Publications by authors named "Elizabeth Thomas"

322 Publications

Oncology social work practice behaviors: a national survey of AOSW members.

J Psychosoc Oncol 2021 Jun 29:1-15. Epub 2021 Jun 29.

College of Social Work, University of Tennessee, Knoxville, Tennessee, USA.

Purpose: Few studies have examined the practices of U.S. oncology social workers since the implementation of distress screening. This study presents data about oncology social work practice behaviors, including participation in distress screening and interdisciplinary team integration.

Design: Using a cross-sectional survey design, Association of Oncology Social Work (AOSW) members were invited to complete the anonymous web-based survey between June and September 2019.

Sample: AOSW members ( = 1116) were invited through email and listserv posts to participate in the survey with 533 (47.8%) responding.

Methods: A quantitative on-line survey was used to investigate demographics, distress screening roles and other practice behaviors. Descriptive analyses were conducted on the data.

Results: Respondents engaged in a range of practice behaviors consistent with the Standards and Scope of Practice published by AOSW, primarily engaging in patient-focused work. They reported viewing their role as integrated with the interdisciplinary team. Respondents were highly involved in distress screening processes, primarily receiving referrals from distress screening but also collecting/reviewing screening results and referring patients to other providers based on those results.

Implications For Psychosocial Providers: Knowledge about the ways that oncology social workers enact their role across settings and locations could be useful to those developing effective and integrated psychosocial oncology programs, especially distress screening protocols. Specific knowledge about the practice behaviors of oncology social workers in the U.S. may also help to delineate the role from the work of other interdisciplinary oncology team members.
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http://dx.doi.org/10.1080/07347332.2021.1942386DOI Listing
June 2021

Exploring peer specialists' experiences with spirituality in their work: Recommendations for future directions.

Psychiatr Rehabil J 2021 Jun 24. Epub 2021 Jun 24.

Department of Social and Behavioral Sciences.

Objective: Spirituality is part of recovery for many people with lived experience of mental health issues, including those who become peer specialists and utilize their own recovery experiences to facilitate the recovery of others. This research explores how peer specialists view spirituality in their work with their peers and the factors that impact conversations in this area.

Method: Eleven peer specialists participated in individual qualitative interviews. Inquiries were made about their own experiences of spirituality and how these were used to support others. Additional questions probed factors that facilitated or served as barriers to their ability to engage in such conversations. Data were subjected to thematic analysis.

Results: Peer specialists experienced well-being, hope, and self-acceptance through spirituality. Use of spirituality in peer support was influenced by their personal spiritual journey, specifically because they understood its value to recovery. Barriers to use included fear of rejection and lack of formal support. The number one facilitator was their personal experience, but they suggested the need for training and guidelines as important future facilitators.

Conclusions And Implications For Practice: Results indicate that at least some peer specialists are thinking about the role of spirituality in their work but express some struggles with such activities. There appears a need for guidelines on how to use spirituality in peer support, better definitions of the competencies peer specialists need, and more attention to training and supervision in this area-possibly to maximize the benefit of the lived experience that many peer specialists bring to their work. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/prj0000495DOI Listing
June 2021

Neonatal Abstinence Syndrome in Rural Appalachia.

Soc Work 2021 Jul;66(3):197-205

assistant professor, College of Social Work, University of Tennessee, Knoxville.

As the United States faces the repercussions of the current opioid epidemic, it is important for social workers to be able to identify risks for poor birth outcomes in infants with neonatal abstinence syndrome (NAS). Although some studies have identified single risk factors, no studies have tested associations between total amount of risk (that is, cumulative risk) and birth outcomes in infants with NAS. Authors examined 318 mothers who used opioids during pregnancy and their infants' birthweight, length, head circumference, and Apgar scores (which measure overall infant health after birth). All infants were admitted to a neonatal intensive care unit in Appalachia and were diagnosed with NAS. Authors found that high cumulative risk during pregnancy was associated with lower birthweight and Apgar scores one and five minutes after birth as well as shorter length and smaller head circumference at birth. Social workers are encouraged to assess for the quantity of prenatal adversity experienced by the mothers they serve and to consider multicomponent, comprehensive community-based interventions to reduce cumulative risk.
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http://dx.doi.org/10.1093/sw/swab014DOI Listing
July 2021

Beliefs About the Causes of Psychosis Among Persons With Psychosis and Mental Health Professionals: A Scoping Review.

Psychiatr Serv 2021 Jun 15:appips202000460. Epub 2021 Jun 15.

Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel (Rosenthal Oren, Roe); Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel (Hasson-Ohayon); Ginsburg Health Sciences Library, Temple University, Philadelphia (Roth); Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia (Thomas, Zisman-Ilani).

Objective: The beliefs that people with psychosis hold about causes of their illness (causal beliefs) can affect their choice to adhere to treatment and engage in mental health services. However, less is known about causal beliefs of mental health professionals (MHPs) and their impact on treatment adherence and service engagement. This review explored literature focusing on MHPs' causal beliefs and mapped the degree of concordance between their causal beliefs and those of people with psychosis.

Methods: A systematic literature search of PubMed, Embase, Scopus, PsycINFO, and Applied Social Sciences Index Abstracts and a gray-literature search of PsyArXiv and MedNar yielded 11,821 eligible references. The first author reviewed all titles and abstracts, and the coauthors reviewed 10% (N=1,200).

Results: Forty-two articles were included. Most articles indicated that MHPs tend to endorse biogenetic beliefs (9 of 15 articles assessing MHPs' beliefs, 60%), whereas people with psychosis tend to endorse psychosocial beliefs (16 of 31 articles, 52%) and other nonbiogenetic beliefs (in 8 of 31 articles, 26%). Most studies did not compare causal beliefs of people with psychosis and their treating MHP. Studies varied in design, setting, and measures.

Conclusions: MHPs and people with psychosis often hold complex views composed of different types of causal beliefs. However, a gap in causal beliefs between these groups appears to exist, which may affect the therapeutic relationship and pose barriers to treatment adherence. Future studies should address this gap by developing interventions that facilitate open communication about causal beliefs to promote treatment alliance and shared decision making.
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http://dx.doi.org/10.1176/appi.ps.202000460DOI Listing
June 2021

Fecal Contamination on the Household Compound and in Water Sources are Associated with Subsequent Diarrhea in Young Children in Urban Bangladesh (CHoBI7 Program).

Am J Trop Med Hyg 2021 Jun 7. Epub 2021 Jun 7.

2Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

We investigated the environmental and individual-level risk factors for diarrheal disease among young children in slum areas of Dhaka, Bangladesh. A prospective cohort study was conducted among 884 children under 5 years of age. Caregiver reports were collected on sociodemographic factors and hygiene behaviors. Diarrhea surveillance data was collected monthly based on caregiver-reported diarrhea for children in the past 2 weeks during the 12-month study period. Unannounced spot checks of the household compound were performed at 1, 3, 6, 9, and 12 months after enrollment to check for the presence of feces (animal or human) and the presence of animals in the child's sleeping space, to assess child and caregiver hands for the presence of dirt, and to collect samples of the household's source and stored drinking water. Children with feces found on the household compound during spot checks had a significantly higher odds of diarrhea (odds ratio: 1.71; 95% confidence interval: 1.23-2.38). Children residing in households with > 100 colony forming units/100 mL Escherichia coli in source drinking water had a significantly higher odds of diarrhea (OR: 1.43; 95% CI: 1.06-1.92). The presence of feces on the household compound and source drinking water with > 100 colony forming units/100 mL E. coli were significant risk factors for diarrheal disease for children < 5 years of age in slum areas of Dhaka, Bangladesh. These findings demonstrate the urgent need for comprehensive interventions to reduce fecal contamination on the household compound to protect the health of susceptible pediatric populations.
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http://dx.doi.org/10.4269/ajtmh.20-1516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8274748PMC
June 2021

Relationships among non-interpersonal and interpersonal trauma types, posttraumatic stress, and posttraumatic growth.

J Clin Psychol 2021 Jun 1. Epub 2021 Jun 1.

Department of Psychology, University of Tennessee - Knoxville, Knoxville, Tennessee, USA.

Methods: Adults seeking behavioral health or medical treatment (N = 158) were recruited from a community healthcare agency and a residential support program in the southeastern United States.

Results: Individuals who reported interpersonal trauma had significantly higher total PTS severity and symptom clusters. No significant difference was found in perceived PTG based on trauma type. No significant curvilinear relationship between PTS and perceived PTG was found. A significant negative linear relationship was observed between PTS and perceived PTG for non-interpersonal trauma, but not interpersonal trauma.

Conclusion: Trauma type may influence the PTS and perceived PTG relationship and, while associated with PTS, seems less important to reporting of perceived PTG.
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http://dx.doi.org/10.1002/jclp.23190DOI Listing
June 2021

Psychosocial Difficulties (PSD) Experienced by People across Brain Disorders and the Implications for Occupational Therapy: A Cross-Sectional Study.

Occup Ther Health Care 2021 May 31:1-18. Epub 2021 May 31.

Occupational Therapy Unit, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India.

Psychosocial difficulties are defined as impairments in mental and body functions, activity limitations and participation restrictions, experienced in common across brain disorders. This cross-sectional study compared the psychosocial difficulties among people with Parkinson's disease (n = 61), schizophrenia (n = 84) and stroke (n = 70). The extent of difficulties was found to be similar across the three disorders in most of the domains studied. Psychosocial difficulties were also found to be associated with sociodemographic and illness related factors. The results challenge the brain disorder-specific approach to psychosocial difficulties commonly carried out in neurological and psychiatric research. Implications to occupational therapy are presented.
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http://dx.doi.org/10.1080/07380577.2021.1926045DOI Listing
May 2021

Cannabidiol Modulates Mitochondrial Redox and Dynamics in MCF7 Cancer Cells: A Study Using Fluorescence Lifetime Imaging Microscopy of NAD(P)H.

Front Mol Biosci 2021 11;8:630107. Epub 2021 May 11.

Research Centre for Optimal Health, School of Life Sciences, University of Westminster, London, United Kingdom.

The cannabinoid, cannabidiol (CBD), is part of the plant's natural defense system that when given to animals has many useful medicinal properties, including activity against cancer cells, modulation of the immune system, and efficacy in epilepsy. Although there is no consensus on its precise mode of action as it affects many cellular targets, CBD does appear to influence mitochondrial function. This would suggest that there is a cross-kingdom ability to modulate stress resistance systems that enhance homeostasis. As NAD(P)H autofluorescence can be used as both a metabolic sensor and mitochondrial imaging modality, we assessed the potential of this technique to study the effects of CBD using 2-photon excitation and fluorescence lifetime imaging microscopy (2P-FLIM) of NAD(P)H against more traditional markers of mitochondrial morphology and cellular stress in MCF7 breast cancer cells. 2P-FLIM analysis revealed that the addition of CBD induced a dose-dependent decrease in bound NAD(P)H, with 20 µM treatments significantly decreased the contribution of bound NAD(P)H by 14.6% relative to the control ( < 0.001). CBD also increased mitochondrial concentrations of reactive oxygen species (ROS) (160 ± 53 vs. 97.6 ± 4.8%, 20 µM CBD vs. control, respectively, < 0.001) and Ca (187 ± 78 vs. 105 ± 10%, 20 µM CBD vs. the control, respectively, < 0.001); this was associated with a significantly decreased mitochondrial branch length and increased fission. These are all suggestive of mitochondrial stress. Our results support the use of NAD(P)H autofluorescence as an investigative tool and provide further evidence that CBD can modulate mitochondrial function and morphology in a dose-dependent manner, with clear evidence of it inducing oxidative stress at higher concentrations. This continues to support emerging data in the literature and may provide further insight into its overall mode of action, not only in cancer, but potentially its function in the plant and why it can act as a medicine.
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http://dx.doi.org/10.3389/fmolb.2021.630107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8144465PMC
May 2021

Do Personal Stories Make Patient Decision Aids More Effective? An Update from the International Patient Decision Aids Standards.

Med Decis Making 2021 May 22:272989X211011100. Epub 2021 May 22.

Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK.

Background: This article evaluates the evidence for the inclusion of patient narratives in patient decision aids (PtDAs). We define patient narratives as stories, testimonials, or anecdotes that provide illustrative examples of the experiences of others that are relevant to the decision at hand.

Method: To evaluate the evidence for the effectiveness of narratives in PtDAs, we conducted a narrative scoping review of the literature from January 2013 through June 2019 to identify relevant literature published since the last International Patient Decision Aid Standards (IPDAS) update in 2013. We considered research articles that examined the impact of narratives on relevant outcomes or described relevant theoretical mechanisms.

Results: The majority of the empirical work on narratives did not measure concepts that are typically found in the PtDA literature (e.g., decisional conflict). Yet, a few themes emerged from our review that can be applied to the PtDA context, including the impact of narratives on relevant outcomes (knowledge, behavior change, and psychological constructs), as well as several theoretical mechanisms about how and why narratives work that can be applied to the PtDA context.

Conclusion: Based on this evidence update, we suggest that there may be situations when narratives could enhance the effectiveness of PtDAs. The recent theoretical work on narratives has underscored the fact that narratives are a multifaceted construct and should no longer be considered a binary option (include narratives or not). However, the bottom line is that the evidence does not support a recommendation for narratives to be a necessary component of PtDAs.
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http://dx.doi.org/10.1177/0272989X211011100DOI Listing
May 2021

Staging Encystation Progression in Using Encystation-Specific Vesicle Morphology and Associating Molecular Markers.

Front Cell Dev Biol 2021 27;9:662945. Epub 2021 Apr 27.

Department of Biology, University of Washington, Seattle, WA, United States.

Differentiation into environmentally resistant cysts is required for transmission of the ubiquitous intestinal parasite . Encystation in requires the production, processing and transport of Cyst Wall Proteins (CWPs) in developmentally induced, Golgi-like, Encystation Specific Vesicles (ESVs). Progress through this trafficking pathway can be followed by tracking CWP localization over time. However, there is no recognized system to distinguish the advancing stages of this process which can complete at variable rates depending on how encystation is induced. Here, we propose a staging system for encysting based on the morphology of CWP1-stained ESVs. We demonstrate the molecular distinctiveness of maturing ESVs at these stages by following Rab GTPases through encystation. Previously, we established that 's sole Rho family GTPase, Rac, associates with ESVs and has a role in regulating their maturation and the secretion of their cargo. As a proof of principle, we delineate the relationship between Rac and ESV stages. Through proteomic studies, we identify putative interactors of Rac that could be used as additional ESV stage markers. This staging system provides a common descriptor of ESV maturation regardless of the source of encysting cells. Furthermore, the identified set of molecular markers for ESV stages will be a powerful tool for characterizing trafficking mutants that impair ESV maturation and morphology.
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http://dx.doi.org/10.3389/fcell.2021.662945DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8111296PMC
April 2021

Predicting outcome following mild traumatic brain injury: protocol for the longitudinal, prospective, observational Concussion Recovery () cohort study.

BMJ Open 2021 05 13;11(5):e046460. Epub 2021 May 13.

Curtin Health Innovation Research Institute, Curtin University Faculty of Health Sciences, Bentley, Western Australia, Australia

Introduction: Mild traumatic brain injury (mTBI) is a complex injury with heterogeneous physical, cognitive, emotional and functional outcomes. Many who sustain mTBI recover within 2 weeks of injury; however, approximately 10%-20% of individuals experience mTBI symptoms beyond this 'typical' recovery timeframe, known as persistent post-concussion symptoms (PPCS). Despite increasing interest in PPCS, uncertainty remains regarding its prevalence in community-based populations and the extent to which poor recovery may be identified using early predictive markers.

Objective: (1) Establish a research dataset of people who have experienced mTBI and document their recovery trajectories; (2) Evaluate a broad range of novel and established prognostic factors for inclusion in a predictive model for PPCS.

Methods And Analysis: The Concussion Recovery Study () is a prospective, longitudinal observational cohort study conducted in Perth, Western Australia. is recruiting adults aged 18-65 from medical and community-based settings with acute diagnosis of mTBI. will create a state-wide research dataset of mTBI cases, with data being collected in two phases. collates data on demographics, medical background, lifestyle habits, nature of injury and acute mTBI symptomatology. In , participants undergo neuropsychological evaluation, exercise tolerance and vestibular/ocular motor screening, MRI, quantitative electroencephalography and blood-based biomarker assessment. Follow-up is conducted telephone interview at 1, 3, 6 and 12 months after injury. Primary outcome measures are presence of PPCS and quality of life, as measured by the Post-Concussion Symptom Scale and the Quality of Life after Brain Injury questionnaires, respectively. Multivariate modelling will examine the prognostic value of promising factors.

Ethics And Dissemination: Human Research Ethics Committees of Royal Perth Hospital (#RGS0000003024), Curtin University (HRE2019-0209), Ramsay Health Care (#2009) and St John of God Health Care (#1628) have approved this study protocol. Findings will be published in peer-reviewed journals and presented at scientific conferences.

Trial Registration Number: ACTRN12619001226190.
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http://dx.doi.org/10.1136/bmjopen-2020-046460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126315PMC
May 2021

Summer warmth of the past six interglacials on Greenland.

Proc Natl Acad Sci U S A 2021 May;118(20)

Department of Geology, State University of New York at Buffalo, Buffalo, NY 14260.

The relative warmth of mid-to-late Pleistocene interglacials on Greenland has remained unknown, leading to debates about the regional climate forcing that caused past retreat of the Greenland Ice Sheet (GrIS). We analyze the hydrogen isotopic composition of terrestrial biomarkers in Labrador Sea sediments through interglacials of the past 600,000 y to infer millennial-scale summer warmth on southern Greenland. Here, we reconstruct exceptionally warm summers in Marine Isotope Stage (MIS) 5e, concurrent with strong Northern Hemisphere summer insolation. In contrast, "superinterglacial" MIS11 demonstrated only moderate warmth, sustained throughout a prolonged interval of elevated atmospheric carbon dioxide. Strong inferred GrIS retreat during MIS11 relative to MIS5e suggests an indirect relationship between maximum summer temperature and cumulative interglacial mass loss, indicating strong GrIS sensitivity to duration of regional warmth and elevated atmospheric carbon dioxide.
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http://dx.doi.org/10.1073/pnas.2022916118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157949PMC
May 2021

Psychosocial Factors Mediating the Effect of the CHoBI7 Mobile Health Program on Handwashing With Soap and Household Stored Water Quality: A Randomized Controlled Trial.

Health Educ Behav 2021 May 5:1090198120987134. Epub 2021 May 5.

International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.

Household members of diarrhea patients are at higher risk of developing diarrheal diseases (>100 times for cholera) than the general population during the 7 days after the diarrhea patient is admitted at a health facility. There is growing evidence demonstrating that theory-driven water, sanitation, and hygiene (WASH) interventions are likely to yield greater behavior change than those based on health education alone. The Cholera Hospital-Based Intervention for 7-Days (CHoBI7) mobile health (mHealth) program is a theory-driven WASH intervention initially delivered to a diarrhea patient by a health promoter during a health facility visit and reinforced through weekly voice and text messages. In the recent randomized controlled trial (RCT) of the CHoBI7-mHealth program in Bangladesh, this intervention significantly reduced diarrheal disease and stunting, and increased handwashing with soap and stored drinking water quality over the 12-month program period. The aim of this study was to assess the underlying mechanism of change of this intervention. Handwashing with soap was measured by 5-hour structured observation. Stored drinking water quality was assessed by the presence of during unannounced spot checks. Psychosocial factors were measured among 1,468 participants in the CHoBI7-mHealth RCT. Perceived susceptibility, response efficacy, self-efficacy, dirt reactivity, and diarrhea knowledge were mediators of the CHoBI7-mHealth program's effect on stored drinking water quality at the 1-week follow-up. Self-efficacy, response efficacy, and diarrhea knowledge were mediators of the intervention's effect on handwashing with soap habit maintenance and stored drinking water quality at the 12-month follow-up. This study demonstrates how theory-driven approaches for intervention design can facilitate WASH behavior change.
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http://dx.doi.org/10.1177/1090198120987134DOI Listing
May 2021

Plasma neurofilament light in Huntington's disease: A marker for disease onset, but not symptom progression.

Parkinsonism Relat Disord 2021 Jun 28;87:32-38. Epub 2021 Apr 28.

Department of Epidemiology, University of California Irvine, Irvine, CA, USA; Institute for Interdisciplinary Salivary Bioscience Research, University of California Irvine, Irvine, CA, USA. Electronic address:

Objective: To investigate whether plasma NfL levels correlate with clinical symptom severity in premanifest (PM) and manifest HD (HD) individuals, and whether a NfL cut-point could distinguish PM from HD patients with reasonable accuracy.

Method: 98 participants (33 control, 26 PM, 39 HD), underwent blood sample collection and clinical assessment, using both UHDRS and non-UHDRS measures, at one academic HD Center. Years to onset (YTO), probability of disease onset in 5 years, and predicted years until 60% onset probability were also calculated. NfL levels were measured using a Meso Scale Discovery assay.

Results: Cohorts differed by age. NfL levels differed significantly across diagnostic groups and were significantly correlated with age. Age-adjusted NfL levels were not correlated with clinical measures in either HD or PM cohorts, but were correlated when cohorts were combined. In PM subjects, NfL levels correlated with YTO, probability of onset in 5 years, and years until 60% onset probability. Using ROC analysis, a NfL cut-point of <53.15 pg/ml distinguished HD from control; <74.84 pg/ml distinguished HD from PM.

Conclusions: These findings implicate plasma NfL as a peripheral prognostic marker for premanifest-HD. Notably, we show that significant correlations between NfL and clinical symptoms are detected only when PM + HD subjects are combined, but not within HD subjects alone. To date, prior studies have investigated the clinical usefulness of NfL exclusively in merged PM + HD cohorts. Our data suggests a biasing of these previous correlations, and hence potentially limited usefulness of plasma NfL in monitoring HD symptom progression, for example, in clinical trials.
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http://dx.doi.org/10.1016/j.parkreldis.2021.04.017DOI Listing
June 2021

Acetate Induces Growth Arrest in Colon Cancer Cells Through Modulation of Mitochondrial Function.

Front Nutr 2021 15;8:588466. Epub 2021 Apr 15.

Research Centre of Optimal Health, School of Life Sciences, University of Westminster, London, United Kingdom.

Acetate is one of the main short chain fatty acids produced in the colon when fermentable carbohydrates are digested. It has been shown to affect normal metabolism, modulating mitochondrial function, and fatty acid oxidation. Currently, there is no clear consensus regarding the effects of acetate on tumorigenesis and cancer metabolism. Here, we investigate the metabolic effects of acetate on colon cancer. HT29 and HCT116 colon cancer cell lines were treated with acetate and its effect on mitochondrial proliferation, reactive oxygen species, density, permeability transition pore, cellular bioenergetics, gene expression of acetyl-CoA synthetase 1 () and 2 (), and lipid levels were investigated. Acetate was found to reduce proliferation of both cell lines under normoxia as well as reducing glycolysis; it was also found to increase both oxygen consumption and ROS levels. Cell death observed was independent of expression. Under hypoxic conditions, reduced proliferation was maintained in the HT29 cell line but no longer observed in the HCT116 cell line. expression together with cellular lipid levels was increased in both cell lines under hypoxia which may partly protect cells from the anti-proliferative effects of reversed Warburg effect caused by acetate. The findings from this study suggest that effect of acetate on proliferation is a consequence of its impact on mitochondrial metabolism and during normoxia is independent of expression.
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http://dx.doi.org/10.3389/fnut.2021.588466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081909PMC
April 2021

Child Mouthing of Soil and Contaminated Fomites and Unimproved Sanitation are Associated with Subsequent Poor Child Developmental Outcomes in Urban Bangladesh (CHoBI7 Program).

J Pediatr 2021 Aug 23;235:184-189. Epub 2021 Apr 23.

International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.

Objective: To evaluate the relationship between mouthing of soil and living in unsanitary conditions and child cognitive development in urban Bangladesh.

Study Design: This prospective cohort study of 224 children under 5 years of age was conducted in urban Dhaka, Bangladesh. Developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem solving, and combined developmental scores measured by the Extended Ages and Stages Questionnaire (EASQ) at a 12-month follow-up visit.

Results: Children who had caregiver reports of puting soil in their mouths at the majority of surveillance visits had significantly lower combined EASQ Z scores (coefficient, -0.53; 95% CI, -0.83 to -0.22) at the 12-month follow-up visit. Children who had caregiver reports of putting visibly dirty objects in their mouths at the majority of visits had significantly lower combined EASQ Z scores (-0.50; 95% CI, -0.79 to -0.22). Children in households with unimproved sanitation had significantly lower combined EASQ Z scores (-0.63; 95% CI, -1.11 to -0.16).

Conclusions: Children found to frequently put soil and visibly dirty objects in their mouths, and those who resided in households using unimproved sanitation, had lower subsequent cognitive developmental outcomes. These findings demonstrate the importance of interventions targeting child mouthing behaviors and sanitation infrastructure to decrease exposure to fecal pathogens and improve child cognitive developmental outcomes.
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http://dx.doi.org/10.1016/j.jpeds.2021.04.016DOI Listing
August 2021

Beyond rationality: Expanding the practice of shared decision making in modern medicine.

Soc Sci Med 2021 05 3;277:113900. Epub 2021 Apr 3.

Department of Social and Behavioral Sciences, College of Public Health, Temple University, 1101 W. Montgomery Avenue, Philadelphia, PA, 19122, USA. Electronic address:

The contemporary healthcare field operates according to an autonomy model of medical decision-making. This model stipulates that patients have the right to make informed choices about their care. Shared decision making (SDM) has arisen as the dominant approach for clinicians and patients to collaborate in care planning and implementation. This approach relies heavily on normative (rational) decision-making processes, and often leaves out descriptive influences that stem from personal, social, and environmental factors and explain how decisions are typically made in the real world. The lack of attention to descriptive decision-making limits SDM in many ways. A multi-level approach to expanding the practice of SDM is proposed, including tailoring the decision encounter based on patients' social, cultural, and environmental context; using relational elements strategically as part of the SDM process; and modifying incentive models to promote greater attention to descriptive impacts on decision-making. These modifications are expected to make SDM, and thus patient care, more inclusive, effective, and acceptable to diverse patients.
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http://dx.doi.org/10.1016/j.socscimed.2021.113900DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8119352PMC
May 2021

Urine Leak From the Necrotic Lower Pole of a Transplanted Kidney: A Rare Complication in a Pediatric Deceased Donor Kidney Transplant Recipient.

Cureus 2021 Feb 28;13(2):e13613. Epub 2021 Feb 28.

Transplant Surgery, University of Texas Health Science Center at San Antonio, San Antonio, USA.

Kidney transplant patients are prone to a variety of complications, even for the most experienced surgical teams. Our busy transplant center recently performed its 5,000th solid organ transplant. We present the case of an 18-year-old male with end-stage renal disease who underwent a deceased donor kidney transplant. He developed a urine leak from the necrotic lower pole of his graft kidney and subsequently developed urosepsis and was admitted. Clinicians must have a high suspicion for complications in the immediate post-operative period in kidney transplant patients. In this report, we will highlight our diagnostic and treatment steps to preserve the patient's graft while addressing his rare complications.
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http://dx.doi.org/10.7759/cureus.13613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011469PMC
February 2021

Mapping the Ethical Issues of Brain Organoid Research and Application.

AJOB Neurosci 2021 Mar 26:1-14. Epub 2021 Mar 26.

RIKEN Center for Biosystems Dynamics Research, BDR-Otsuka Pharmaceutical Collaboration Center.

In 2008, researchers created human three-dimensional neural tissue - known as the pioneering work of "brain organoids." In recent years, some researchers have transplanted human brain organoids into animal brains for applicational purposes. With these experiments have come many ethical concerns. It is thus an urgent task to clarify what is ethically permissible and impermissible in brain organoid research. This paper seeks (1) to sort out the ethical issues related to brain organoid research and application and (2) to propose future directions for additional ethical consideration and policy debates in the field. Toward (1), this paper first outlines the current state of brain organoid research, and then briefly responds to previously raised related ethical concerns. Looking next at anticipated scientific developments in brain organoid research, we will discuss (i) ethical issues related to in vitro brain organoids, (ii) ethical issues raised when brain organoids form complexes or have relationships with other entities, and (iii) ethical issues of research ethics and governance. Finally, in pursuit of (2), we propose research policies that are mindful of the ethics of brain organoid research and application and also suggest the need for an international framework for research and application of brain organoids.
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http://dx.doi.org/10.1080/21507740.2021.1896603DOI Listing
March 2021

A multimillion-year-old record of Greenland vegetation and glacial history preserved in sediment beneath 1.4 km of ice at Camp Century.

Proc Natl Acad Sci U S A 2021 Mar;118(13)

Keck Carbon Cycle Accelerator Mass Spectrometer Laboratory, Department of Earth System Science, University of California, Irvine, CA 92697-3100.

Understanding the history of the Greenland Ice Sheet (GrIS) is critical for determining its sensitivity to warming and contribution to sea level; however, that history is poorly known before the last interglacial. Most knowledge comes from interpretation of marine sediment, an indirect record of past ice-sheet extent and behavior. Subglacial sediment and rock, retrieved at the base of ice cores, provide terrestrial evidence for GrIS behavior during the Pleistocene. Here, we use multiple methods to determine GrIS history from subglacial sediment at the base of the Camp Century ice core collected in 1966. This material contains a stratigraphic record of glaciation and vegetation in northwestern Greenland spanning the Pleistocene. Enriched stable isotopes of pore-ice suggest precipitation at lower elevations implying ice-sheet absence. Plant macrofossils and biomarkers in the sediment indicate that paleo-ecosystems from previous interglacial periods are preserved beneath the GrIS. Cosmogenic Al/Be and luminescence data bracket the burial of the lower-most sediment between <3.2 ± 0.4 Ma and >0.7 to 1.4 Ma. In the upper-most sediment, cosmogenic Al/Be data require exposure within the last 1.0 ± 0.1 My. The unique subglacial sedimentary record from Camp Century documents at least two episodes of ice-free, vegetated conditions, each followed by glaciation. The lower sediment derives from an Early Pleistocene GrIS advance. Al/Be ratios in the upper-most sediment match those in subglacial bedrock from central Greenland, suggesting similar ice-cover histories across the GrIS. We conclude that the GrIS persisted through much of the Pleistocene but melted and reformed at least once since 1.1 Ma.
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http://dx.doi.org/10.1073/pnas.2021442118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020747PMC
March 2021

Ancient plant DNA reveals High Arctic greening during the Last Interglacial.

Proc Natl Acad Sci U S A 2021 Mar;118(13)

Institute of Arctic and Alpine Research and Department of Geological Sciences, University of Colorado, Boulder, CO 80303.

Summer warming is driving a greening trend across the Arctic, with the potential for large-scale amplification of climate change due to vegetation-related feedbacks [Pearson et al., (3), 673-677 (2013)]. Because observational records are sparse and temporally limited, past episodes of Arctic warming can help elucidate the magnitude of vegetation response to temperature change. The Last Interglacial ([LIG], 129,000 to 116,000 y ago) was the most recent episode of Arctic warming on par with predicted 21st century temperature change [Otto-Bliesner et al., (371), 20130097 (2013) and Post et al., (5), eaaw9883 (2019)]. However, high-latitude terrestrial records from this period are rare, so LIG vegetation distributions are incompletely known. Pollen-based vegetation reconstructions can be biased by long-distance pollen transport, further obscuring the paleoenvironmental record. Here, we present a LIG vegetation record based on ancient DNA in lake sediment and compare it with fossil pollen. Comprehensive plant community reconstructions through the last and current interglacial (the Holocene) on Baffin Island, Arctic Canada, reveal coherent climate-driven community shifts across both interglacials. Peak LIG warmth featured a ∼400-km northward range shift of dwarf birch, a key woody shrub that is again expanding northward. Greening of the High Arctic-documented here by multiple proxies-likely represented a strong positive feedback on high-latitude LIG warming. Authenticated ancient DNA from this lake sediment also extends the useful preservation window for the technique and highlights the utility of combining traditional and molecular approaches for gleaning paleoenvironmental insights to better anticipate a warmer future.
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http://dx.doi.org/10.1073/pnas.2019069118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020792PMC
March 2021

Sex hormones and cognition in aging.

Vitam Horm 2021 17;115:511-533. Epub 2021 Feb 17.

Monash Alfred Psychiatry Research Centre, Monash University Central Clinical School and The Alfred Hospital, Melbourne, VIC, Australia.

Hormones of the hypothalamic-pituitary-gonadal axis that regulate reproductive function are also potent neurosteriods that have multiple effects on the development, maintenance and function of the brain. There is a growing body of evidence linking sex hormones to cognitive functioning across the lifespan. Both subjective and objective cognitive changes can occur with aging. For women, cognitive complains are commonly associated with the menopause transition-a time of significant hormone flux. Sex differences in neurodegenerative conditions associated with cognitive dysfunction, such as Alzheimer's disease and Parkinson's disease, suggest a potential link between sex hormones and cognitive decline. Evidence for the effects of hormone therapy on cognition is growing, but remains inconclusive. This chapter provides an overview of sex hormones and cognition in association with healthy aging, including a focus on the menopause transition, as well as reviewing findings linking sex hormones to cognitive decline associated with Alzheimer's disease and Parkinson's disease. An overview of hormone therapy and cognition is also provided.
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http://dx.doi.org/10.1016/bs.vh.2020.12.020DOI Listing
February 2021

A cross-sectional study reporting concussion exposure, assessment and management in Western Australian general practice.

BMC Fam Pract 2021 03 2;22(1):46. Epub 2021 Mar 2.

Curtin Medical School, Curtin University, Bentley, Australia.

Background: General Practitioners (GPs) may be called upon to assess patients who have sustained a concussion despite limited information being available at this assessment. Information relating to how concussion is actually being assessed and managed in General Practice is scarce. This study aimed to identify characteristics of current Western Australian (WA) GP exposure to patients with concussion, factors associated with GPs' knowledge of concussion, confidence of GPs in diagnosing and managing patients with concussion, typical referral practices and familiarity of GPs with guidelines.

Methods: In this cross-sectional study, GPs in WA were recruited via the RACGP WA newsletter and shareGP and the consented GPs completed an electronic survey. Associations were performed using Chi-squared tests or Fisher's Exact test.

Results: Sixty-six GPs in WA responded to the survey (response rate = 1.7%). Demographics, usual practice, knowledge, confidence, identification of prolonged recovery as well as guideline and resource awareness of GPs who practised in regional and metropolitan areas were comparable (p > 0.05). Characteristics of GPs were similar between those who identified all symptoms of concussion and distractors correctly and those who did not (p > 0.05). However, 84% of the respondents who had never heard of concussion guidelines were less likely to answer all symptoms and distractors correctly (p = 0.039). Whilst 78% of the GPs who were confident in their diagnoses had heard of guidelines (p = 0.029), confidence in managing concussion was not significantly associated with GPs exposure to guidelines. It should be noted that none of the respondents correctly identified signs of concussion and excluded the distractors.

Conclusions: Knowledge surrounding concussion guidelines, diagnosis and management varied across GPs in WA. Promotion of available concussion guidelines may assist GPs who lack confidence in making a diagnosis. The lack of association between GPs exposure to guidelines and confidence managing concussion highlights that concussion management may be an area where GPs could benefit from additional education and support.
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http://dx.doi.org/10.1186/s12875-021-01384-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7927406PMC
March 2021

Formative research for the development of baby water, sanitation, and hygiene interventions for young children in the Democratic Republic of the Congo (REDUCE program).

BMC Public Health 2021 03 1;21(1):427. Epub 2021 Mar 1.

Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5535, Baltimore, MD, 21205-2103, USA.

Background: Research exploring the unique exposure pathways to fecal pathogens for young children and innovative water, sanitation, and hygiene (WASH) interventions for susceptible pediatric populations is needed to reduce the burden of diarrheal diseases and stunting globally. The Reducing Enteropathy, Diarrhea, Undernutrition, and Contamination in the Environment (REDUCE) program seeks to 1) identify exposure pathways to fecal pathogens that are significant contributors to morbidity for young children in South Kivu, Democratic Republic of the Congo, and 2) develop and evaluate scalable interventions that reduce fecal contamination and exposure from these pathways. The formative research portion of the project sought to identify feasible and acceptable WASH interventions to modify behaviors found to be associated with diarrheal disease and impaired growth in our REDUCE cohort study.

Methods: Ninety-one semi-structured interviews, 6 focus group discussions, and a pilot study of 102 households were conducted during 24 months of formative research. Thirty-one interviews and six focus group discussions were conducted with caregivers, community health workers, and village leaders to explore existing WASH practices and to identify barriers and facilitators to WASH behaviors. Findings were organized using the Integrated Behavioral Model for Water, Sanitation and Hygiene to facilitate interpretation and identify determinants to Baby WASH behaviors in this setting. Care Group modules and enabling technology were developed based on exploratory findings and then revised during a two-part, iterative pilot study. Sixty interviews were conducted with participants in a pilot study of the REDUCE Baby WASH Care Group modules to learn about their experiences with the intervention.

Results: Six REDUCE Baby WASH Care Group modules were developed based on formative research findings and covered the following topics: 1) living with animals; 2) child mouthing of fomites and feces; 3) composting animal feces; 4) child feces disposal; 5) handwashing with soap; and 6) water treatment.

Conclusion: This study took a theory-driven and evidence-based approach to formative research and the development of the REDUCE Baby WASH Care Group modules. Intervention design focused on interrupting the exposure routes for infants and young children to fecal pathogens in the environment and promoting low-cost, low-burden Baby WASH behavioral recommendations and enabling technology. These developed REDUCE Baby WASH Care Group modules are currently being rolled out to over 1,000,000 beneficiaries in Democratic Republic of the Congo.
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http://dx.doi.org/10.1186/s12889-021-10246-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923459PMC
March 2021

Serum estradiol as a blood-based biomarker predicting hormonal treatment outcomes in women with schizophrenia.

Psychoneuroendocrinology 2021 Apr 10;126:105165. Epub 2021 Feb 10.

Monash Alfred Psychiatry Research Centre, Monash University, 4/607 St Kilda Rd, Melbourne 3004, VIC, Australia.

Patients diagnosed with schizophrenia display substantial heterogeneity in terms of their clinical presentations, and treatment response. Accumulating research suggests that such high diversity may reflect distinct biological subtypes with differentially affected underlying neurobiology. Novel treatments, including sex hormone estradiol treatments, provide alternative efficacious treatment avenues but also should be studied within the context of potential heterogeneity. This repeated-measures study characterised the association between hormone levels (estrogen, progesterone, testosterone, prolactin, FSH, LH, DHEA) and symptom treatment outcomes (defined by The Positive and Negative Syndrome Scale (PANSS)) across a 56-day study of 200 ug adjunctive estradiol treatment in women with schizophrenia. Group-based trajectory models was used to account for potential heterogeneity (subgroups). Receiver operating characteristic (ROC) curves were evaluated to define the predictive value of endogenous estradiol levels as a treatment-response biomarker of estradiol treatment. The results generated two subgroups; a treatment-responder group who demonstrated decreasing PANSS scores across time, and a treatment non-responder group, demonstrating stable PANSS scores across time. The treatment-responder subgroup was significantly negatively predicted by estradiol blood level (b= -2.34, SE= 1.17, p = 0.047), while FSH blood level was positively associated with the treatment non-responders (b= 7.14, SE= 2.54, p = 0.008). ROC for day 28, 56 time points yielded area under the curve of 0.52 and 0.55, respectively. Harrell's C-statistic = 0.59. This is the first study to identify endocrine markers in blood serum predicting response to estradiol treatment in female schizophrenia patients, highlighting the existence of heterogeneity of response, indicative of molecular subtypes. Characterising the differential underlying biology of the subgroups may lead to better targeted, specific treatments in the future.(ClinicalTrials.gov Identifier: NCT00357006). https://www.clinicaltrials.gov/ct2/show/NCT00357006.
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http://dx.doi.org/10.1016/j.psyneuen.2021.105165DOI Listing
April 2021

Treatment decision-making needs among emerging adults with early psychosis.

Early Interv Psychiatry 2021 Feb 17. Epub 2021 Feb 17.

College of Public Health, Temple University, Philadelphia, Pennsylvania, USA.

Aim: Many emerging adults disengage from early intervention in psychosis (EIP) services prematurely. Service disengagement may be in part due to having unresolved treatment decision-making needs about use of mental health services. A basic understanding of the decision-making needs of this population is lacking. The purpose of this qualitative study was to identify the range of treatment decisions that emerging adults face during their initial engagement in an EIP program and elucidate barriers and facilitators to decision-making.

Methods: Twenty emerging adults with early psychosis were administered semistructured interviews to capture treatment decision-making experiences during the first six months after enrolment in an EIP program. Interviews were audio-recorded and transcribed verbatim. Responses were independently coded by two authors using an integrated thematic analysis approach; differences in coding were discussed to consensus. Data analysis was facilitated using NVivo 12 Plus.

Results: Emerging adults identified numerous decisions faced after EIP enrolment. Decisions pertaining to life and treatment goals and to starting and continuing psychiatric medication were commonly selected as the most difficult/complicated. Decision-making barriers included not having the right amount or type of information/knowledge, social factors (e.g., lacking social support, opposition/pressure), lacking internal resources (e.g., cognitive and communication skills, self-efficacy, motivation) and unappealing options. Obtaining information/knowledge, social supports (e.g., connection/trust, learning from others' experiences, encouragement), considering personal values, and time were decision-making facilitators.

Conclusions: This study informs development and optimization of interventions to support decision-making among emerging adults with early psychosis, which may promote service engagement.
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http://dx.doi.org/10.1111/eip.13134DOI Listing
February 2021

Diclofenac in adolescents: diagnosing and treating gastrointestinal adverse drug reactions can prevent future deaths.

BMJ Evid Based Med 2021 Feb 10. Epub 2021 Feb 10.

Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.

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http://dx.doi.org/10.1136/bmjebm-2020-111640DOI Listing
February 2021

Educator Perspectives on Data-Based Decision Making in Germany and the United States.

J Learn Disabil 2021 Jul 20;54(4):284-299. Epub 2021 Jan 20.

University of Missouri, Columbia, USA.

The purpose of this explorative study was to examine the use and understanding of key components of data-based decision making by educators in two countries-Germany and the United States. Educators responded to a survey that asked about data use and characteristics related to data-based decision making (DBDM). Results suggest educators in both countries are focused on using data to monitor progress, although less so in Germany. Educators in both countries noted similar understanding of important features (e.g., psychometric properties) of data. Educators in the United States reported they used data for decision making at the classroom level almost twice as often as their counterparts in Germany, while German educators focused on decision making at the student level. These findings will influence future research, including joint studies that could use the best practices of both countries, and professional learning opportunities for educators in Germany and the United States.
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http://dx.doi.org/10.1177/0022219420986120DOI Listing
July 2021

Efficacy of Clorpactin in refractory bladder pain syndrome/interstitial cystitis: a randomized controlled trial.

Int Urogynecol J 2021 May 16;32(5):1177-1183. Epub 2021 Jan 16.

Mercy Hospital for Women, Melbourne, Australia.

Introduction: Clorpactin is an antibacterial agent with limited evidence for its use as instillation therapy in patients with bladder pain syndrome/interstitial cystitis (BPS/IC). This was a multi-centre, single-blinded randomized controlled trial to investigate whether Clorpactin instillation results in symptom improvement in patients with refractory BPS/IC.

Methods: Fifty women with refractory BPS/IC were randomized to undergo cystoscopy/hydrodistension (25) or instillation of Clorpactin 0.4% solution (25) under general anaesthesia. Primary outcome was based on Global Response Assessment (GRA) at 3 months; secondary outcomes were based on O'Leary Sant Symptom (OLSI) and Problem (OLPI) questionnaire scores, visual analogue scale (VAS) score for pain and bladder diary parameters.

Results: Complete follow-up data were available on 22 in the hydrodistension group and 16 in the Clorpactin group. GRA improvement was 4.5% for hydrodistension and 56% for Clorpactin (p = 0.001) at 3 months. Reduction in mean total scores for OLSI (14.1 to 9.1; p = 0.004) and OLPI (12.6 to 7.4; p = 0.001) was seen in the Clorpactin group only. VAS pain scores were reduced in the Clorpactin group only (7.4 to 3.3; p < 0.001). Post-treatment VAS pain scores did not differ between groups although 6/25 (24%) women in the Clorpactin group required admission for pain compared to 1/25 (4%) in the hydrodistension group.

Conclusions: Clorpactin treatment results in significant improvement in BPS/IC symptoms, bother and pain based on the GRA, OLSI/OLPI and VAS pain scores at 3 months post-treatment compared to cystoscopy/hydrodistension. These conclusions are limited by the high loss to follow-up in both groups.
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http://dx.doi.org/10.1007/s00192-020-04652-3DOI Listing
May 2021

Evaluating the feasibility of a decision aid to promote shared decision making among young adults with first-episode psychosis: protocol for a pilot study.

Pilot Feasibility Stud 2021 Jan 11;7(1):22. Epub 2021 Jan 11.

Department of Social and Behavioral Science, College of Public Health, Temple University, Philadelphia, PA, USA.

Background: Young adults ages 18 to 25 with first episode psychosis (FEP) have an increased risk of discontinuation antipsychotic medications and psychiatric service disengagement that lead to symptom exacerbation and deterioration. We seek to (1) examine the feasibility, usability, and potential impact of a Shared Decision Making (SDM) Antipsychotic Medication Decision Aid (DA) on decision-making, adherence to the decision made, and service engagement among young adults with FEP and (2) understand the role of additional patient-level factors on SDM.

Methods: A randomized controlled trial is being conducted in a coordinated specialty care community program for FEP in an urban setting. Eligible patients are randomly assigned to receive an intervention, the Antipsychotic Medication Decision Aid, or treatment as usual. Patients receive their assigned intervention before their medication appointment with the psychiatrist and complete four interviews: before the appointment (T0), after the appointment (T1), and at 3- and 6-month follow-ups (T2 and T3). The study staff and participating psychiatrists are not blinded to the intervention. The data are de-identified to maintain blinding during the analysis process. The primary aims are feasibility of intervention delivery and research procedures and preliminary impact of the intervention on SDM-related outcomes, medication adherence, and service engagement. As a secondary aim, we will explore the contribution of personality and motivation variables, clinical relationships, cognitive functioning, and mental-health-related stigma to SDM. If the sample size permits, we plan to conduct parametric tests such as independent-samples t tests at T1 to compare differences in SDM, adherence, and engagement scales. In the case of a small sample size, we will use non-parametric tests and descriptive statistics.

Discussion: This protocol outlines the methodology for a feasibility pilot comparing the effect of a novel SDM Antipsychotic Medication encounter DA with treatment as usual on SDM, medication adherence, and service engagement in FEP care. SDM is endorsed as a framework for use in FEP and antipsychotic pharmacotherapy, but its impact on adherence and health outcomes is unclear. Understanding the potential contribution of an SDM Antipsychotic Medication DA compared with usual care in psychosis pharmacotherapy is critical. The study will help answer several key questions new to SDM research, including the contribution of personality and clinical relationships to SDM in mental health and psychosis in particular. The study will serve to gather feasibility data to inform future studies and scale-up.

Trial Registration: Ethics approval was obtained through Temple University's institutional review board (IRB) and the City of Philadelphia's Department of Public Health IRB. The study has been retrospectively registered with ClinicalTrials.gov as NCT04373590 on 29 April 2020. https://clinicaltrials.gov/ct2/show/NCT04373590?term=NCT04373590&draw=2&rank=1.
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http://dx.doi.org/10.1186/s40814-020-00757-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798319PMC
January 2021
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