The Role of Psychological Factors in Chronic Pain Treatment Outcomes in the Military.

PURPOSE: Chronic pain treatment in the military includes complementary and integrative health (CIH) therapies that may affect psychological factors such as pain catastrophizing, chronic pain acceptance, pain self-efficacy, and patient activation. The unique roles that psychosocial factors play in how CIH approaches reduce pain are not clear. This study examined if a holistic pain management program improved pain outcomes through psychological mediators in service members with chronic pain. DESIGN: Secondary analysis of a clinical trial. METHODS: Active-duty service members (n = 210) were randomly assigned to a 3-week course of standard rehabilitative care or standard rehabilitative care combined with CIH therapies. Both treatments were followed by a 3-week functional restoration program. Study measures were completed pre- and post-treatment using the Military Health System's Pain Assessment Screening Tool and Outcomes Registry. Mediation analyses tested the indirect effects of the change in psychological factors before functional restoration on the change in pain impact (e.g., pain intensity, pain interference, functional status) after functional restoration. RESULTS: All psychological factors except for chronic pain acceptance were related to improved pain impact (p<.05). Furthermore, a change in psychological factors prior to functional restoration was related to the change in pain impact after functional restoration. However, the addition of CIH therapies to standard rehabilitative care did not result in changes in pain outcomes mediated by the psychological factors. CONCLUSIONS: Although psychological factors were related to pain outcomes, the effect of CIH therapies on chronic pain did not occur via a change in the four psychological factors.

Loneliness mediates the association of minority stress and depression in sexual and gender minority populations in Thailand.

Loneliness is a significant risk factor for depression in adults. Sexual and gender minority (SGM) individuals are at risk for loneliness and depression due to stigma and discrimination. However, little is known about the influences of loneliness on the mental health of SGM populations. Guided by the Minority Stress and Integrative Mediation Frameworks, the authors aimed to examine loneliness's direct and indirect effects on the relationships between minority stressors and depression among Thai SGM adults. Data were drawn from a larger cross-sectional survey. Standardized measures of minority stressors (discrimination, victimization, identity concealment, and internalized sexual stigma), loneliness, and depression were selected and translated by expert panels. A convenience sample was recruited, and data were collected using online and in-person methods. Participants (N = 411, M = 29.5 years) were primarily male (90.5%), gay (79.3%), and cisgender (76.6%). More than 40% of participants reported clinically significant levels of loneliness (M = 38.59, standard deviation [SD] = 11.11) and depression (M = 9.46, SD = 8.43). Discrimination, identity concealment, and internalized sexual stigma were directly associated with loneliness (all p < 0.05). Minority stressors were significantly related to depression through indirect associations via loneliness accounting for 33%-54% of the total effect. Indirect effects (95% confidence interval) were 0.25 [0.12, 0.40] for discrimination, -0.41 [-0.67, -0.18] for identity concealment, and 0.42 [0.06, 0.79] for internalized sexual stigma. Loneliness was prevalent and played a mediating role in the associations between minority stressors and depression. Study findings have implications for the development of intervention research.

High rate of dyspareunia and probable vulvodynia in Ehlers-Danlos syndromes and hypermobility spectrum disorders: An online survey.

Vulvodynia is debilitating vulvar pain accompanied by dyspareunia (pain with sexual intercourse). Ehlers-Danlos syndromes (EDS) and hypermobility spectrum disorders (HSD) may represent a predisposing factor for vulvodynia given a high rate of dyspareunia in these conditions. We conducted an online survey of women with EDS or HSD to assess rates of dyspareunia and estimate rates of vulvodynia, report rates of comorbid conditions common to EDS or HSD and vulvodynia, and examine rates of conditions contributing to dyspareunia in women with EDS or HSD. Women with EDS or HSD (N = 1,146) recruited via social media were 38.2 ± 11.5 years old, primarily White (94.4%), and resided in the United States (78.5%). 63.7% of participants reported dyspareunia and 50% screened positive for vulvodynia. The rate of comorbid conditions common to EDS or HSD and vulvodynia were: irritable bowel syndrome, 6.5%; fibromyalgia, 40.0%; temporomandibular joint dysfunction, 56.4%; migraine, 6.7%; interstitial cystitis, 1.7%; and mast cell activation syndrome, 10.2%. Participants reporting dyspareunia also reported ovarian cysts, fibroids, or abdominal or pelvic scars, 47.5%; endometriosis, 26.5%; and genital lacerations, 19.3%. Women with EDS or HSD may have a higher rate of vulvodynia (50.0%) than women in the U.S. population at large (8%) and should be assessed for dyspareunia and vulvodynia.

A Dietary Supplement Frequency Questionnaire Correctly Ranks Nutrient Intakes in US Older Adults When Compared to a Comprehensive Dietary Supplement Inventory.

BACKGROUND: Dietary supplements are commonly taken by adults in the United States and can contribute substantially to daily nutrient intakes. Short supplement-use questionnaires are often used in dietary surveys, but their accuracy has not been well studied. OBJECTIVES: The primary objective was to evaluate the accuracy of a short, self-administered supplement frequency questionnaire (SFQ) relative to a comprehensive 1-y inventory of supplement use. A secondary objective was to compare SFQ responses for participants in the intensive measurement study to those from a control group to investigate a possible research participation effect. METHODS: The Supplement Reporting study enrolled 1029 older adults in 2005-2006, with a mean age of 67.8 y, who participated in the Multiethnic Cohort and reported regular use of dietary supplements. Of these, 375 were interviewed quarterly to collect detailed information on types and amounts of dietary supplements used, while 654 served as the control group. All participants completed 2 SFQs, 1 y apart. RESULTS: Agreement between the 2 instruments in use at least weekly ranged from 88% to 97% for 15 of 16 supplement types, with a lower agreement of 74% for vitamin D. The correlations of nutrient intakes from supplements between the 2 instruments were high, ranging from 0.48 to 0.75, except for iron (r = 0.29). However, mean nutrient intakes as reported on the SFQ were higher than intakes from the inventory for most nutrients, sometimes twice as high. Nutrient intakes based on the SFQ were similar for the inventory and control groups, at both baseline and the end of the study. CONCLUSIONS: A self-administered short SFQ can be used in large surveys to identify participants who use 16 categories of dietary supplements at least once a week and can correctly rank participant intakes of nutrients. However, the SFQ does not accurately estimate absolute levels of nutrient intakes from supplements.

Prepregnancy Obesity Does Not Impact Placental Iron Trafficking.

BACKGROUND: Iron is critical for fetal development. Neonates of obese women may be at risk for poor iron status at birth as a result of maternal inflammation-driven overexpression of hepcidin. OBJECTIVES: The objective of this study was to determine differences in placental transfer of oral iron (57Fe) and expression of placental transferrin receptor 1 (TFR1) and ferroportin (FPN) mRNA and protein and their association with maternal and neonatal iron-related parameters, including maternal hepcidin, among women with and without prepregnancy (PP) obesity. METHODS: 57Fe ingested during the third trimester of pregnancy was recovered in venous umbilical cord blood among 20 PP obese [BMI (in kg/m2): 30.5-43.9] and 22 nonobese (BMI: 18.5-29.0) women aged 17-39 y. Placental TFR1 and FPN mRNA and protein expression were quantified via qPCR and Western blot. Maternal and neonatal markers of iron status and regulation, as well as inflammation, were measured. Descriptive and inferential statistical tests (e.g., Student t test, Pearson correlation) were used for data analysis. RESULTS: There was no difference in cord blood enrichment of 57Fe or placental mRNA or protein expression of TFR1 or FPN among the women with and without PP obesity. Maternal hepcidin was not correlated with cord blood enrichment of 57Fe or placental FPN mRNA or protein expression. Maternal log ferritin (corrected for inflammation) was inversely correlated with log percent enrichment of 57Fe in cord blood (partial r = -0.50; P < 0.01, controlled for marital status) and protein expression of TFR1 (r = -0.43; P = 0.01). CONCLUSIONS: Placental iron trafficking did not differ among women with and without PP obesity. Findings reinforce the importance of maternal iron stores in regulating placental iron trafficking.

Sedentary Behavior in Older Adults With Preclinical Cognitive Impairment With and Without Chronic Kidney Disease.

Older adults with preclinical cognitive impairment can have chronic conditions and lifestyle factors that influence health. Sedentary behavior is common in older adults with and without chronic kidney disease (CKD). The objective of the current study was to determine the differences in sedentary behavior for older adults with preclinical cognitive impairment with and without CKD. Our study evaluated 48 older adults with preclinical cognitive impairment with and without CKD who underwent assessment of sedentary behavior via accelerometry. We found that older adults with preclinical cognitive impairment with and without CKD were sedentary, but there were no significant differences between groups. Fragmentation index was different (p < 0.05), with a lower fragmentation index found in those with CKD. Sedentary behavior should be assessed and evaluated as a potential target for interventions to improve health in these at-risk older adults; however, further investigation is needed. [Journal of Gerontological Nursing, 47(6), 35-42.].

Double-blinding of an acupuncture randomized controlled trial optimized with clinical translational science award resources.

BACKGROUND: Clinical trial articles often lack detailed descriptions of the methods used to randomize participants, conceal allocation, and blind subjects and investigators to group assignment. We describe our systematic approach to implement and measure blinding success in a double-blind phase 2 randomized controlled trial testing the efficacy of acupuncture for the treatment of vulvodynia. METHODS: Randomization stratified by vulvodynia subtype is managed by Research Electronic Data Capture software's randomization module adapted to achieve complete masking of group allocation. Subject and acupuncturist blinding assessments are conducted multiple times to identify possible correlates of unblinding. RESULTS: At present, 48 subjects have been randomized and completed the protocol resulting in 87 subject and 206 acupuncturist blinding assessments. DISCUSSION: Our approach to blinding and blinding assessment has the potential to improve our understanding of unblinding over time in the presence of possible clinical improvement.

Vulvodynia, "A Really Great Torturer": A Mixed Methods Pilot Study Examining Pain Experiences and Drug/Non-drug Pain Relief Strategies.

BACKGROUND: Women with vulvodynia, a chronic pain condition, experience vulvar pain and dyspareunia. Few studies examine the range and combination of treatment strategies that women are actually using to reduce vulvodynia. AIM: To describe pain experiences and pain relief strategies of women with vulvodynia. METHODS: Convenience sample, 60 women with vulvodynia (median age 32.5 [interquartile range {IQR} 8.5] years; 50 white, 10 racial/ethnic minorities) completed PAINReportIt and reported use of drugs and alcohol and responded to open-ended questions. Univariate descriptive statistics and bivariate inferential tests were used to describe average pain intensity scores, alcohol use, smoking, number of pain relief strategies, and their associations. Women's open-ended responses about their pain experiences and drug and non-drug pain relief strategies (NDPRS) were analyzed for patterns. OUTCOMES: Our mixed methods analysis connected data from pain measures, prescribed treatments and self-reported behaviors with women's free responses. This enabled nuanced insights into women's vulvodynia pain experiences. RESULTS: Women's descriptions of their pain and suffering aligned with their reported severe pain and attempts to control their pain, with a median pain intensity of 6.7 (IQR 2.0) despite use of adjuvant drugs (median 2.0 [IQR 2.0]), and opioids (median 1.0 [IQR 2.0]). 36 women (60%) used alcohol to lessen their pain. 26 women (43%) listed combining analgesics and alcohol to relieve their pain. 30 women (50%) smoked cigarettes. 54 women (90%) used ≥1 NDPRS. The mean number of NDPRS used was 2.1 ± 1.3 (range 0-6). The 5 most common NDPRS from women's comments were herbal medicine (40%), acupuncture (27%), massage (22%), hypnosis (15%), and mental healthcare (13%). CLINICAL IMPLICATIONS: Severe pain in women with vulvodynia may be a clinical indicator of those at higher risk of combining prescription pain medications with alcohol, which are all central nervous system depressants and may potentiate overdose. STRENGTHS AND LIMITATIONS: This pilot study demonstrated that the mixed methods approach to help understand the complexity of vulvodynia was feasible. We identified data showing a reliance on a high-risk mix of prescriptions and alcohol to reduce vulvodynia pain and a high prevalence of cigarette smoking. However, as a pilot study, these results are considered preliminary; the sample may not be representative. Perhaps only women at the extreme end of the pain continuum participated, or women took the survey twice because identifiers were not collected. CONCLUSION: Despite attempts to reduce pain using multiple therapies, including alcohol, women's vulvodynia pain is severe and not controlled. Schlaeger JM, Pauls HA, Powell-Roach KL, et al. Vulvodynia, "A Really Great Torturer": A Mixed Methods Pilot Study Examining Pain Experiences and Drug/Non-drug Pain Relief Strategies. J Sex Med 2019;16:1255-1263.

Evaluation of a Randomized Clinical Trial Comparing the Effectiveness of a Culturally Targeted and Nontargeted Smoking Cessation Intervention for Lesbian, Gay, Bisexual, and Transgender Smokers.

PURPOSE: To examine the benefits of a culturally targeted compared with a nontargeted smoking cessation intervention on smoking cessation outcomes among lesbian, gay, bisexual, and transgender (LGBT) smokers. METHODS: A prospective randomized design was used to evaluate the added benefits of an LGBT culturally targeted Courage to Quit (CTQ-CT) smoking cessation treatment (N = 172) compared with the standard intervention (CTQ; N = 173). The smoking cessation program consisted of six treatment sessions combined with 8 weeks of nicotine replacement therapy. The primary smoking cessation outcome was 7-day point prevalence quit rates. Secondary outcomes examined included changes in nicotine dependence, nicotine withdrawal, cigarettes per day, smoking urges, self-efficacy, and readiness to quit. RESULTS: Overall quit rates were 31.9% at 1 month, 21.1% at 3 months, 25.8% at 6 months, and 22.3% at 12 months. Quit rates did not differ between treatment groups [1 month OR = 0.81 (0.32, 2.09), 3 months OR = 0.65 (0.23, 1.78), 6 months OR = 0.45 (0.17, 1.21), 12 months OR = 0.70 (0.26, 1.91)]. Compared with baseline levels, all secondary smoking cessation outcomes measured were improved at 1 month and were maintained at 12-month follow-up. Compared with the CTQ, the CTQ-CT intervention was more highly rated on program effectiveness (d = 0.2, p = .011), intervention techniques (d = 0.2, p = .014), the treatment manual (d = 0.3, p < .001), and being targeted to the needs of LGBT smokers (d = 0.5, p < .0001). CONCLUSIONS: LGBT smokers receiving the CTQ intervention achieved smoking cessation outcomes in the range reported for other demographic groups. Cultural targeting improved the acceptability of the intervention but did not confer any additional benefit for smoking cessation outcomes. IMPLICATIONS: Study results have implications for understanding the benefits of culturally targeted compared with nontargeted smoking cessation interventions for improving smoking cessation outcomes among LGBT smokers. Shorter and longer term 7-day point prevalence quit rates associated with the targeted and nontargeted interventions were modest but comparable with other group-based interventions delivered in a community setting. Although cultural targeting improved the overall acceptability of the intervention, no added benefits were observed for the culturally targeted intervention on either the primary or secondary outcomes.

Criteria for gauging response to sodium oxybate for narcolepsy.

Our objective was to define responder criteria using an anchor-based approach for frequency of cataplexy attacks and excessive daytime sleepiness in patients with narcolepsy undergoing sodium oxybate treatment. We used pooled data from two randomized, placebo-controlled, double-blind, multicentre 4- and 8-week trials of sodium oxybate for narcolepsy with cataplexy and analysed using receiver operator characteristics analysis. The percentage change in frequency of weekly cataplexy attacks and the Epworth Sleepiness Scale outcomes were compared with Clinical Global Impression of Change ratings, used as the anchor to define true response. Participants (n = 336) were 39% male, 89% white, with a mean age of 41.5 (15.3) years, reporting a median of 20.5 cataplexy attacks per week and a mean Epworth Sleepiness score of 17.5 at baseline. A majority (51%) were Much Improved or Very Much Improved based on Clinical Global Impression of Change ratings, considered a true response to treatment. Area under the curve values for % reduction in cataplexy attacks (77%) and % change in sleepiness score (78%) supported response definition thresholds of 46% and 12%, respectively. Classification using either response definition agreed with the anchor for approximately 71% of participants. Cataplexy response definition was more sensitive (cataplexy = 0.77, Epworth Sleepiness Scale = 0.69), while sleepiness was more specific (cataplexy = 0.66, Epworth Sleepiness Scale = 0.75). Both responder definitions showed a dose-response relationship with sodium oxybate, demonstrating their validity using an external criterion. Weekly cataplexy attacks and Epworth Sleepiness Scale can be used to help document clinical response to narcolepsy treatment using criteria of 46% and 12% reductions, respectively.

Randomized controlled pilot of a group antenatal care model and the sociodemographic factors associated with pregnancy-related empowerment in sub-Saharan Africa.

BACKGROUND: The links between empowerment and a number of health-related outcomes in sub-Saharan Africa have been documented, but empowerment related to pregnancy is under-investigated. Antenatal care (ANC) is the entry point into the healthcare system for most women, so it is important to understand how ANC affects aspects of women's sense of control over their pregnancy. We compare pregnancy-related empowerment for women randomly assigned to the standard of care versus CenteringPregnancy-based group ANC (intervention) in two sub-Saharan countries, Malawi and Tanzania. METHODS: Pregnant women in Malawi (n = 112) and Tanzania (n = 110) were recruited into a pilot study and randomized to individual ANC or group ANC. Retention at late pregnancy was 81% in Malawi and 95% in Tanzania. In both countries, individual ANC, termed focused antenatal care (FANC), is the standard of care. FANC recommends four ANC visits plus a 6-week post-birth visit and is implemented following the country's standard of care. In group ANC, each contact included self- and midwife-assessments in group space and 90 minutes of interactive health promotion. The number of contacts was the same for both study conditions. We measured pregnancy-related empowerment in late pregnancy using the Pregnancy-Related Empowerment Scale (PRES). Independent samples t-tests and multiple linear regressions were employed to assess whether group ANC led to higher PRES scores than individual ANC and to investigate other sociodemographic factors related to pregnancy-related empowerment. RESULTS: In Malawi, women in group ANC had higher PRES scores than those in individual ANC. Type of care was a significant predictor of PRES and explained 67% of the variation. This was not so in Tanzania; PRES scores were similar for both types of care. Predictive models including sociodemographic variables showed religion as a potential moderator of treatment effect in Tanzania. Muslim women in group ANC had a higher mean PRES score than those in individual ANC; a difference not observed among Christian women. CONCLUSIONS: Group ANC empowers pregnant women in some contexts. More research is needed to identify the ways that models of ANC can affect pregnancy-related empowerment in addition to perinatal outcomes globally.

What barriers thwart postpartum women's physical activity goals during a 12-month intervention? A process evaluation of the Na Mikimiki Project.

Approximately 70% of new mothers do not meet national guidelines for moderate-to-vigorous physical activity (MVPA). The Na Mikimiki ("the active ones") Project (2008-2011) was designed to increase MVPA among women with infants 2-12 months old. Participants' barriers to exercising and achievement of specific MVPA goals were discussed during telephone counseling calls over 12 months. Healthy, inactive women (n = 115, mean age = 31 ± 5 years, infants' mean age = 5.5 ± 3 months; 80% racial/ethnic minorities) received a total of 17 calls over 12 months in three phases. During Phase 1 weekly calls were made for a month, in Phase 2 biweekly calls were made for 2 months, and in Phase 3 monthly calls were made for 9 months. Across all phases, the most frequent barriers to achieving MVPA goals were: time/too busy (25%), sick child (11%), and illness (10%). Goals for MVPA minutes per week were achieved or surpassed 40.6% of the time during weekly calls, 39.9% during biweekly calls, and 42.0% during monthly calls. The least likely MVPA goals to be achieved (p < 0.04) were those which the woman encountered and for which she failed to overcome the barriers she had previously anticipated would impair her improvement of MVPA. This process evaluation demonstrated that telephone counseling somewhat facilitated the resolution of barriers and achievement of MVPA goals; thus, if clinical settings adopted such methods, chronic disease risks could be reduced in this vulnerable population of new mothers.

Effectiveness of a 12-month randomized clinical trial to increase physical activity in multiethnic postpartum women: results from Hawaii's Na Mikimiki Project.

OBJECTIVE: Few postpartum ethnic minority women perform leisure-time moderate-to-vigorous physical activity (MVPA). The study tested the effectiveness of a 12-month tailored intervention to increase MVPA in women with infants 2-12months old. METHODS: From 2008 to 2011, women (n=311) with infants (average age=5.7months) from Honolulu, Hawaii were randomly assigned to receive tailored telephone calls and access to a mom-centric website (n=154) or access to a standard PA website (n=157). MVPA was measured at baseline, 6, and 12months using self-report and acclerometers. RESULTS: Controlling for covariates, the tailored condition significantly increased self-reported MVPA from an average of 44 to 246min/week compared with 46 to 156min/week for the standard condition (p=0.027). Mothers with≥2 children had significantly greater increases in MVPA in response to the tailored intervention than those with one child (p=0.016). Accelerometer-measured MVPA significantly increased over time (p=0.0001), with no condition differences. There was evidence of reactivity to initially wearing accelerometers; the tailored intervention significantly increased MVPA among women with low baseline accelerometer MVPA minutes, but not among those with high minutes (pinteraction=0.053). CONCLUSION: A tailored intervention effectively increased MVPA over 12months in multiethnic women with infants, particularly those with more than one child.

Dietary isoflavone intake is not statistically significantly associated with breast cancer risk in the Multiethnic Cohort.

Given the high intake levels of soya and low incidence rates of breast cancer in Asian countries, isoflavones, substances with an oestrogen-like structure occurring principally in soyabeans, are postulated to be cancer protective. In the present study, we examined the association of dietary isoflavone intake with breast cancer risk in 84,450 women (896 in situ and 3873 invasive cases) who were part of the Multiethnic Cohort (Japanese Americans, whites, Latinos, African Americans and Native Hawaiians) with a wide range of soya intake levels. The absolute levels of dietary isoflavone intake estimated from a baseline FFQ were categorised into quartiles, with the highest quartile being further subdivided to assess high dietary intake. The respective intake values for the quartiles (Q1, Q2, Q3, and lower and upper Q4) were 0-< 3·2, 3·2-< 6·7, 6·7-< 12·9, 12·9-< 20·3, and 20·3-178·7 mg/d. After a mean follow-up period of 13 years, hazard ratios (HR) and 95% CI were calculated using Cox regression models stratified by age and adjusted for known confounders. Linear trends were tested by modelling continuous variables of interest assigned the median value within the corresponding quartile. No statistically significant association was observed between dietary isoflavone intake and overall breast cancer risk (HR for upper Q4 v. Q1: 0·96 (95% CI 0·85, 1·08); P trend = 0·40). While the test for interaction was not significant (P=0·14), stratified analyses suggested possible ethnic/racial differences in risk estimates, indicating that higher isoflavone intakes may be protective in Latina, African American and Japanese American women. These results are in agreement with those of previous meta-analyses showing no protection of isoflavones at low intake levels, but suggesting inverse associations in populations consuming high amounts of soya.

Act or Wait? Presentation Delay in Symptomatic Breast Cancer in China.

BACKGROUND: In Western countries, factors contributing to breast cancer presentation delay have been identified, but little is known about presentation delay in China, where culture and healthcare systems are quite different. OBJECTIVE: To describe the delay interval among newly diagnosed breast cancer patients in China and to identify factors influencing delay, including the COVID-19 pandemic. METHODS: Using a cross-sectional design, we recruited 154 participants within 3 months of pathological diagnosis of breast cancer. Data were collected using standardized scales and open-ended questions. RESULTS: We found 44.8% of participants delayed ≥1 month, and 24.7% delayed ≥3 months before presentation, after self-discovery of symptoms. Logistic regression analysis showed that factors associated with longer delay (≥1 month) included preferring female physicians for breast examination, fewer negative emotions (afraid, anxious, distressed) regarding breast symptoms, more competing priorities, believing folk therapy can help treat lumps, and visiting a secondary or tertiary hospital instead of primary healthcare providers (P < .05 for all). Interaction tests showed perceived seriousness of symptoms significantly predicted delay of ≥1 month only when perceived healthcare access or trust in physicians was low. Patients (14%) reported delaying due to fear of COVID-19 infection and inability to leave home. CONCLUSIONS: Presentation delays were substantial and multilevel barriers to timely presentation were identified, which would be expected to contribute to later-stage cancer at diagnosis. IMPLICATIONS FOR PRACTICE: Findings suggest that nursing interventions and improved health policies are urgently needed in China, including breast cancer education to increase awareness.

Lack of Diversity in Research on Females with Ehlers-Danlos Syndromes: Recruitment Protocol for a Quantitative Online Survey.

BACKGROUND: Ehlers-Danlos syndromes (EDS) are a group of connective tissue disorders caused by fragile lax collagen. Current EDS research lacks racial and ethnic diversity. The lack of diversity may be associated with the complexities of conducting a large international study on an underdiagnosed condition and a lack of EDS health care providers who diagnose and conduct research outside of the United States and Europe. Social media may be the key to recruiting a large diverse EDS sample. However, studies that have used social media to recruit have not been able to recruit diverse samples. OBJECTIVE: This study aims to discuss challenges, strategies, outcomes, and lessons learned from using social media to recruit a large sample of females with EDS. METHODS: Recruitment on social media for a cross-sectional survey examining dyspareunia (painful sexual intercourse) in females was examined. Inclusion criteria were (1) older than 18 years of age, (2) assigned female at birth, and (3) diagnosed with EDS. Recruitment took place on Facebook and Twitter (now X), from June 1 to June 25, 2019. RESULTS: A total of 1178 females with EDS were recruited from Facebook (n=1174) and X (n=4). On Facebook, participants were recruited via support groups. A total of 166 EDS support groups were identified, 104 permitted the principal investigator to join, 90 approved posting, and the survey was posted in 54 groups. Among them, 30 of the support groups posted in were globally focused and not tied to any specific country or region, 21 were for people in the United States, and 3 were for people outside of the United States. Recruitment materials were posted on X with the hashtag #EDS. A total of 1599 people accessed the survey and 1178 people were eligible and consented. The average age of participants was 38.6 (SD 11.7) years. Participants were predominantly White (n=1063, 93%) and non-Hispanic (n=1046, 92%). Participants were recruited from 29 countries, with 900 (79%) from the United States and 124 (11%) from Great Britain. CONCLUSIONS: Our recruitment method was successful at recruiting a large sample. The sample was predominantly White and from North America and Europe. More research needs to be conducted on how to recruit a diverse sample. Areas to investigate may include connecting with more support groups from outside the United States and Europe, researching which platforms are popular in different countries, and translating study materials into different languages. A larger obstacle to recruiting diverse samples may be the lack of health care providers that diagnose EDS outside the United States and Europe, making the pool of potential participants small. There needs to be more health care providers that diagnose and treat EDS in countries that are predominantly made up of people of color as well as research that specifically focuses on these populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/53646.

Role of Pain Catastrophizing in the Effects of Cognitive Behavioral Therapy for Chronic Pain in Different Subgroups: An Exploratory Secondary Data Analysis Using Finite Mixture Models.

INTRODUCTION: Providing effective treatment for debilitating chronic pain is a challenge among many populations including military service members. Cognitive behavioral therapy for chronic pain (CBT-CP) is a leading psychological pain treatment. Pain catastrophizing is a pivotal mediator of pain-related outcomes. The purpose of this study was (1) to identify patient subgroups who differ in response to CBT-CP and (2) to explore the characteristics that define these patient subgroups. The overall goal was to obtain a better understanding of factors that may influence response to CBT-CP. MATERIALS AND METHODS: This study was a secondary analysis of data from a clinical trial of 149 U.S. active duty service members with chronic pain. Participants underwent group-based CBT-CP for 6 weeks and completed pre- and posttreatment assessments. Finite mixture models were employed to identify subgroups in treatment response, with pain impact score as the primary outcome measure. RESULTS: We identified two classes of nearly equal size with distinct pain impact responses. One class reported improved pain impact scores following CBT-CP. This improvement was significantly associated with lower (better) baseline depression scores and greater improvement in posttreatment pain catastrophizing. In contrast, the other class reported slightly worse mean pain impact scores following CBT-CP treatment; this response was not related to baseline depression or change in pain catastrophizing. CONCLUSIONS: Our findings demonstrate that a sizable proportion of individuals with chronic pain may not respond to group-based CBT-CP and may require a more individualized treatment approach.

Randomized trial of tailored skin cancer prevention for children: the Project SCAPE family study.

This study evaluated a tailored intervention to promote sun protection in parents and their children, hypothesizing that the tailored intervention would lead to improved skin cancer prevention behaviors compared to generic materials. Families were recruited through schools and community centers and were included if there was 1 child in Grades 1-3 at moderate to high risk for skin cancer. Participants were randomized into one of two intervention groups: a tailored intervention, in which they received personalized skin cancer education through the mail; or a control group who received generic skin cancer information materials. Before and after intervention, parents completed questionnaires about their and their children's skin cancer risk and prevention knowledge and behaviors. Parents also completed 4-day sun exposure and protection diaries for their child and themselves. Tailored group participants demonstrated significantly greater positive changes in prevention behavior after the intervention, including children's use of sunscreen, shirts, and hats, and parents' use of shade, and skin examinations. Effect sizes were small and perceived benefits and social norms mediated intervention effects. Findings from this study support the efficacy of focusing tailored communications to families in order to change skin cancer prevention practices in young children.

Pain Catastrophizing and Its Association with Military Medical Disability Among US Active Duty Service Members with Chronic Predominately Musculoskeletal Pain: A Retrospective Cohort Analysis.

Context: Pain catastrophizing is characterized by negative emotional and cognitive responses to pain and is a predictor of work-related disability. Its association with military medical disability has not been studied. Objective: To (1) identify the pain catastrophizing scale (PCS) score cut point most strongly associated with military medical disability, (2) measure the difference in rate of disability between service members with baseline PCS scores above versus below the cut point, and (3) determine if improvement in PCS score during pain specialty care is associated with decreased likelihood of disability. Methods: This was a retrospective cohort analysis comparing PCS scores collected from US Army active duty service members at time of initial visit to an interdisciplinary pain management center and periodically during pain treatment. Outcome was determination during the following year of a military service-disqualifying disability. Results: Receiver operating characteristic (ROC) curves determined that a PCS score of 20 was the single cut point most closely associated with subsequent disability. Kaplan-Meier curves showed significantly higher disability rate during the following year among those with baseline PCS scores ≥20 (52%) compared to those with lower scores (26%). Scheffe-adjusted contrasts showed that service members with PCS scores ≥20 whose scores improved to <20 at follow-up were significantly less likely to have a medical disability (42.6%; 95% CI, 0.07-0.58) than those whose PCS score remained ≥20 (76.3%; 95% CI, 68.0%-84.7%). Conclusion: A PCS score cut point of 20 distinguishes between high versus low likelihood of disability among service members. Those with high baseline PCS score had twice the likelihood of disability than those with low scores. Service members who decreased their PCS score from high to low during pain specialty care had lower likelihood of disability. Prospective research is needed to determine if treatments that lower pain catastrophizing yield reduced likelihood of subsequent disability.

Effectiveness of Telementoring in Improving Provider Knowledge, Attitudes, and Perceived Competence in Managing Chronic Pain: A Mixed Methods Study.

INTRODUCTION: Telementoring is an evidence-based approach to meet the educational needs of primary care providers (PCPs) and to improve the quality of chronic pain care. This mixed methods study evaluated the effectiveness of pain management telementoring in improving provider knowledge, attitudes, and perceived competence. MATERIALS AND METHODS: The study was conducted at Madigan Army Medical Center. Using a non-randomized quasi-experimental approach, 25 providers were assigned to intervention arm and control arm (14 intervention and 13 control). Providers in the intervention group attended telementoring sessions. Videoconference technology was used to deliver weekly 90-minute TelePain sessions to the PCPs in the intervention group. The first 25-30 minutes of each session consisted of a didactic presentation led by a panel of interdisciplinary pain management clinicians. During the remaining 60 minutes, all PCPs in the intervention group presented clinical histories and asked specific management questions regarding patients of their choosing. An interdisciplinary panel of pain management clinicians provided telementoring consultations. The panel included experts from pain medicine, primary care, psychology or psychiatry, chiropractic, clinical pharmacy, and nursing. Changes in provider knowledge, attitudes, and perceived competence were evaluated using the Knowledge and Attitudes Survey Regarding Pain, KnowPain-12, and the Perceived Competence Scale (n = 23; 12 intervention and 11 control). Qualitative interviews were conducted among a subset of providers (n = 12; 8 intervention and 4 control), and provider narratives were analyzed using content analysis. RESULTS: Increased provider knowledge (Z = 2.0, P = .046 [KnowPain-12]) and perceived competence (Z = 2.1, P = .033) were observed among intervention group providers. Provider narratives supported more implementation of non-pharmacological pain management strategies, use of strategies to engage patients in reducing reliance on opioids, and perception of TelePain as a helpful resource especially in the context of inadequate preparation in chronic pain management during professional training. CONCLUSIONS: Telementoring may hold significant potential to support providers in their efforts to decrease use of prescription opioids. Overall, this study provides further support for the value of telementoring in improving comprehensive chronic pain management in military settings.