plasmablasts from 7 RA patients and 4 healthy controls, respectively. Antibody reactivity with citrullinated antigens was tested by a second-generation anti-cyclic citrullinated peptide (anti-CCP) kit and by enzyme-linked immunosorbent assays (ELISAs) against citrullinated human antigens. Antibody reactivity with P gingivalis was tested by ELISAs against outer membrane antigens (OMAs) and citrullinated enolase from P gingivalis. RESULTS: Approximately 19.5% of plasmablast-derived antibodies from anti-CCP-positive RA patients, but none from 1 anti-CCP-negative RA patient or the healthy controls, specifically recognized citrullinated antigens. The immunoglobulin genes encoding these ACPAs were highly mutated, with increased ratios of replacement mutations to silent mutations, suggesting the involvement of active antigen selection in ACPA generation. Interestingly, 63% of the ACPAs cross-reacted with OMAs and/or citrullinated enolase from P gingivalis. The reactivity of ACPAs against citrullinated proteins from P gingivalis was confirmed by immunoblotting and mass spectrometry. Furthermore, some germline-reverted ACPAs retained their reactivity with P gingivalis antigens but completely lost their reactivity with citrullinated human antigens. CONCLUSION: These results suggest that circulating plasmablasts in RA patients produce ACPAs and that this process may be facilitated by anti-P gingivalis immune responses.

Hippocampus ghrelin signaling mediates appetite through lateral hypothalamic orexin pathways.

Feeding behavior rarely occurs in direct response to metabolic deficit, yet the overwhelming majority of research on the biology of food intake control has focused on basic metabolic and homeostatic neurobiological substrates. Most animals, including humans, have habitual feeding patterns in which meals are consumed based on learned and/or environmental factors. Here we illuminate a novel neural system regulating higher-order aspects of feeding through which the gut-derived hormone ghrelin communicates with ventral hippocampus (vHP) neurons to stimulate meal-entrained conditioned appetite. Additional results show that the lateral hypothalamus (LHA) is a critical downstream substrate for vHP ghrelin-mediated hyperphagia and that vHP ghrelin activated neurons communicate directly with neurons in the LHA that express the neuropeptide, orexin. Furthermore, activation of downstream orexin-1 receptors is required for vHP ghrelin-mediated hyperphagia. These findings reveal novel neurobiological circuitry regulating appetite through which ghrelin signaling in hippocampal neurons engages LHA orexin signaling.