Publications by authors named "Emily Wright"

102 Publications

The gut microbiota and gut disease.

Intern Med J 2021 Oct;51(10):1594-1604

Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia.

The gut microbiota has a key role in the maintenance of good health, and in the pathogenesis of gastrointestinal diseases. These conditions include the inflammatory bowel diseases, colorectal cancer, coeliac disease and metabolic liver disease. Although the nature of the microbial disturbance in these conditions has not been fully characterised, this has not prevented the development of microbially based therapies. Microbial-changing therapies may address newly recognised pathophysiological contributors of disease and have the potential to replace or supplement standard therapies. Antibiotics play a role in initial Clostridiodes difficile disease and some specific inflammatory disorders. Probiotics have a more limited proven role. Faecal microbiota transplantation is of proven therapeutic benefit in recurrent C. difficile disease and ulcerative colitis. We review the current literature for microbiota-targeted therapies in gut disorders.
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http://dx.doi.org/10.1111/imj.15520DOI Listing
October 2021

Development of a Prognostic Awareness Impact Scale for Patients with Advanced Cancer.

J Palliat Med 2021 Oct 11. Epub 2021 Oct 11.

Massachusetts General Hospital, Boston, Massachusetts, USA.

No reliable instruments exist to measure prognostic awareness and its psychological and behavioral impacts for patients with advanced cancer. We developed the Prognostic Awareness Impact Scale (PAIS) using a qualitative approach. During phase 1, we convened a working group with a transdisciplinary team of clinicians from oncology ( = 2), psychology ( = 2), psychiatry ( = 1), palliative care ( = 3), and survey development ( = 1) to identify key domains of PAIS. Using a consensus-driven process, the team generated an item bank for each domain. During phase 2, we conducted cognitive interviews with 39 patients with advanced cancer to assess the understandability of the PAIS. The working group developed a conceptual framework for PAIS, identifying three domains: (1) cognitive understanding of prognosis (capacity to understand intellectually one's prognosis), (2) emotional coping (capacity to process prognostic uncertainty and terminal prognosis), and (3) adaptive response (capacity to use prognostic awareness to inform life decisions). Cognitive interviews revealed that patients had an accurate understanding of most PAIS items. Patients reported difficulty with binary response options for questions pertaining to emotional coping. They expressed difficulty answering numerous questions regarding their cognitive understanding of their prognosis. We revised the PAIS by (1) replacing binary response options with ordinal agreement scales; and (2) reducing the number of items focused on cognitive understanding of prognosis. We developed a conceptual framework to capture prognostic awareness and its psychological and behavioral impacts for patients with advanced cancer using the PAIS. Future work should focus on validating the PAIS by testing its psychometric properties.
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http://dx.doi.org/10.1089/jpm.2021.0238DOI Listing
October 2021

Interventions to Improve Adherence to Preventive Care in Inflammatory Bowel Disease: A Systematic Review.

Inflamm Bowel Dis 2021 Oct 7. Epub 2021 Oct 7.

Department of Gastroenterology, St. Vincent's Hospital Melbourne, Melbourne, Australia.

Background: Preventive health measures reduce treatment and disease-related complications including infections, osteoporosis, and malignancies in patients with inflammatory bowel disease (IBD). Although guidelines and quality measures for IBD care highlight the importance of preventive care, their uptake remains variable. This systematic review evaluates interventions aimed at improving the rates of provision and uptake of preventive health measures, including vaccinations, bone density assessment, skin cancer screening, cervical cancer screening, and smoking cessation counseling.

Methods: We searched PubMed, MEDLINE, EMBASE, and CENTRAL for full text articles published until March 2021. Studies were included if they evaluated interventions to improve the provision or uptake of 1 or more preventive health measures in adult IBD patients and if they reported pre- and postintervention outcomes.

Results: In all, 4655 studies were screened, and a total of 17 studies were included, including 1 randomized controlled trial, 1 cluster-controlled trial, and 15 prospective interventional studies. A variety of interventions were effective in improving the rates of adherence to preventive health measures. The most common interventions targeted gastroenterologists, including education, electronic medical records tools, and audit feedback. Other interventions targeted patients, such as education, questionnaires, and offering vaccine administration at clinic visits. Few interventions involved IBD nurses or primary care physicians.

Conclusions: A range of interventions-targeted at gastroenterologists, patients, or both-were effective in improving the provision and uptake of preventive care. Future studies should involve randomized controlled trials evaluating multifaceted interventions that target barriers to adherence and involve IBD nurses and primary care physicians.
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http://dx.doi.org/10.1093/ibd/izab247DOI Listing
October 2021

Enriched laboratory housing increases sensitivity to social stress in female California mice ().

Appl Anim Behav Sci 2021 Aug 29;241. Epub 2021 Jun 29.

Department of Psychology, University of California Davis, CA 95616.

Domesticated mice and rats have shown to be powerful model systems for biomedical research, but there are cases in which the biology of species is a poor match for the hypotheses under study. The California mouse () has unique traits that make it an ideal model for studying biological mechanisms underlying human-relevant behaviors such as intra-female aggression, biparental care, and monogamy. Indeed, peer-reviewed scientific publications using California mouse as a model for behavioral research have more than doubled in the past decade. Critically, behavioral outcomes in captive animals can be profoundly affected by housing conditions, but there is very limited knowledge regarding species-specific housing needs in California mice. Currently, California mouse investigators have to rely on guidelines aimed for more common laboratory species that show vastly different physiology, behavior, and/or ecological niche. This not only could be suboptimal for animals' welfare, but also result in lack of standardization that could potentially compromise experimental reproducibility and replicability across laboratories. With the aim of assessing how different housing systems can affect California mouse behavior both in the home cage as well as the open field and social interaction tests before and after social defeat stress, here we tested three different caging systems: 1. Standard mouse cage, 2. Large cage, and 3. Large cage + environmental enrichment (EE), which focused on increasing vertical complexity based on observations that California mice are semiarboreal in the wild. We found that the effects of housing were largely sex specific: compared to standard cages, in females large + EE reduced home cage stereotypic-like backflipping and rearing behaviors, while large cage increased social interactions. In males, the large+EE cage reduced rearing and digging but did not significantly affect backflipping behavior. Interestingly, while there were no significant differences in the open field and social interaction pre-stress behaviors, large and large+EE housing increased the sensitivity of these tests to detect stress induced phenotypes in females. Together, these results suggest that increasing social and environmental complexity affects home cage behaviors in male and female California mice without interfering with, but rather increasing the magnitude of, the effects of defeat stress on the open field and social interaction tests.
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http://dx.doi.org/10.1016/j.applanim.2021.105381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8345022PMC
August 2021

Ictal asystole: an uncommon but significant cause of transient loss of consciousness-a case series.

BMJ Case Rep 2021 Jul 20;14(7). Epub 2021 Jul 20.

Department of Medicine for the Elderly, Queen Elizabeth University Hospital Campus, Glasgow, UK.

Ictal bradycardia and asystole are rare, but potentially serious complications of epileptic seizures. We present a case series of three such patients diagnosed through our syncope service. For two patients, treatment with anticonvulsant therapy alone achieved symptom control. The third patient was initially managed with permanent pacemaker insertion due to detection of a significant ventricular pause. He subsequently developed more pronounced symptoms suggestive of seizure.Ictal asystole can cause significant diagnostic challenge and management strategies remain controversial due to the overlap in presentation to cardiology and neurology services. The number of patients affected is low, impeding the formulation of an evidence base for treatment. We propose multidisciplinary working facilitated by a specialist syncope service as a means of recognising and treating this condition more effectively.
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http://dx.doi.org/10.1136/bcr-2020-240268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8292728PMC
July 2021

Telehealth model of care for outpatient inflammatory bowel disease care in the setting of the COVID-19 pandemic.

Intern Med J 2021 07;51(7):1038-1042

Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.

Background: Advances in inflammatory bowel disease (IBD) monitoring, greater number of available treatments and a shift towards tight disease control, IBD care has become more dynamic with regular follow ups.

Aims: We assessed the impacts of the COVID-19 pandemic on outpatient IBD patient care at a tertiary centre in Melbourne. More specifically, we assessed patient satisfaction with a telehealth model of care, failure to attend rates at IBD clinics and work absenteeism prior to and during the pandemic.

Methods: We conducted a retrospective, qualitative analysis to assess our aims through an online survey. We invited patients who attended an IBD outpatient clinic from April to June 2020 to participate. This study was conducted at a single, tertiary referral hospital in Melbourne. The key data points that we analysed were patient satisfaction with a telehealth model of care and the effect of telehealth clinics on work absenteeism.

Results: One hundred and nineteen (88.1%) patients were 'satisfied' or 'very satisfied' with the care received in the telehealth clinic. Eighty-four (60.4%) patients reported needing to take time off work to attend a face-to-face appointment, compared to 29 (20.9%) patients who needed to take time off work to attend telehealth appointments (P < 0.001). Clinic non-attendance rates were similar prior to and during the pandemic with rates of 11.4% and 10.4% respectively (P = 0.840).

Conclusions: Patients report high levels of satisfaction with a telehealth model of care during the COVID-19 pandemic, with clinic attendance rates not being affected. Telehealth appointments significantly reduced work absenteeism when compared to traditional face-to-face clinics.
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http://dx.doi.org/10.1111/imj.15168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8444910PMC
July 2021

Quick Response codes for virtual learner evaluation of teaching and attendance monitoring.

Can Med Educ J 2021 Jun 30;12(3):169-170. Epub 2021 Jun 30.

Hinchingbrooke Hospital, North West Anglia NHS Trust, Huntingdon, UK.

Implication Statement Monitoring attendance and obtaining timely learner evaluations for virtual teaching sessions can be challenging. At our Obstetrics and Gynecology webinar programme, we have utilised Quick Response (QR) codes this purpose. Following each session, attendees scan an on-screen QR code which links to an online evaluation form and registers their attendance. Feedback can therefore be obtained quickly, is scalable to large participant numbers and is securely stored in digital format. QR reader applications are widely available and cost-free, which makes this technique accessible for learners. Using QR codes for teaching evaluation is simple and could be adopted across many educational applications. Énoncé des implications de la recherche Contrôler la présence des étudiants aux cours en ligne et obtenir en temps utile leur évaluation des séances d'enseignement virtuelles peut constituer un défi. Dans notre programme de webinaires en obstétrique et gynécologie, nous le faisons à l'aide de codes de réponse rapide (codes QR). Après chaque séance, les participants scannent un code QR qui apparaît sur leur écran; la lecture du code permet de confirmer leur présence et renvoie à un formulaire d'évaluation en ligne. Ce mécanisme rend possible la rétroaction rapide, la participation d'un grand nombre de personnes et la conservation sécuritaire de l'information en format numérique. Les applications de lecture de codes QR sont largement disponibles et gratuites, et donc accessibles aux étudiants. L'utilisation des codes QR pour évaluer les cours est simple et elle peut être intégrée dans de nombreuses applications éducatives.
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http://dx.doi.org/10.36834/cmej.71708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263033PMC
June 2021

Fecal microbiota transplantation therapy in Crohn's disease: Systematic review.

J Gastroenterol Hepatol 2021 Oct 6;36(10):2672-2686. Epub 2021 Jul 6.

Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia.

Background: The gastrointestinal microbiota is the key antigenic drive in the inflammatory bowel diseases. Randomized controlled trials (RCTs) in ulcerative colitis have established fecal microbiota transplantation (FMT) as an effective therapy. We have conducted a systematic review to evaluate the efficacy of FMT in Crohn's disease.

Methods: A systematic literature search was performed through to August 2020 (MEDLINE; Embase). Studies were included if they reported FMT administration in patients with Crohn's disease, and reported on clinical outcomes.

Results: Fifteen studies published between 2014 and 2020, comprising 13 cohort studies and two RCTs, were included in the analysis. The majority of trials evaluated FMT for induction of remission, with follow-up duration varying from 4 to 52 weeks. One RCT in 21 patients, of single-dose FMT versus placebo, following steroid-induced remission, showed a higher rate of steroid-free clinical remission in the FMT group compared to the control group: 87.5% vs 44.4% at week 10 (P = 0.23). Another RCT, two-dose FMT in 31 patients, showed an overall clinical remission rate of 36% at week 8, however, with no difference in clinical or endoscopic endpoints between FMT administered by gastroscopy and colonoscopy. Considering all studies, the clinical response rates in early follow up were higher following multiple FMT than with single FMT. FMT dose did not appear to influence clinical outcomes, nor did whether FMT was fresh or frozen. FMT delivered via upper gastrointestinal route demonstrated higher early efficacy rates of 75 to 100% compared with lower delivery route rates of 30% to 58%, but on follow up beyond 8 weeks, this difference was not maintained. Whether pre-FMT antibiotic administration was beneficial was not able to be determined due to the limited number of patients receiving antibiotics and varying antibiotic regimens. No serious adverse events were reported.

Conclusions: Preliminary studies suggest that FMT may be an effective therapy in Crohn's disease. However large controlled trials are needed. No serious safety concerns have been identified.
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http://dx.doi.org/10.1111/jgh.15598DOI Listing
October 2021

Systematic review: efficacy of escalated maintenance anti-tumour necrosis factor therapy in Crohn's disease.

Aliment Pharmacol Ther 2021 08 21;54(3):249-266. Epub 2021 Jun 21.

Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, The University of Melbourne, Melbourne, Vic., Australia.

Background: Loss of response to anti-TNF agents is a common clinical problem. Dose escalation may be effective for reestablishing clinical response in Crohn's disease (CD).

Aims: To perform a systematic review assessing the efficacy of escalated maintenance anti-TNF therapy in CD.

Methods: EMBASE, MEDLINE, Web of Science, and CENTRAL databases were searched for English language publications through to April 25, 2021. Full-text articles evaluating escalated maintenance treatment (infliximab or adalimumab) in adult CD patients were included.

Results: A total of 4733 records were identified, and 68 articles met eligibility criteria. Rates of clinical response (33%-100%) and remission (15%-83%) after empiric dose escalation for loss of response to standard anti-TNF therapy were high but varied across studies. Dose intensification strategies (doubling the dose versus shortening the therapeutic interval) were similarly efficacious. Dose-escalated patients tended to have higher serum drug levels compared to those on standard dosing. An exposure-response relationship following dose escalation was found in a number of observational studies. Randomised controlled trials comparing therapeutic drug monitoring (TDM) to empiric treatment intensification have failed to reach their primary end-points. Strategies including Bayesian dashboard-dosing and early treatment escalation targeting biomarker normalisation were found to be associated with improved long-term outcomes.

Conclusions: Empiric escalation of maintenance anti-TNF therapy can recapture clinical response in a majority of patients with secondary loss of response to standard maintenance doses. Proactive optimisation of maintenance dosing might prolong time to loss of response in some patients.
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http://dx.doi.org/10.1111/apt.16479DOI Listing
August 2021

Characterization of the prion protein gene in axis deer () and implications for susceptibility to chronic wasting disease.

Prion 2021 12;15(1):44-52

Department of Natural Resources Management, Texas Tech University,Lubbock, TX USA.

Axis deer () occur both in captivity and free-ranging populations in portions of North America, but to-date, no data exist pertaining to the species' susceptibility to CWD. We sequenced the prion protein gene () from axis deer. We then compared axis deer PrP sequences and amino acid polymorphisms to those of CWD susceptible species. A single allele with no evidence of intraspecies variation was identified in axis deer that indicates axis deer is most similar to North American elk () . Therefore, axis deer may be susceptible to CWD. We recommend proactively increasing CWD surveillance for axis deer, particularly where CWD has been detected and axis deer are sympatric with native North American CWD susceptible species.
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http://dx.doi.org/10.1080/19336896.2021.1910177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043172PMC
December 2021

Non-invasive biomarkers as treatment targets: What do we all need to know?

Authors:
Emily Wright

J Gastroenterol Hepatol 2021 Apr;36 Suppl 1:12-13

St Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/jgh.15449DOI Listing
April 2021

A Single Educational Intervention Improves Pregnancy-Related Knowledge and Emotional Health Among Women With IBD Who Are Pregnant or Wish to Conceive.

Inflamm Bowel Dis 2021 Mar 11. Epub 2021 Mar 11.

Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.

Background: There is considerable interest in improving the education and care of women with inflammatory bowel disease (IBD) to improve pregnancy outcomes. Despite increased awareness, not all women with IBD have access to pregnancy-related education and the quality of counseling is variable. We aimed to assess the effectiveness of a simple educational intervention for improving pregnancy-related knowledge and to evaluate the effect of education on patient outcomes including anxiety, depression, and quality of life in women with IBD.

Methods: This prospective study of women with IBD who were pregnant or planning a pregnancy evaluated the effectiveness of a single gastroenterologist-led educational intervention in improving pregnancy-related knowledge, measured using the Crohn's and Colitis Pregnancy Knowledge score 1 month postintervention. Secondary outcomes included the effect on anxiety and depression, quality of life, medication adherence, and patient satisfaction.

Results: One hundred women with IBD were recruited. Fifty percent were pregnant at the time of the intervention. Baseline knowledge scores were similar independent of the patients' pregnancy status or whether they had previously received counseling from their gastroenterologist. Median Crohn's and Colitis Pregnancy Knowledge scores postintervention (n = 82) were higher than preintervention scores (14/17 vs 10/17; P < 0.001). In addition, 32% of patients had poor knowledge at baseline (score ≤7/17), compared to only 5% after the intervention (P < 0.001). There was a significant improvement in total anxiety and depression and quality of life scores postintervention. Medication adherence and patient satisfaction were excellent.

Conclusions: Uptake of this gastroenterologist-led educational intervention has the potential to improve pregnancy knowledge, promote medication adherence, and enhance quality of life for women with IBD globally.
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http://dx.doi.org/10.1093/ibd/izab021DOI Listing
March 2021

Standardisation of intestinal ultrasound scoring in clinical trials for luminal Crohn's disease.

Aliment Pharmacol Ther 2021 04 28;53(8):873-886. Epub 2021 Feb 28.

Calgary, AB, Canada.

Background: Intestinal ultrasound (IUS) is a valuable tool for assessment of Crohn's disease (CD). However, there is no widely accepted luminal disease activity index.

Aims: To identify appropriate IUS protocols, indices, items, and scoring methods for measurement of luminal CD activity and integration of IUS in CD clinical trials.

Methods: An expert international panel of adult and paediatric gastroenterologists (n = 15) and radiologists (n = 3) rated the appropriateness of 120 statements derived from literature review and expert opinion (scale of 1-9) using modified RAND/UCLA methodology. Median panel scores of 1 to ≤3.5, >3.5 to <6.5 and ≥6.5 to 9 were considered inappropriate, uncertain and appropriate ratings respectively. The statement list and survey results were discussed prior to voting.

Results: A total of 91 statements were rated appropriate with agreement after two rounds of voting. Items considered appropriate measures of disease activity were bowel wall thickness (BWT), vascularity, stratification and mesenteric inflammatory fat. There was uncertainty if any of the existing IUS disease activity indices were appropriate for use in CD clinical trials. Appropriate trial applications for IUS included patient recruitment qualification when diseased segments cannot be adequately assessed by ileocolonoscopy and screening for exclusionary complications. At outcome assessment, remission endpoints including BWT and vascularity, with or without mesenteric inflammatory fat, were considered appropriate. Components of an ideal IUS disease activity index were identified based upon panel discussions.

Conclusions: The panel identified appropriate component items and applications of IUS for CD clinical trials. Empiric evidence, and development and validation of an IUS disease activity index are needed.
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http://dx.doi.org/10.1111/apt.16288DOI Listing
April 2021

Maternal thiopurine metabolism during pregnancy in inflammatory bowel disease and clearance of thiopurine metabolites and outcomes in exposed neonates.

Aliment Pharmacol Ther 2021 04 19;53(7):810-820. Epub 2021 Feb 19.

Melbourne, Vic., Australia.

Background: Azathioprine and mercaptopurine are considered safe during pregnancy. However, the pharmacokinetic effects of pregnancy on thiopurine metabolism are undefined.

Aims: To characterise thiopurine metabolism in pregnancy and measure infant metabolite levels and outcomes.

Methods: Women with IBD who were taking a thiopurine and pregnant or trying to conceive were recruited. Maternal thiopurine metabolites were measured pre-conception, in each trimester, at delivery and post-partum. Infant metabolite levels, full blood examination and liver function testing were performed at birth, and repeated until levels undetectable and haematological and biochemical abnormalities resolved.

Results: Forty patients were included with measurements on at least two occasions, and two with only mother-baby levels at delivery. The median maternal 6-TGN level dropped in the second trimester compared with post-partum (179.0 vs 323.5 pmol/8 × 10 RBCs, P < 0.001) and the median 6-MMP level increased in the second trimester compared with post-partum (1103.0 vs 329.5 pmol/8 × 10 RBCs, P < 0.01). At delivery, the median 6-TGN level was lower in infants (n = 20) than mothers (78.5 vs 217 pmol/8 × 10 RBCs) (P < 0.001). Metabolites were not detected at 6 weeks in any infants. Anaemia was not seen, but thrombocytosis and abnormal liver biochemistry were detected in 80% of infants from 6 weeks, which gradually improved.

Conclusions: 6-TGN levels decrease and 6-MMP levels increase in the second trimester of pregnancy. Infants are exposed to thiopurine metabolites at low levels with clearance by 6 weeks and no anaemia. The cause of infant thrombocytosis and abnormal liver biochemistry in the absence of metabolites is unclear.
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http://dx.doi.org/10.1111/apt.16294DOI Listing
April 2021

Long-term outcomes of perianal fistulizing Crohn's disease in the biologic era.

JGH Open 2021 Feb 20;5(2):235-241. Epub 2020 Dec 20.

Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.

Background And Aim: While the advent of biologic therapy has led to improved outcomes in perianal fistulizing Crohn's disease (pfCD), loss of response is common. Previous studies suggest that patients who achieve radiological healing (with healing of underlying tracts on magnetic resonance imaging [MRI]) have a longer duration of response. The aim of this study was to characterize MRI outcomes of pfCD at a specialist inflammatory bowel disease (IBD) unit and compare the long-term clinical outcomes between patients achieving MRI and clinical healing.

Methods: A retrospective analysis of perianal fistulizing Crohn's patients treated at one specialist IBD unit was performed. Records were reviewed for patient demographics, disease history, clinical assessments, investigation results, and disease flares. Clinical remission was defined as closure of all baseline fistula openings. Radiological healing was defined as the absence of any T2-hyperintense sinuses, tracts, or collections. The primary end-point was rate of MRI healing. The secondary outcome was defined as flare-free period (time between clinical or radiological healing and patients' first signs/symptoms requiring therapy escalation).

Results: A total of 93 patients were included, with a median follow-up of 4.8 years (interquartile range, 2.4-6 years). Of 44 patients, 22 (50%) achieved clinical remission, while 15 of 93 (16%) achieved radiological healing. Of 22 patients, 10 (45%) with clinical remission had a subsequent disease flare (median time of 7 months) compared with 3 of 15 (20%) patients with MRI healing (median time of 3.6 years). Radiological healing was associated with a significantly longer flare-free period ( = 0.01).

Conclusion: Radiological healing occurs less commonly but represents a deeper form of healing, associated with improved long-term clinical outcomes.
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http://dx.doi.org/10.1002/jgh3.12475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857282PMC
February 2021

The influence of adverse childhood experiences on internalizing and externalizing problems in early adulthood: Evidence of a gene × environment × sex interaction.

Child Abuse Negl 2021 04 3;114:104962. Epub 2021 Feb 3.

College of Criminology and Criminal Justice, Florida State University, 145 Convocation Way, 315 Eppes Hall, Tallahassee, FL, 32306-1273, USA; Center for Social and Humanities Research, King Abdulaziz University, Jeddah, Saudi Arabia. Electronic address:

Background: Although adverse childhood experiences (ACEs) have negative effects on subsequent wellbeing, questions remain regarding how and why they do so. Sex, environmental effects, and genetic influences may play a role in both one's exposure to ACEs as well as one's reactions to ACEs.

Objective: To understand the combined genetic and environmental influences on males' and females' exposure and reactions to ACEs, and to determine whether sex differences in offending and depressive symptoms were partially impacted by genetic influences.

Methods: We employed a sample of monozygotic twins (n = 217 pairs), same-sex dizygotic twins (n = 185 pairs), and same-sex full siblings (n = 446 pairs) from the National Longitudinal Study of Adolescent to Adult Health (N = 848 pairs) and estimated a series of multivariable biometric models. Participants were aged between 12 and 21 during Wave I, between 13 and 22 at Wave II, between 18 and 26 at Wave III, and 24 and 32 at Wave IV.

Results: First, there appears to be a stronger genetic influence on ACEs exposure among males than females. Second, genetic influences were stronger on offending among males and depression among females. Third, ACEs moderate the genetic influences on offending and depressive symptomology among males and females: among males, genetic influences on offending decreased as exposure to ACEs increased, while among females, genetic influences on depressive symptoms decreased as exposure to ACEs increased.

Conclusions: Systematic sex differences in the exposure and reactions to ACEs are at least partially due to genetic differences. Exposure to ACEs is partially influenced by genetics among males, but not females, and the more male and females' experience ACEs, the less influence genes have on their offending and depressive symptomology, respectively.
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http://dx.doi.org/10.1016/j.chiabu.2021.104962DOI Listing
April 2021

Impact of Differential Privacy and Census Tract Data Source (Decennial Census Versus American Community Survey) for Monitoring Health Inequities.

Am J Public Health 2021 02 22;111(2):265-268. Epub 2020 Dec 22.

Nancy Krieger, Jarvis T. Chen, Pamela D. Waterman, Emily Wright, and Tamara Rushovich are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Rachel C. Nethery is with the Department of Biostatistics, Harvard T. H. Chan School of Public Health. Brent A. Coull is with the Department of Biostatistics and Department of Environmental Health, Harvard T. H. Chan School of Public Health.

To investigate how census tract (CT) estimates of mortality rates and inequities are affected by (1) differential privacy (DP), whereby the public decennial census (DC) data are injected with statistical "noise" to protect individual privacy, and (2) uncertainty arising from the small number of different persons surveyed each year in a given CT for the American Community Survey (ACS). We compared estimates of the 2008-2012 average annual premature mortality rate (death before age 65 years) in Massachusetts using CT data from the 2010 DC, 2010 DC with DP, and 2008-2012 ACS 5-year estimate data. For these 3 denominator sources, the age-standardized premature mortality rates (per 100 000) for the total population respectively equaled 166.4 (95% confidence interval [CI] = 162.2, 170.6), 166.4 (95% CI = 162.2, 170.6), and 166.3 (95% CI = 162.1, 170.5), and inequities in the range from best to worst quintile for CT racialized economic segregation were from 103.4 to 260.1, 102.9 to 258.7, and 102.8 to 262.4. Similarity of results across CT denominator sources held for analyses stratified by gender and race/ethnicity. Estimates of health inequities at the CT level may not be affected by use of 2020 DP data and uncertainty in the ACS data.
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http://dx.doi.org/10.2105/AJPH.2020.305989DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811099PMC
February 2021

Assessing the Quality and Coherence of Network Meta-Analyses of Biologics in Plaque Psoriasis: What Does All This Evidence Synthesis Tell Us?

Dermatol Ther (Heidelb) 2021 Feb 22;11(1):181-220. Epub 2020 Dec 22.

Dermatology Centre, Salford Royal NHS Foundation Trust, University of Manchester, NIHR Biomedical Research Centre, Manchester, UK.

Introduction: A range of treatments are available for moderate-to-severe psoriasis; however, there remains a paucity of direct comparisons of these in head-to-head trials. Network meta-analyses (NMA) allow comparisons of these to support clinical decision making. This systematic literature review assesses the methodological quality of NMAs available for moderate-to-severe psoriasis and compares their methods and results. Their validity and applicability for current practice is also assessed.

Methods: A systematic review of published NMAs of at least two biologics for moderate-to-severe psoriasis was undertaken. Embase, MEDLINE, MEDLINE In-Process, and the Cochrane Library were last searched on 19 February 2020. The quality of NMAs was assessed using the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) criteria. NMA methodology, funding, and results were compared and differences in results explored.

Results: Twenty-five analyses evaluating up to 19 different treatments at 8-24 weeks, and two analyses at 1 year, were included. Psoriasis Area Severity Index (PASI) response was assessed in 23, facilitating comparisons between NMAs. All NMAs met at least half of the ISPOR criteria. The major limitations were explaining the rationale for methodology, exploring effect modifiers, and consistency between direct and indirect estimates. The analyses differed in model type (Bayesian or frequentist), analysis of PASI response (binomial or multinomial), and analysis of different treatment doses (separate or pooled). PASI results were broadly similar, except for the Cochrane Collaboration NMA which provided lower estimates of treatment efficacy versus placebo. This analysis differed methodologically from others, including pooling data for different doses.

Conclusions: Based on PASI 90 at induction, the majority of recent NMAs came to similar conclusions: interleukin (IL) 17 inhibitors (brodalumab, ixekizumab, secukinumab), IL-23 inhibitors (guselkumab and risankizumab) and infliximab were most efficacious, supporting the validity of NMAs in this clinical area. Decisions should be made using high-quality, up-to-date NMAs with assumptions relevant to clinical practice.
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http://dx.doi.org/10.1007/s13555-020-00463-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7858721PMC
February 2021

The Effects of Soil Depth on the Structure of Microbial Communities in Agricultural Soils in Iowa, USA.

Appl Environ Microbiol 2020 Dec 11. Epub 2020 Dec 11.

Department of Agronomy and Horticulture, University of Nebraska-Lincoln, Lincoln, Nebraska 68588, USA

This study investigated the differences in microbial community abundance, composition and diversity throughout the depth profiles in soils collected from corn and soybean fields in lowa, USA using 16S rRNA amplicon sequencing. The results revealed decreased richness and diversity in microbial communities at increasing soil depth. Soil microbial community composition differed due to crop type only in the top 60 cm and due to location only in the top 90 cm. While the relative abundance of most phyla decreased in deep soils, the relative abundance of the phylum increased and dominated agricultural soils below the depth of 90 cm. Although soil depth was the most important factor shaping microbial communities, edaphic factors including soil organic matter, soil bulk density and the length of time that deep soils were saturated with water were all significant factors explaining the variation in soil microbial community composition. Soil organic matter showed the highest correlation with the exponential decrease in bacterial abundance with depth. A greater understanding of how soil depth influences the diversity and composition of soil microbial communities is vital for guiding sampling approaches in agricultural soils where plant roots extend beyond the upper soil profile. In the long term a greater knowledge of the influence of depth on microbial communities should contribute to new strategies that enhance the sustainability of soil which is a precious resource for food security. Determining how microbial properties change across different soils and within the soil depth profile, will be potentially beneficial to understanding the long-term processes that are involved in the health of agricultural ecosystems. Most literature on soil microbes has been restricted to the easily accessible surface soils. However, deep soils are important in soil formation, carbon sequestration, and in providing nutrients and water for plants. In the most productive agricultural systems in the USA where soybean and corn are grown, crop plant roots extend into the deeper regions of soils (> 100 cm), but little is known about the taxonomic diversity or the factors that shape deep soil microbial communities. The findings reported here highlight the importance of soil depth in shaping microbial communities, provide new information about edaphic factors that influence the deep soil communities and reveal more detailed information on taxa that exist in deep agricultural soils.
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http://dx.doi.org/10.1128/AEM.02673-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851703PMC
December 2020

Examining adverse childhood experiences among Native American persons in a nationally representative sample: Differences among racial/ethnic groups and race/ethnicity-sex dyads.

Child Abuse Negl 2021 01 19;111:104812. Epub 2020 Nov 19.

School of Criminology and Criminal Justice, University of Nebraska Omaha, USA.

Background: Existing research using nationally representative samples has provided valuable information regarding the prevalence and context of childhood adversity, but Native American persons have largely been absent from these studies.

Objective: We examined adverse childhood experiences (ACEs) among persons identifying as White, Black, Asian, Hispanic, and Native American in the NESARC, a longitudinal study (Wave 1: 2001-2002; Wave 2: 2004-2005) using a nationally representative sample from the United States.

Methods: Means tests and negative binomial regression were used to examine the prevalence and variety of ACEs across racial/ethnic groups and race/ethnicity-sex dyads.

Results: Native American persons reported the greatest average number and variety of ACEs than persons from any other racial/ethnic group, and reported the highest rates of physical abuse, sexual abuse, parental substance abuse, and witnessing violence than members of any other racial/ethnic category. Native American females reported the greatest rates of emotional abuse, while Native American males reported the greatest rates of physical neglect; the highest rates of parental substance use among the race/ethnicity-sex dyads were reported by both Native American females and males. Significantly higher rates of sexual violence were reported by Native American females compared to other groups; almost 1 in 4 Native American females reported sexual violence.

Conclusions: Future research should make a concerted effort to broaden examinations of ACEs to include Native American respondents and to include measures of historical trauma and racial discrimination. Broader support for system change as well as increased development and use of culturally responsive prevention and intervention programming is likely necessary to reduce ACEs among Native American persons.
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http://dx.doi.org/10.1016/j.chiabu.2020.104812DOI Listing
January 2021

Efficacy of drug and endoscopic treatment of Crohn's disease strictures: A systematic review.

J Gastroenterol Hepatol 2021 Feb 27;36(2):344-361. Epub 2020 Dec 27.

Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia.

Background And Aims: Strictures are the commonest complication in Crohn's disease. Surgery and endoscopic dilation are the mainstays of treatment, while drug therapy has often been considered contraindicated. The benefit of nonsurgical treatments, particularly drug and endoscopic therapy, need to be defined.

Methods: Ovid MEDLINE, Embase, Emcare, PsycINFO, CINAHL and the Cochrane Library (inception until August 30, 2019) were searched. Studies with ≥ 10 patients with Crohn's disease strictures, reporting on outcomes following medication or endoscopic treatment, were included.

Results: Of 3480 records, 85 studies met inclusion criteria and formed the basis of this analysis. Twenty-five studies assessed drug therapy; none were randomized trials. Despite study heterogeneity anti-tumor necrosis factor (TNF) therapy appeared effective, with 50% of patients avoiding surgery after 4 years of follow up. No other drug therapy was of demonstrable benefit. Sixty studies assessed endoscopic therapy including 56 on endoscopic balloon dilation, two assessed needle knife stricturotomy, and two stent insertion. Dilation was equally effective for de novo and anastomotic strictures ≤ 5 cm in length, with most studies reporting a subsequent surgical rate of 30% to 50%. Repeat dilation was required in approximately half of all patients.

Conclusions: Anti-TNF drug therapy and endoscopic balloon dilation are effective strategies for avoiding surgery in patients with stricturing Crohn's disease. Additional endoscopic therapies require further evaluation. Early data suggest that combining these therapies may provide greater benefit than individual therapies. Optimization of current drug and endoscopic therapy, and the incorporation of newer therapies, are needed for stricturing Crohn's disease.
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http://dx.doi.org/10.1111/jgh.15330DOI Listing
February 2021

Atypical presentations in the hospitalised older adult testing positive for SARS-CoV-2: a retrospective observational study in Glasgow, Scotland.

Scott Med J 2021 May 11;66(2):89-97. Epub 2020 Oct 11.

Consultant Physician, Department of Medicine for the Elderly, Queen Elizabeth University Hospital, UK.

Understanding of how SARS-CoV-2 manifests itself in older adults was unknown at the outset of the pandemic. We undertook a retrospective observational analysis of all patients admitted to older people's services with confirmed COVID-19 in one of the largest hospitals in Europe. We detail presenting symptoms, prognostic features and vulnerability to nosocomial spread. We retrospectively collected data for each patient with a positive SARSCoV-2 RT PCR between 18th March and the 20th April 2020 in a department of medicine for the elderly in Glasgow. 222 patients were included in our analysis. Age ranged from 56 to 99 years (mean = 82) and 148 were female (67%). 119 patients had a positive swab for SARS-CoV-2 within the first 14 days of admission, only 32% of these patients presented with primarily a respiratory type illness. 103 patients (46%) tested positive after 14 days of admission - this was felt to represent likely nosocomial infection. 95 patients (43%) died by day 30 after diagnosis. This data indicates that older people were more likely to present with non-respiratory symptoms. High clinical frailty scores, severe lymphopenia and cumulative comorbidities were associated with higher mortality rates. Several contributing factors will have led to nosocomial transmission.
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http://dx.doi.org/10.1177/0036933020962891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554410PMC
May 2021

Infliximab, adalimumab and vedolizumab concentrations across pregnancy and vedolizumab concentrations in infants following intrauterine exposure.

Aliment Pharmacol Ther 2020 11 27;52(10):1551-1562. Epub 2020 Sep 27.

Fitzroy, VIC, Australia.

Background: The impact of pregnancy on levels of biologic agents in patients with IBD is undefined and time to elimination in vedolizumab-exposed infants is unknown.

Aims: To determine the effect of pregnancy on infliximab, adalimumab and vedolizumab levels and to study infant vedolizumab clearance METHODS: In a prospective observational study, maternal drug levels were measured pre-conception, in each trimester, at delivery and postpartum. The association between drug levels and gestation in weeks was assessed using generalised estimating equation modelling. Infant vedolizumab levels were performed at birth (cord blood), 6 weeks and 3 months or until undetectable.

Results: We included 50 IBD patients (23 on infliximab, 15 on adalimumab and 12 on vedolizumab) with at least two intrapartum observations, plus 5 patients on vedolizumab with only mother and baby samples at delivery. Modelling showed no change in adalimumab levels, an increase in infliximab levels of 0.16 (95% CI 0.08-0.24) µg/L/week (P < 0.001) and a decrease of 0.18 (95% CI: -0.33 to -0.02) µg/L/week (P = 0.03) for vedolizumab. In 17 mother-baby pairs, median infant vedolizumab levels at birth were lower than maternal levels (P < 0.05) with an infant:maternal ratio of 0.7 (IQR 0.5-0.9). Vedolizumab was undetectable between 15 and 16 weeks of age in all 12 infants completing follow-up testing.

Conclusions: During pregnancy, adalimumab levels remain stable, while infliximab levels increase and vedolizumab levels decrease. However, the increments were small suggesting that intrapartum therapeutic drug monitoring and dose adjustment are not indicated. Unlike infliximab and adalimumab, infant vedolizumab levels are lower in cord blood than in mothers and appear to clear rapidly.
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http://dx.doi.org/10.1111/apt.16102DOI Listing
November 2020

Neurobiological Insights Into Stress-Induced Attention Deficit.

Authors:
Emily C Wright

Biol Psychiatry 2020 10;88(7):e29-e31

Department of Psychology, University of California-Davis, Davis, California. Electronic address:

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http://dx.doi.org/10.1016/j.biopsych.2020.07.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475766PMC
October 2020

Luminal microbiota related to Crohn's disease recurrence after surgery.

Gut Microbes 2020 11 21;11(6):1713-1728. Epub 2020 Jun 21.

Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Melbourne, Australia and Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge , Cambridge, UK.

Background: Microbial factors are likely to be involved in the recurrence of Crohn's disease (CD) after bowel resection. We investigated the luminal microbiota before and longitudinally after surgery, in relation to disease recurrence, using 16S metagenomic techniques.

Methods: In the prospective Post-Operative Crohn's Endoscopic Recurrence (POCER) study, fecal samples were obtained before surgery and 6, 12, and 18 months after surgery from 130 CD patients. Endoscopy was undertaken to detect disease recurrence, defined as Rutgeerts score ≥i2, at 6 months in two-thirds of patients and all patients at 18 months after surgery. The V2 region of the 16S rRNA gene was sequenced using Illumina MiSeq. Cluster analysis was performed at family level, assessing microbiome community differences between patients with and without recurrence.

Results: Six microbial cluster groups were identified. The cluster associated with maintenance of remission was enriched for the family [adjusted OR 0.47 (0.27-0.82), = .007]. The OTU diversity of within this cluster was significantly greater than in all other clusters. The cluster enriched for was associated with an increased risk of disease recurrence [adjusted OR 6.35 (1.24-32.44), = .026]. OTU diversity of within this cluster was significantly greater than in other clusters.

Conclusions: Luminal bacterial communities are associated with protection from, and the occurrence of, Crohn's disease recurrence after surgery. Recurrence may relate to a higher abundance of facultatively anaerobic pathobionts from the family. The ecologic change of depleted , a genus of butyrate-producing bacteria, may permit expansion of through luminal environmental perturbation.
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http://dx.doi.org/10.1080/19490976.2020.1778262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524166PMC
November 2020

Perceptions of danger, tolerance of delinquency, and economic disadvantage: Examining neighborhood influences on child physical abuse.

Child Abuse Negl 2020 08 29;106:104562. Epub 2020 May 29.

School of Criminology and Criminal Justice, Nebraska Center for Justice Research, University of Nebraska, Omaha, 6001 Dodge Street, 218 CPACS, Omaha, NE 68182-0149, United States. Electronic address:

Background: Social disorganization theory posits that both structural and social features of a particular geographic unit are associated with criminal behavior. Despite many tests of social disorganization theory, few studies have assessed its relevance to child abuse.

Objective: This study seeks to explain neighborhood variation in child maltreatment. The goal of the current study is to fill this gap by investigating whether or not child physical abuse is related to neighborhood economic disadvantage, perceptions of the dangerousness of the neighborhood, and norms regarding delinquency.

Participants And Setting: Data were drawn from the Project on Human Development in Chicago Neighborhoods (PHDCN) and included 2364 respondents from 79 neighborhoods. The dependent variable, the variety or number of acts of severe child physical abuse, was reported by caregivers, while neighborhood characteristics were based on information from the U.S. Census Data and adult respondents living in Chicago neighborhoods.

Methods: A multilevel, over-dispersed, Poisson regression models were utilized to predict the variety of acts of severe physical abuse that a child living within a given neighborhood would experience.

Results: Neighborhood economic disadvantage was not significantly associated with greater variety of physical abuse. However, neighborhoods perceived as dangerous had greater variety of physical abuse (b = .25, p < .05), while those with a greater tolerance for deviance had somewhat lower variety of physical abuse (b= -.69, p ≤ .10).

Conclusions: These results suggest that some contextual factors may help explain child maltreatment and should be subject to additional research.
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http://dx.doi.org/10.1016/j.chiabu.2020.104562DOI Listing
August 2020

Monitoring Inflammatory Bowel Disease in Pregnancy Using Gastrointestinal Ultrasonography.

J Crohns Colitis 2020 Oct;14(10):1405-1412

Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia.

Background And Aims: Inflammatory bowel disease [IBD] affects women during their childbearing years. Gastrointestinal ultrasonography [GIUS] accurately identifies disease activity in non-pregnant patients with IBD. The utility of GIUS in pregnancy has not been established. We aimed to determine the feasibility and accuracy of GIUS in the assessment of IBD during pregnancy progression.

Methods: A multicentre observational study of women with IBD undergoing GIUS during pregnancy. Clinicians assessed the adequacy of bowel views and disease activity in four colonic segments and the terminal ileum. Location[s] in which views were impeded by the uterus were documented. GIUS disease activity [bowel wall thickness >3 mm] was compared with biochemical disease activity [faecal calprotectin >100 μg/g].

Results: Ninety patients and 127 GIUS examinations were included [median gestation 19 weeks, range 4-33]. Adequate colonic views were obtained in 116/127 [91%] scans. Adequate ileal views were obtained in 62/67 [93%] scans <20 weeks and 30/51 [59%] scans at 20-26 weeks. There was a positive correlation between bowel wall thickness and calprotectin [r = 0.26, p = 0.03]. GIUS delivered a specificity of 83%, sensitivity of 74%, and negative predictive value of 90% compared with calprotectin.

Conclusions: GIUS is a feasible and accurate modality for monitoring IBD in pregnancy. Adequate GIUS views of the colon and terminal ileum can be obtained in the majority of patients up to 20 weeks of gestation. Beyond 20 weeks, GIUS provides good views of the colon but the terminal ileum becomes difficult to assess.
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http://dx.doi.org/10.1093/ecco-jcc/jjaa082DOI Listing
October 2020

Cancer Stage at Diagnosis, Historical Redlining, and Current Neighborhood Characteristics: Breast, Cervical, Lung, and Colorectal Cancers, Massachusetts, 2001-2015.

Am J Epidemiol 2020 10;189(10):1065-1075

In the 1930s, maps created by the federal Home Owners' Loan Corporation (HOLC) nationalized residential racial segregation via "redlining," whereby HOLC designated and colored in red areas they deemed to be unsuitable for mortgage lending on account of their Black, foreign-born, or low-income residents. We used the recently digitized HOLC redlining maps for 28 municipalities in Massachusetts to analyze Massachusetts Cancer Registry data for late stage at diagnosis for cervical, breast, lung, and colorectal cancer (2001-2015). Multivariable analyses indicated that, net of age, sex/gender, and race/ethnicity, residing in a previously HOLC-redlined area imposed an elevated risk for late stage at diagnosis, even for residents of census tracts with present-day economic and racial privilege, whereas the best historical HOLC grade was not protective for residents of census tracts without such current privilege. For example, a substantially elevated risk of late stage at diagnosis occurred among men with lung cancer residing in currently privileged areas that had been redlined (risk ratio = 1.17, 95% confidence interval: 1.06, 1.29), whereas such risk was attenuated among men residing in census tracts lacking such current privilege (risk ratio = 1.01, 95% confidence interval: 0.94, 1.08). Research on historical redlining as a structural driver of health inequities is warranted.
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http://dx.doi.org/10.1093/aje/kwaa045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666416PMC
October 2020

Anxious to see you: Neuroendocrine mechanisms of social vigilance and anxiety during adolescence.

Eur J Neurosci 2020 07 20;52(1):2516-2529. Epub 2019 Dec 20.

Department of Psychology, University of California, Davis, CA, USA.

Social vigilance is a behavioral strategy commonly used in adverse or changing social environments. In animals, a combination of avoidance and vigilance allows an individual to evade potentially dangerous confrontations while monitoring the social environment to identify favorable changes. However, prolonged use of this behavioral strategy in humans is associated with increased risk of anxiety disorders, a major burden for human health. Elucidating the mechanisms of social vigilance in animals could provide important clues for new treatment strategies for social anxiety. Importantly, during adolescence the prevalence of social anxiety increases significantly. We hypothesize that many of the actions typically characterized as anxiety behaviors begin to emerge during this time as strategies for navigating more complex social structures. Here, we consider how the social environment and the pubertal transition shape neural circuits that modulate social vigilance, focusing on the bed nucleus of the stria terminalis and prefrontal cortex. The emergence of gonadal hormone secretion during adolescence has important effects on the function and structure of these circuits, and may play a role in the emergence of a notable sex difference in anxiety rates across adolescence. However, the significance of these changes in the context of anxiety is still uncertain, as not enough studies are sufficiently powered to evaluate sex as a biological variable. We conclude that greater integration between human and animal models will aid the development of more effective strategies for treating social anxiety.
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http://dx.doi.org/10.1111/ejn.14628DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7255921PMC
July 2020

Nature of Discussions about Systemic Therapy Discontinuation or Hospice among Patients, Families, and Palliative Care Clinicians during Care for Incurable Cancer: A Qualitative Study.

J Palliat Med 2020 04 13;23(4):542-547. Epub 2019 Nov 13.

Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.

Patient/clinician communication is critical to quality cancer care at the end-of-life (EOL). Yet discussions about systemic therapy discontinuation or hospice as a care option are commonly deferred. Real-time communication about these complex topics has not been evaluated. Palliative care visits may provide useful insight into how communication about EOL care occurs over time. To explore the nature of discussions about systemic therapy discontinuation and hospice among patients, families, and palliative care clinicians during care for incurable cancer. Qualitative study of palliative care visits. We audiorecorded visits of patients and families who participated in a palliative care trial from diagnosis of incurable lung or noncolorectal gastrointestinal cancer through the course of cancer care ( = 30). We used thematic analysis to characterize communication patterns in the context of clinical events. Content and tenor of discussions shifted in relation to patient health status. In the absence of acute medical deterioration, discussions addressed hospice broadly as an EOL care option. Candid exchanges between patients and families and their clinicians supported increasing depth and specificity of EOL care communication. As clinicians identified that patients were not tolerating treatment, the clinicians encouraged contemplation about quality-of-life implications of continuing treatment or the possibility that treatment might harm more than help, in anticipation of change in health status. Longitudinal relationships with palliative care clinicians functioned through multiple pathways to support patients and families in making complex EOL care decisions. Results inform models and interventions of communication at the EOL.
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http://dx.doi.org/10.1089/jpm.2019.0402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104900PMC
April 2020
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