Activity-Dependent Synaptic Plasticity in the Medial Prefrontal Cortex of Male Rats Underlies Resilience-Related Behaviors to Social Adversity.

Individuals considered resilient can overcome adversity, achieving normal physical and psychological development, while those deemed vulnerable may not. Adversity promotes structural and functional alterations in the medial prefrontal cortex (mPFC) and hippocampus. Moreover, activity-dependent synaptic plasticity is intricately linked to neuronal shaping resulting from experiences. We hypothesize that this plasticity plays a crucial role in resilience processes. However, there is a notable absence of studies investigating this plasticity and behavioral changes following social adversity at different life stages. Consequently, we evaluated the impact of social adversity during early postnatal development (maternal separation [MS]), adulthood (social defeat [SD]), and a combined exposure (MS + SD) on behavioral outcomes (anxiety, motivation, anhedonia, and social interaction). We also examined cFos expression induced by social interaction in mPFC and hippocampus of adult male rats. Behavioral analyses revealed that SD-induced anhedonia, whereas MS + SD increased social interaction and mitigated SD-induced anhedonia. cFos evaluation showed that social interaction heightened plasticity in the prelimbic (PrL) and infralimbic (IL) cortices, dentate gyrus (DG), CA3, and CA1. Social interaction-associated plasticity was compromised in IL and PrL cortices of the MS and SD groups. Interestingly, social interaction-induced plasticity was restored in the MS + SD group. Furthermore, plasticity was impaired in DG by all social stressors, and in CA3 was impaired by SD. Our findings suggest in male rats (i) two adverse social experiences during development foster resilience; (ii) activity-dependent plasticity in the mPFC is a foundation for resilience to social adversity; (iii) plasticity in DG is highly susceptible to social adversity.

Associations between perinatal risk and physical health in pre-adolescence in the Adolescent Brain Cognitive Development (ABCD) Study®: the unexpected relationship with sleep disruption.

BACKGROUND: To investigate relationships among different physical health problems in a large, sociodemographically diverse sample of 9-to-10-year-old children and determine the extent to which perinatal health factors are associated with childhood physical health problems. METHODS: A cross-sectional study was conducted utilizing the Adolescent Brain Cognitive Development℠ (ABCD) Study (n = 7613, ages 9-to-10-years-old) to determine the associations among multiple physical health factors (e.g., prenatal complications, current physical health problems). Logistic regression models controlling for age, sex, pubertal development, household income, caregiver education, race, and ethnicity evaluated relationships between perinatal factors and childhood physical health problems. RESULTS: There were significant associations between perinatal and current physical health measures. Specifically, those who had experienced perinatal complications were more likely to have medical problems by 9-to-10 years old. Importantly, sleep disturbance co-occurred with several physical health problems across domains and developmental periods. CONCLUSION: Several perinatal health factors were associated with childhood health outcomes, highlighting the importance of understanding and potentially improving physical health in youth. Understanding the clustering of physical health problems in youth is essential to better identify which physical health problems may share underlying mechanisms. IMPACT: Using a multivariable approach, we investigated the associations between various perinatal and current health problems amongst youth. Our study highlights current health problems, such as sleep problems at 9-to-10 years old, that are associated with a cluster of factors occurring across development (e.g., low birth weight, prenatal substance exposure, pregnancy complications, current weight status, lifetime head injury). Perinatal health problems are at large, non-modifiable (in this retrospective context), however, by identifying which are associated with current health problems, we can identify potential targets for intervention and prevention efforts.

Soft-Tissue Sarcomas of the Genitourinary Tract with Radiologic-Pathologic Correlation.

Genitourinary tract soft-tissue sarcomas are rare neoplasms with varied pathologic and clinical features. While some of these tumors may be aggressive high-grade malignancies, others are low grade with a relatively better prognosis. Given that the grade and extent of the disease are important prognostic factors in these tumors, timely diagnosis is crucial. Unfortunately, most imaging features of these malignancies are not pathognomonic, and various histologic subtypes do not manifest with typical classic imaging features. Therefore, reliable differentiation of the various histologic tumor types is not always possible based solely on the radiologic manifestations. Imaging findings need to be considered in the context of clinical history in corroboration with radiologic-pathologic correlation. The authors discuss the specific imaging and pathologic characteristics of various genitourinary tract soft-tissue sarcomas, emphasizing diagnostic difficulties and differential diagnoses. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Health Needs Assessment of Unhoused Youth in Charleston, South Carolina.

BACKGROUND: Over 35 000 youth experience homelessness on any given night in the United States (US). Unhoused youth experience unique physical and mental health challenges and face barriers in every social determinant of health (SDoH), which may be amplified in the LGBTQ+ population. OBJECTIVE: The objective of this study was to define characteristics of the unhoused youth population and their utilization of healthcare to inform programs to meet their needs. METHODS: Secondary analysis of data from the College of Charleston's YOUth Count survey was conducted, focusing on health-related characteristics, challenges, healthcare utilization, and SDoH of youth aged 18 to 25 experiencing homelessness in Charleston, SC. RESULTS: Almost three-quarters of respondents (74.6%) reported mental health challenges and 35% reported physical health challenges. A significantly higher proportion of those who engaged in survival sex were LGBTQ+ . More than half (68.4%) visited the emergency department (ED) and 29.3% were admitted to the hospital in the past 12 months. Housing status, safety, food insecurity, sexual orientation, prior foster care, and survival sex were all significantly associated with ED utilization. Housing status and survival sex were significantly associated with hospital admission. CONCLUSIONS: Addressing SDoH is essential to improving health outcomes and healthcare utilization among unhoused youth, particularly in the LGBTQ+ population.

Perception and Counseling for Cardiac Health in Breast Cancer Survivors.

Context: Breast cancer survivors have increased cardiovascular disease (CVD) risk compared to those without cancer history. CVD is the leading cause of death for breast cancer survivors. Objective: To assess current CVD risk counseling practices and risk perception in breast cancer survivors. Study design and analysis: Interviews conducted with breast cancer survivors. Analysis of categorical data by frequency and quantitative variables by mean and standard deviation. Inductive qualitative analysis performed using NVIVO. Setting: Academic Family Medicine Outpatient Practices Population studied: Breast cancer survivors with an identified primary care provider. Intervention/instrument: Interviews on CVD risk behaviors, risk perception, challenges with risk reduction, and previous history of risk counseling. Outcome measures: Self-reported history of CVD, risk perception, and risk behaviors. Results: The average age of participants (n=19) was 57 with 57% being white and 32% African American. Of interviewed women, 89.5% reported a personal history and 89.5% reported a family history of CVD. Only 52.6% had previously reported receipt of CVD counseling. Primary care providers most commonly provided the counseling (72.7%), however it was additionally provided by oncology (27.3%). Among breast cancer survivors, 31.6% perceived they were at increased CVD risk and 47.5% were unsure of their relative CVD risk compared to women their age. Factors affecting perceived CVD risk included family history, cancer treatments, cardiovascular diagnoses, and lifestyle factors. Video (78.9%) and text messaging (68.4%) were the most highly reported mechanisms through which breast cancer survivors requested to receive additional information and counseling on CVD risk and risk reduction. Commonly reported barriers to adopting risk reduction strategies (such as increasing physical activity) included time, resources, physical limitations, and competing responsibilities. Barriers specific to survivorship status include concerns for immune status during COVID, physical limitations associated with cancer treatment, and psychosocial aspects of cancer survivorship. Conclusions: These data suggest improving the frequency and content of CVD risk reduction counseling is needed. Strategies should identify the best methods for providing CVD counseling, and should address general barriers as well as unique challenges faced by cancer survivors.

Behavioral Activation-Based Digital Smoking Cessation Intervention for Individuals With Depressive Symptoms: Randomized Clinical Trial.

BACKGROUND: Depression is common among adults who smoke cigarettes. Existing depression-specific cessation interventions have limited reach and are unlikely to improve smoking prevalence rates among this large subgroup of smokers. OBJECTIVE: This study aimed to determine whether a mobile app-based intervention tailored for depression paired with a mailed sample of nicotine replacement therapy (NRT) is efficacious for treating depression and promoting smoking cessation. METHODS: A 2-arm nationwide remote randomized clinical trial was conducted in the United States. Adults (N=150) with elevated depressive symptoms (Patient Health Questionnaire-8≥10) who smoked were enrolled. The mobile app ("Goal2Quit") provided behavioral strategies for treating depression and quitting smoking based on Behavioral Activation Treatment for Depression. Goal2Quit participants also received a 2-week sample of combination NRT. Treatment as usual participants received a self-help booklet for quitting smoking that was not tailored for depression. Primary end points included Goal2Quit usability, change in depression (Beck Depression Inventory-II) across 12 weeks, and smoking cessation including reduction in cigarettes per day, incidence of 24-hour quit attempts, floating abstinence, and 7-day point prevalence abstinence (PPA). RESULTS: In total, 150 participants were enrolled between June 25, 2020, and February 23, 2022, of which 80 were female (53.3%) and the mean age was 38.4 (SD 10.3) years. At baseline, participants on average reported moderate depressive symptoms and smoked a mean of 14.7 (SD 7.5) cigarettes per day. Goal2Quit usability was strong with a mean usability rating on the System Usability Scale of 78.5 (SD 16.9), with 70% scoring above the ≥68 cutoff for above-average usability. Retention data for app use were generally strong immediately following trial enrollment and declined in subsequent weeks. Those who received Goal2Quit and the NRT sample reported lower mean depressive symptoms over the trial duration as compared to treatment as usual (difference of mean 3.72, SE 1.37 points less; P=.01). Across time points, all cessation outcomes favored Goal2Quit. Regarding abstinence, Goal2Quit participants reported significantly higher rates of 7-day PPA at weeks 4 (11% vs 0%; P=.02), 8 (7-day PPA: 12% vs 0%; P=.02), and 12 (16% vs 2%; P=.02). CONCLUSIONS: A mobile app intervention tailored for depression paired with a sample of NRT was effective for depression treatment and smoking cessation. Findings support the utility of this intervention approach for addressing the currently unmet public health treatment need for tailored, scalable depression-specific cessation treatments. TRIAL REGISTRATION: ClinicalTrials.gov NCT03837379; https://clinicaltrials.gov/ct2/show/NCT03837379.

Evaluation of a telemedicine pilot program for the provision of HIV pre-exposure prophylaxis in the Southeastern United States.

Pre-exposure prophylaxis (PrEP) is a daily regimen that reduces the risk of acquiring HIV by up to 97%. There is limited information on the use of telehealth to provide PrEP in a program aimed toward the primary prevention of HIV. This was a 6-month telePrEP feasibility study that assessed process measures, clinical outcomes and patient satisfaction. Descriptive statistics and Chi-square analysis were used to evaluate measures and outcomes from the start to the end of the study. Twenty patients enrolled, and 80% completed the study. Participants were cisgender males (100%) with an average age of 35.6 years, white (95%), and were college graduates or higher (55%). The majority (75%) had very high comfort with video calls before the program. Self-reported adherence to PrEP medication remained high throughout the program (60%-70%). Without this program 31.2% of participants were unlikely to have received PrEP. For obtaining PrEP 56.3% preferred telemedicine only, and 31.2% preferred a combination of telemedicine and in-person office visits. PrEP is an effective method of preventing HIV infection for those at high risk. Our program shows that telemedicine can be useful to expand access to medication for patients at high risk.

Proactive Electronic Visits for Smoking Cessation and Chronic Obstructive Pulmonary Disease Screening in Primary Care: Randomized Controlled Trial of Feasibility, Acceptability, and Efficacy.

BACKGROUND: Most smokers with chronic obstructive pulmonary disease (COPD) have not yet been diagnosed, a statistic that has remained unchanged for over two decades. A dual-focused telehealth intervention that promotes smoking cessation, while also facilitating COPD screening, could help address national priorities to improve the diagnosis, prevention, treatment, and management of COPD. The purpose of this study was to preliminarily evaluate an integrated asynchronous smoking cessation and COPD screening e-visit (electronic visit) that could be delivered proactively to adult smokers at risk for COPD, who are treated within primary care. OBJECTIVE: The aims of this study were (1) to examine e-visit feasibility and acceptability, particularly as compared to in-lab diagnostic pulmonary function testing (PFT), and (2) to examine the efficacy of smoking cessation e-visits relative to treatment as usual (TAU), all within primary care. METHODS: In a randomized clinical trial, 125 primary care patients who smoke were randomized 2:1 to receive either proactive e-visits or TAU. Participants randomized to the e-visit condition were screened for COPD symptoms via the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE). Those with scores ≥2 were invited to complete both home spirometry and in-lab PFTs, in addition to two smoking cessation e-visits. Smoking cessation e-visits assessed smoking history and motivation to quit and included completion of an algorithm to determine the best Food and Drug Administration-approved cessation medication to prescribe. Primary outcomes included measures related to (1) e-visit acceptability, feasibility, and treatment metrics; (2) smoking cessation outcomes (cessation medication use, 24-hour quit attempts, smoking reduction ≥50%, self-reported abstinence, and biochemically confirmed abstinence); and (3) COPD screening outcomes. RESULTS: Of 85 participants assigned to the e-visits, 64 (75.3%) were invited to complete home spirometry and in-lab PFTs based on CAPTURE. Among those eligible for spirometry, 76.6% (49/64) completed home spirometry, and 35.9% (23/64) completed in-lab PFTs. At 1 month, all cessation outcomes favored the e-visit, with a significant effect for cessation medication use (odds ratio [OR]=3.22). At 3 months, all cessation outcomes except for 24-hour quit attempts favored the e-visit, with significant effects for cessation medication use (OR=3.96) and smoking reduction (OR=3.09). CONCLUSIONS: A proactive, asynchronous e-visit for smoking cessation and COPD screening may offer a feasible, efficacious approach for broad interventions within primary care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04155073; https://clinicaltrials.gov/ct2/show/NCT04155073.

Preventive Care Utilization by Patients Who Use Virtual Urgent Care.

Introduction: The use of direct to patient (DTP) telemedicine for common acute conditions is widespread. It provides certain advantages over in-person visits, but has led to concerns about fragmentation of care. It is unknown whether use of DTP telemedicine decreases use of primary care services in a way that leads to missed preventive screenings and immunizations. Methods: Virtual urgent care (VUC) is a DTP telemedicine service to treat common acute conditions. All VUC encounters completed at an academic health system from July 2018 to December 2019 were evaluated and analyzed in 2020. Only patients established with primary care (at least one primary care visit in the same year as VUC encounter) were included. Specific preventive screenings (breast cancer, gonorrhea/chlamydia, and cervical cancer) and immunizations (tetanus and influenza) were characterized as up to date based on national guidelines. Chi-squares and multivariate logistic regressions were used to assess receipt of screenings and immunizations. Regressions included VUC and primary care utilization and demographic factors. Results: Patients evaluated (N = 1025) were mostly 25-50 years old (69.7%), women (81.8%), and white (74.9%). More than half (56.5%) had only used VUC once. In multivariate analyses, VUC utilization was not negatively associated with any of the preventive services evaluated, whereas primary care utilization was associated with receipt of both immunizations and gonorrhea/chlamydia screening. Conclusions: Higher VUC utilization is not negatively associated with receipt of preventive services, as long as a primary care relationship is established. VUC may provide a useful method of encouraging receipt of preventive services, especially for younger patients.

Facilitators and barriers to utilization of medications for opioid use disorder in primary care in South Carolina.

OBJECTIVE: Utilization of medications for opioid use disorder (MOUD) has not been widely adopted by primary care providers. This study sought to identify interprofessional barriers and facilitators for use of MOUD (specifically naltrexone and buprenorphine) among current and future primary care providers in a southeastern academic center in South Carolina. METHOD: Faculty, residents, and students within family medicine, internal medicine, and a physician assistant program participated in focus group interviews, and completed a brief survey. Survey data were analyzed quantitatively, and focus group transcripts were analyzed using a deductive qualitative content analysis, based upon the theory of planned behavior. RESULTS: Seven groups (N = 46) completed focus group interviews and surveys. Survey results indicated that general attitudes towards MOUD were positive and did not differ significantly among groups. Subjective norms around prescribing and controllability (i.e., beliefs about whether prescribing was up to them) differed between specialties and between level of training groups. Focus group themes highlighted attitudes about MOUD (e.g., "opens the flood gates" to patients with addiction) and perceived facilitators and barriers of using MOUD in primary care settings. Participants felt that although MOUD in primary care would improve access and reduce stigma for patients, prescribing requires improved provider education and an integrated system of care. CONCLUSIONS: The results of this study provide an argument for tailoring education to specifically address the barriers primary care prescribers perceive. Results promote the utilization of active, hands-on learning approaches, to ultimately promote uptake of MOUD prescribing in the primary care setting in South Carolina.

Evaluation of a Proactive Smoking Cessation Electronic Visit to Extend the Reach of Evidence-Based Cessation Treatment via Primary Care.

Background:Best practice guidelines for smoking cessation treatment through primary care advise the 5As model. However, compliance with these guidelines is poor, leaving many smokers untreated. The purpose of this study was to develop and preliminarily evaluate an asynchronous smoking cessation electronic visit (e-visit) that could be delivered proactively through the electronic health record (EHR) to adult smokers treated within primary care. The goal of the e-visit is to automate 5As delivery to ensure that all smokers receive evidence-based cessation treatment. As such, the aims of this study were twofold: (1) to examine acceptability, feasibility, and treatment metrics associated with e-visit utilization and (2) to preliminarily examine efficacy relative to treatment as usual (TAU) within primary care.Methods:Participants (n = 51) were recruited from primary care practices between November 2018 and October 2019 and randomized 2:1 to receive either the smoking cessation e-visit or TAU. Participants completed assessments of cessation outcomes 1-month and 3-months postenrollment and e-visit analytics data were gathered from the EHR.Results:Self-report feedback from e-visit participants indicated satisfaction with the intervention and interest in using e-visits again in the future. Nearly all e-visits resulted in prescription of a U.S. Food and Drug Administration (FDA)-approved smoking cessation medication. In general, smoking cessation outcomes favored the e-visit condition at both 1 (odds ratios [ORs]: 2.10-5.39) and 3 months (ORs: 1.31-4.67).Conclusions:These results preliminarily indicate the feasibility, acceptability, and efficacy of this smoking cessation e-visit within primary care. Future studies should focus on larger scale examination of effectiveness and implementation across settings. The clinicaltrials.gov registration number for this trial is NCT04316260.

A Telehealth Initiative to Overcome Health Care Barriers for People Experiencing Homelessness.

People experiencing homelessness (PEH) encounter barriers to health care, increasing their vulnerability to illness, hospitalization, and death. Telehealth can improve access to health care, but its use in PEH has been insufficiently evaluated. Needs assessment surveys completed by clients at an urban drop-in center for PEH (n = 63) showed mental (58.7%) and physical (52.4%) health challenges were common, as was emergency department (ED) use (75.9%, n = 54). Surveys collected after in-person and telehealth clinical visits showed patient satisfaction was >90% for both visit types (n = 125, 44.0% telehealth and 56.0% in person). Without access to telehealth visits, 29.1% of patients would have gone to the ED and 38.2% would not have gotten care. Providers (n = 93, 69.6% telehealth and 30.4% in person) were more likely to agree/strongly agree they made a positive impact on patients' health through telehealth (92.2%) than in person (71.4%) (p = 0.019). Telehealth is a feasible and potentially cost-effective method to increase access to health care and reduce health outcome disparities in PEH.

A cross-sectional study of United States family medicine residency programme director burnout: implications for mitigation efforts and future research.

BACKGROUND: Academic physician burnout is concerning. Too little is known about factors associated with residency programme director burnout. Continued uncertainty risks adverse outcomes including graduate medical education leadership turnover and negative impact on recruiting and retaining under-represented minority residency programme directors. OBJECTIVE: This study assessed symptoms of burnout (emotional exhaustion, depersonalization) and depression along with evidence-based individual and environmental risk factors in a U.S. sample of family medicine residency programme directors. METHODS: The omnibus 2018 Council of Academic Family Medicine Education Research Alliance survey was used to contact programme directors at all Accreditation Council for Graduate Medical Education accredited U.S. family medicine residency programmes via email. Descriptive data included programme director and programme characteristics, Areas of Worklife (workload, values and control), loneliness (lack companionship, feel left out and feel isolated), burnout (emotional exhaustion, depersonalization) and depressive symptoms. Chi-square tests contrasted descriptive variables with burnout and depressive symptoms. Logistic regression (LR) modelled associations between significant descriptive variables and burnout and depressive symptoms. RESULTS: The survey response rate was 45.2% (268/590). Programme directors reported: emotional exhaustion (25.0%), depersonalization (10.3%) and depressive symptoms (25.3%). LR models found significant associations with emotional exhaustion (Workload: lacking time and other work-related resources); lack of companionship, depersonalization (North West Central residency region; Workload and lack of companionship) and depressive symptoms (Black/African American ethnicity). CONCLUSIONS: One-quarter of U.S. programme directors report burnout or depressive symptoms. Future research should consider associated variables as possible intervention targets to reduce programme director distress and turnover.

Sex differences in reward- and punishment-guided actions.

Differences in the prevalence and presentation of psychiatric illnesses in men and women suggest that neurobiological sex differences confer vulnerability or resilience in these disorders. Rodent behavioral models are critical for understanding the mechanisms of these differences. Reward processing and punishment avoidance are fundamental dimensions of the symptoms of psychiatric disorders. Here we explored sex differences along these dimensions using multiple and distinct behavioral paradigms. We found no sex difference in reward-guided associative learning but a faster punishment-avoidance learning in females. After learning, females were more sensitive than males to probabilistic punishment but less sensitive when punishment could be avoided with certainty. No sex differences were found in reward-guided cognitive flexibility. Thus, sex differences in goal-directed behaviors emerged selectively when there was an aversive context. These differences were critically sensitive to whether the punishment was certain or unpredictable. Our findings with these new paradigms provide conceptual and practical tools for investigating brain mechanisms that account for sex differences in susceptibility to anxiety and impulsivity. They may also provide insight for understanding the evolution of sex-specific optimal behavioral strategies in dynamic environments.

The missing explanation of the false-belief advantage in bilingual children: a longitudinal study.

Bilingual preschoolers often perform better than monolingual children on false-belief understanding. It has been hypothesized that this is due to their enhanced executive function skills, although this relationship has rarely been tested or supported. The current longitudinal study tested whether metalinguistic awareness was responsible for this advantage. Further, we examined the contributions of both executive functioning and language ability to false-belief understanding by including multiple measures of both. Seventy-eight children (n = 40 Spanish-English bilingual; age M = 49.29, SD = 7.38 and, n = 38 English monolingual; age M = 47.75, SD = 6.86) were tested. A year later the children were tested again (n = 22 bilingual, n = 25 monolingual). The results indicated that language and executive function (inhibitory control) at time 1 were related to false belief in monolinguals at time 2. In contrast, bilinguals' metalinguistic performance at time 1 was the sole predictor of false belief at time 2. The different linguistic and cognitive profiles of monolinguals and bilinguals may create different pathways for their development of false-belief understanding. A video abstract of this article can be viewed at: https://youtu.be/vILn2gKjFxw.

The role of Balint group training in the professional and personal development of family medicine residents.

This paper presents a study based on the participation of PGY2 and PGY3 family medicine residents in Balint seminars that occurred twice monthly for 24 months. Balint groups were cofacilitated by leader pairs experienced with the Balint method. Prior to residency graduation, 18 of 19 eligible resident physicians (94.5%) completed 30- to 60-min semistructured interviews conducted by a research assistant. Resident physicians were told that these individual interviews concerned "…how we teach communication in residency." The deidentified transcripts from these interviews formed the raw data that were coded for positive (n = 9) and negative (n = 3) valence themes by four faculty coders utilizing an iterative process based on grounded theory. The consensus positive themes included several elements that have previously been discussed in published literature concerning the nature of Balint groups (e.g., being the doctor that the patient needs, reflection, empathy, blind spots, bonding, venting, acceptance, perspective taking, and developing appreciation for individual experiences). The negative themes pointed to ways of possibly improving future Balint offerings in the residency setting ( repetitive, uneasiness, uncertain impact). These findings appear to have consistency with seminal writings of both Michael and Enid Balint regarding the complex nature of intrapsychic and interpersonal skills required to effectively manage troubling doctor-patient relationships. The implications of findings for medical education (curriculum) development as well as future research efforts are discussed.

Design of a cluster-randomized minority recruitment trial: RECRUIT.

BACKGROUND: Racial/ethnic minority groups remain underrepresented in clinical trials. Many strategies to increase minority recruitment focus on minority communities and emphasize common diseases such as hypertension. Scant literature focuses on minority recruitment to trials of less common conditions, often conducted in specialty clinics and dependent on physician referrals. We identified trust/mistrust of specialist physician investigators and institutions conducting medical research and consequent participant reluctance to participate in clinical trials as key-shared barriers across racial/ethnic groups. We developed a trust-based continuous quality improvement intervention to build trust between specialist physician investigators and community minority-serving physicians and ultimately potential trial participants. To avoid the inherent biases of non-randomized studies, we evaluated the intervention in the national Randomized Recruitment Intervention Trial (RECRUIT). This report presents the design of RECRUIT. Specialty clinic follow-up continues through April 2017. METHODS: We hypothesized that specialist physician investigators and coordinators trained in the trust-based continuous quality improvement intervention would enroll a greater proportion of minority participants in their specialty clinics than specialist physician investigators in control specialty clinics. Specialty clinic was the unit of randomization. Using continuous quality improvement, the specialist physician investigators and coordinators tailored recruitment approaches to their specialty clinic characteristics and populations. Primary analyses were adjusted for clustering by specialty clinic within parent trial and matching covariates. RESULTS: RECRUIT was implemented in four multi-site clinical trials (parent trials) supported by three National Institutes of Health institutes and included 50 associated specialty clinics from these parent trials. Using current data, we have 88% power or greater to detect a 0.15 or greater difference from the currently observed control proportion adjusting for clustering. We detected no differences in baseline matching criteria between intervention and control specialty clinics (all p values > 0.17). CONCLUSION: RECRUIT was the first multi-site randomized control trial to examine the effectiveness of a trust-based continuous quality improvement intervention to increase minority recruitment into clinical trials. RECRUIT's innovations included its focus on building trust between specialist investigators and minority-serving physicians, the use of continuous quality improvement to tailor the intervention to each specialty clinic's specific racial/ethnic populations and barriers to minority recruitment, and the use of specialty clinics from more than one parent multi-site trial to increase generalizability. The effectiveness of the RECRUIT intervention will be determined after the completion of trial data collection and planned analyses.

Moodivate: A self-help behavioral activation mobile app for utilization in primary care-Development and clinical considerations.

Depressive symptoms are highly prevalent and are associated with considerable functional impairment, significant public health costs, and heightened mortality risk. Individuals experiencing impairment due to depressive symptomatology are most likely to report their symptoms to a primary care provider. As such, national guidelines highlight the need to assess and effectively treat depression via primary care. Despite these guidelines, the dissemination of evidence-based psychotherapy via primary care is limited, likely due to both provider- and patient-level treatment barriers. Mobile health (mHealth) technologies are promising for addressing these barriers and for promoting uptake of evidence-based depression treatment. Among evidence-based psychotherapies for depression, brief Behavioral Activation Treatment for Depression (BATD) has shown great promise and is particularly amenable to mHealth delivery. Herein, we discuss the development of a BATD mobile application, Moodivate, that was developed in order to disseminate BATD via primary care. This paper focuses on description of (1) rationale for Moodivate treatment development, (2) Moodivate treatment components, (3) ongoing clinical trial evaluation of Moodivate, and (4) clinical considerations for incorporating Moodivate into clinical practice.

Stressors and coping mechanisms associated with perceived stress in Latinos.

OBJECTIVE: To evaluate the relationship between causes of perceived stress and the coping mechanisms used by Latino adults with perceived stress. DESIGN, SETTING, PARTICIPANTS: This cross-sectional survey was conducted on a convenience sample of 200 Latino adults (aged ≥18 years). They were recruited from clinics, migrant camps, community events, and churches located in Charleston, S.C. This survey included questions regarding causes of perceived stress, perceived stress (Perceived Stress Scale 10), coping mechanisms (Brief COPE), and depression (Perceived Health Questionnaire 9). MEASURES: High perceived stress (PSS ≥15) was the primary outcome measure. Coping mechanisms and stressors were secondary outcomes. RESULTS: Most (92%) of the sample was born outside the United States, and 66% reported high perceived stress. Stressors associated with high perceived stress included discrimination (P=.0010), lack of insurance (P=.0193), health problems (P=.0058), and lack of money (P=.0015). The most frequently utilized coping mechanisms were self-distraction (54.77%), active coping (69.85%), positive reframing (56.78%), planning (63.82%), acceptance (57.87%), and religion (57.79%). Latinos with higher perceived stress were more likely to report discrimination (OR: 3.401; 95%CI 1.285-9.004) and health problems (OR: 2.782; 95%CI 1.088-7.111) as stressors, and to use denial as a coping mechanism (OR: 2.904; 95%CI 1.280-6.589). CONCLUSION: An increased prevalence of perceived stress among the Latinos evaluated in this study was associated with using denial as a coping mechanism, and encountering discrimination and health problems as sources of perceived stress. Most individuals responded to stressors by utilizing a variety of both adaptive and maladaptive coping mechanisms.

Cost and Utilization: Hospitalized Patients on a Family Medicine Service.

OBJECTIVES: The cost of hospitalizations contributes to the rising expense of medical care in the United States. Providing health insurance to uninsured Americans is a strategy to reduce these costs, but only if costs for uninsured patients are disproportionately high. This study examined hospitalization use patterns for uninsured patients compared with those with Medicaid and commercial insurance. METHODS: We performed a retrospective chart review to analyze inpatient admissions to a family medicine teaching service in a 290-bed, for-profit community hospital during a 2-year period based on insurance status of the patient. Outcome variables investigated were length of stay, emergency department visits, and readmission rates to the hospital and/or emergency department. Secondary outcome variables were mean charges. RESULTS: A total of 1102 admissions to a family medicine teaching service were evaluated. Length of stay, readmission rates to the hospital and the emergency department after hospital discharge, and average length of stay compared with diagnosis-related groups were significantly higher in the Medicaid population than for insured and uninsured individuals. Variable costs also were significantly higher. CONCLUSIONS: Insurance status was found to be a significant factor in hospital charges and utilization data, with Medicaid patients having the highest costs. This suggests that moving uninsured patients to Medicaid may not significantly reduce hospitalization costs.