Clinical Program Research Articles

Changes in Homelessness Among US Veterans After Implementation of the Ending Veteran Homelessness Initiative

Homelessness is a persistent and growing problem. What role health systems should play and how that role is incorporated into larger strategic efforts are not well-defined. To compare homelessness among veterans with that in the general population during a 16-year study period before and after implementation of the Ending Veteran Homelessness Initiative, a program to rehouse veterans experiencing homelessness. This national retrospective cohort study using a mixed-methods approach examined annualized administrative (January 1, 2007, to December 31, 2022) and population data prior to (2007-2009) and during (2010-2022) the Ending Veteran Homelessness initiative. Participants included unhoused adults in the US between 2007 and 2022. Enrollment in Veterans Health Administration (VHA) Homeless Program Office components providing housing, case management, and wrap-around clinical and supportive services. Point-in-time (PIT) count data for unhoused veterans and nonveterans during the study period, number of Section 8 housing vouchers provided by Housing and Urban Development-Veterans Administration Supportive Housing, number of community grants awarded by Supportive Services for Veterans and Families, and total number of veterans housed each year. Semistructured interviews with VHA leadership were performed to gain insight into the strategy. In 2022, 33 129 veterans were identified in the PIT count. They were predominantly male (88.7%), and 40.9% were unsheltered. During the active years of the Ending Veteran Homelessness initiative, veteran homelessness decreased 55.3% compared with 8.6% for the general population. The proportion of veterans in this cohort also declined from 11.6% to 5.3%. This change occurred during a shift to "housing first" as agency policy to create low-barrier housing availability. It was also coupled with substantial growth in housing vouchers, grants to community partner agencies, and growth in VHA clinical and social programming to provide homeless-tailored wrap-around services and support once participants were housed. Key respondent interviews consistently cited the shift to housing first, the engagement with community partners, and use of real-time data as critical. In this cohort study of the federal Ending Veteran Homelessness initiative, after program implementation, there was a substantially greater decrease in homelessness among veterans than in the general population. These findings suggest an important role for health systems in addressing complex social determinants of health. While some conditions unique to the VHA facilitated the change in homelessness, lessons learned here are applicable to other health systems.

Optimalisasi Keterampilan Literasi Siswa SMP NW Mataram Melalui Program Klinik Literasi

The Literacy Clinic is a program to improve students' literacy skills, with a focus on guiding and teaching students who are deficient in reading, writing, and others. This service aims to optimize the literacy skills of class VIII students at SMP NW Mataram through the implementation of a literacy clinic program. The method for implementing the literacy clinic program uses three stages: observation, implementation and evaluation. Data was collected through observation, interviews, Pre-Test and Post-Test. The results of the service are that there are still students who are not fluent in reading which was discovered through interviews and observations. This is also proven by the Pre-Test results which show the percentage of students answering correctly 18%. Therefore, the author designed and implemented a Literacy Clinic program that could improve students' literacy skills. After carrying out the Literacy Clinic, the students then answered the Post-Test questions with the percentage of students answering correctly 49%. Based on this description, it can be concluded that the existence of a literacy clinic program can optimize the Literacy Skills of SMP NW Mataram Students

Cancer-Related Fatigue Is Associated With Objective Measures of Physical Function Before and After a Clinical Exercise Program: A Retrospective Analysis

Background: Cancer-related fatigue (CRF) is a common symptom reported by survivors of cancer. CRF is associated with reduced self-reported physical function, but associations with objective measures of physical function are less robust. Exercise programs have been shown to improve both CRF and objective physical function, but the interaction of exercise, CRF, and function has not been explored. Methods: Retrospective data were collected from baseline (n = 420) and final assessments (n = 234) of survivors who participated in a 3-month clinical exercise program. Assessments included measures of CRF (Functional Assessment of Chronic Illness Therapy–Fatigue) and physical function (6-minute walk test, usual and fast gait speed, 30-second sit-to-stand test, and the Timed Up and Go test). Multiple regression analyses investigated associations between CRF and physical function before and after the program. CRF and functional changes following the program were calculated and associations investigated with multiple regressions. Results: All measures of CRF and physical function significantly improved following the program (P < .01). CRF was associated with all functional measures at baseline (standardized β = −0.18 to 0.29, P < .01) and final assessments (r = −0.27 to 0.26, P < .01). Changes in CRF were associated with changes in function (standardized β = −0.12 to 0.23, P < .05), except usual gait speed (P = .17). Conclusion: This investigation demonstrated associations between CRF and objective physical function before and after participation in an exercise program. The 3-way interaction between CRF, physical function, and exercise can be used clinically to personalize rehabilitation strategies. Future studies should investigate changes in CRF and function during an exercise program.

Effect of a Telehealth Navigator Program on Video Visit Scheduling and Completion in Primary Care.

Patients and clinicians face challenges in participating in video telehealth visits. Patient navigation has been effective in other settings in enhancing patients' engagement with clinical programs. Our objective was to assess whether implementing a telehealth navigator program to support patients and clinicians affected video visit scheduling, video usage, and non-attendance. This was a quasi-experimental quality improvement project using difference-in-differences. We included data from 17 adult primary care sites at a large, urban public healthcare system from October 1, 2021 to October 31, 2022. Six sites received telehealth navigators and 11 sites were used as comparators. Navigators contacted patients (by phone) with upcoming video visits to assess and address potential barriers to successful video visit completion. They also provided on-site support to patients and clinicians regarding telehealth visits and usage of an electronic patient portal. The primary outcomes were difference-in-differences for the proportion of telehealth visits scheduled and, separately, completed as video visits and non-attendance for visits scheduled as video visits. There were 65 488 and 71 504 scheduled telehealth appointments at intervention and non-intervention sites, respectively. The adjusted difference-in-differences for the proportion of telehealth visits scheduled as video was -9.1% [95% confidence interval -26.1%, 8.0%], the proportion of telehealth visits completed as video visits 1.3% [-4.9%, 7.4%], and non-attendance for visits scheduled as video visits -3.7% [-6.0%, -1.4%]. Sites with telehealth navigators had comparatively lower video visit non-attendance but did not have comparatively different video visit scheduling or completion rates. Despite this, navigators' on-the-ground presence can help identify opportunities for improvements in care design.

The Role of Female Physicians in Psychosomatic Medicine: Opportunities and Challenges.

Female physicians are in some cases preferred by patients due to their sex-related characteristics such as softness and empathy. Psychosomatic medicine presents a compelling working environment due to its holistic approach. This brief review synthesizes the challenges encountered by female physicians in psychosomatic medicine and outlines potential strategies for overcoming these barriers. The presence of female role models may constitute a crucial advancement in this process. There exists a pressing demand for specialized clinical and scientific programs in psychosomatic medicine at both national and international levels. Such programs, offered by universities and ministries, as well as comprehensive training initiatives, are indispensable in fostering the next generation of females in psychosomatics. Leading journals can lend their support by publishing special issues dedicated to female physicians. Strengthening female physicians throughout all positions in psychosomatic medicine can contribute ultimately to the improvement of patient care.

A review of Bruton's tyrosine kinase inhibitors in multiple sclerosis.

Bruton's tyrosine kinase (BTK) inhibitors are an emerging class of therapeutics in multiple sclerosis (MS). BTK is expressed in B-cells and myeloid cells, key progenitors of which include dendritic cells, microglia and macrophages, integral effectors of MS pathogenesis, along with mast cells, establishing the relevance of BTK inhibitors to diverse autoimmune conditions. First-generation BTK inhibitors are currently utilized in the treatment of B-cell malignancies and show efficacy in B-cell modulation. B-cell depleting therapies have shown success as disease-modifying treatments (DMTs) in MS, highlighting the potential of BTK inhibitors for this indication; however, first-generation BTK inhibitors exhibit a challenging safety profile that is unsuitable for chronic use, as required for MS DMTs. A second generation of highly selective BTK inhibitors has shown efficacy in modulating MS-relevant mechanisms of pathogenesis in preclinical as well as clinical studies. Six of these BTK inhibitors are undergoing clinical development for MS, three of which are also under investigation for chronic spontaneous urticaria (CSU), rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Phase II trials of selected BTK inhibitors for MS showed reductions in new gadolinium-enhancing lesions on magnetic resonance imaging scans; however, the safety profile is yet to be ascertained in chronic use. Understanding of the safety profile is developing by combining safety insights from the ongoing phase II and III trials of second-generation BTK inhibitors for MS, CSU, RA and SLE. This narrative review investigates the potential of BTK inhibitors as an MS DMT, the improved selectivity of second-generation inhibitors, comparative safety insights established thus far through clinical development programmes and proposed implications in female reproductive health and in long-term administration.

Neuropsychiatric Manifestations in Alzheimer's Disease Patients: Genetics and Treatment Options.

Alzheimer's disease (AD) is characterized by neuropsychiatric symptoms (NPS), which cause great misery to those with dementia and those who care for them and may lead to early institutionalization. The present systematic review aims to discuss the various aspects of Alzheimer's, including treatment options. The databases Embase, PubMed, and Web of Science were searched to collect data. Incipient cognitive deterioration is commonly accompanied by these early warning signals of neurocognitive diseases. The neurobiology of NPSs in Alzheimer's disease, as well as particular symptoms, including psychosis, agitation, apathy, sadness, and sleep disorders, will be examined in this review. For NPSs in Alzheimer's disease, clinical trial designs, as well as regulatory issues, were also addressed. A fresh wave of research, however, is helping to push the discipline ahead. For medication development and repurposing, we highlight the most recent results in genetics, neuroimaging, and neurobiology. Even though identifying and treating psychosis in adults with dementia is still a challenging endeavor, new options are coming up that give the field fresh focus and hope. It can be concluded from the complete literature survey that Alzheimer's-related psychosis as well as other symptoms that are not psychotic, have made significant progress in the last decade. These milestones in the development of safer, more effective treatments have been achieved as a consequence of great focus on non-pharmacological interventions like DICE or WHELD; the investigation into ways to improve existing drugs like aripiprazole, risperidone, amisulpride, and Escitalopram for safer precision-based treatment; and the development of a clinical trial program for pimavanserin.

Structure and Funding of Clinical Informatics Fellowships: A National Survey of Program Directors.

In 2011, the American Board of Medical Specialties established clinical informatics (CI) as a subspecialty in medicine, jointly administered by the American Board of Pathology and the American Board of Preventive Medicine. Subsequently, many institutions created CI fellowship training programs to meet the growing need for informaticists. Although many programs share similar features, there is considerable variation in program funding and administrative structures. The aim of our study was to characterize CI fellowship program features, including governance structures, funding sources, and expenses. We created a cross-sectional online REDCap survey with 44 items requesting information on program administration, fellows, administrative support, funding sources, and expenses. We surveyed program directors of programs accredited by the Accreditation Council for Graduate Medical Education between 2014 and 2021. We invited 54 program directors, of which 41 (76%) completed the survey. The average administrative support received was $27,732/year. Most programs (85.4%) were accredited to have two or more fellows per year. Programs were administratively housed under six departments: Internal Medicine (17; 41.5%), Pediatrics (7; 17.1%), Pathology (6; 14.6%), Family Medicine (6; 14.6%), Emergency Medicine (4; 9.8%), and Anesthesiology (1; 2.4%). Funding sources for CI fellowship program directors included: hospital or health systems (28.3%), clinical departments (28.3%), graduate medical education office (13.2%), biomedical informatics department (9.4%), hospital information technology (9.4%), research and grants (7.5%), and other sources (3.8%) that included philanthropy and external entities. CI fellowships have been established in leading academic and community health care systems across the country. Due to their unique training requirements, these programs require significant resources for education, administration, and recruitment. There continues to be considerable heterogeneity in funding models between programs. Our survey findings reinforce the need for reformed federal funding models for informatics practice and training.

Risdiplam for the treatment of spinal muscular atrophy

Spinal muscular atrophy (SMA) is a devastating disease that is the leading genetic cause of death in infants and young children. It includes a broad spectrum of phenotypes that are classified into clinical groups based on the age of onset and maximum motor function achieved. The most common form of SMA is due to a defect in the survival motor neuron 1 gene (SMN1) localized to 5q11.2-q13.3. The development of clinical symptoms and disease progression is thought to be due to decreased levels of survival motor neuron (SMN) protein. SMA type 1 results in almost inevitable mortality within the first 2 years of life. The first two drugs approved globally for the treatment of SMA were the antisense oligonucleotide nusinersen (Spinraza), and the gene therapy onasemnogene abeparvovec-xioi (Zolgensma). Both interventions have approval and restrictions on use in different countries around the world. Despite these approved therapies, the medical unmet need in SMA (the majority of patients with SMA are not on a disease-modifying therapy) remains high with therapies in the pipeline to address some of the remaining limitations. The third and more recently approved drug for SMA is risdiplam (Evrysdi), an orally administered, centrally and peripherally distributed small molecule that modulates SMN2 pre-mRNA splicing toward the production of full-length SMN2 mRNA to increase functional SMN protein levels. In Russia the drug risdiplam was approved for use on November 26, 2020 with indications for the treatment of SMA in patients aged 2 months and older, and in 2023 the indications were expanded - use is allowed starting from the birth. Risdiplam is widely distributed into the CNS and peripheral tissues including muscles. Following risdiplam administration, SMN protein levels compared with baseline levels increase between 2- and 6-fold depending on the SMA phenotype treated. The risdiplam clinical development program currently has four ongoing clinical trials assessing its safety and efficacy. Clinical trials included more than 450 patients receiving risdiplam to date, has been well tolerated and no treatment-related safety findings leading to study withdrawal have been observed. Data from real clinical practice - more than 11.000 patients worldwide receive therapy with risdiplam, also confirm the safety and good tolerability of the drug.

Real-World Cost-Consequence Analysis of an Integrated Chronic Disease Management Program in Saskatchewan, Canada.

An integrated disease management program otherwise called a clinical pathway was recently implemented in Saskatchewan, Canada for patients living with chronic obstructive pulmonary disease (COPD). This study compared the real-world costs and consequences of the COPD clinical pathway program with 2 control treatment programs. The study comprised adult COPD patients in Regina (clinical pathway group, N = 759) matched on propensity scores to 2 independent control groups of similar adults in (1) Regina (historical controls, N = 759) and (2) Saskatoon (contemporaneous controls, N = 759). The study measures included patient-level healthcare costs and acute COPD exacerbation outcomes, both tracked in population-based administrative health data over a one-year follow-up period. Analyses included Cox proportional hazards models and differences in means between groups. The bias-corrected and accelerated bootstrap method was used to calculate 95% confidence intervals (CI). The COPD pathway patients had lower risks of moderate (hazard ratio [HR] =0.57, 95% CI [0.40-0.83]) and severe (HR = 0.43, 95% CI [0.28-0.66]) exacerbations compared to the historical control group, but similar risks compared with the contemporaneous control group. The COPD pathway patients experienced fewer episodes of exacerbations compared with the historical control group (mean difference = -0.30, 95% CI [-0.40, -0.20]) and the contemporaneous control group (mean difference = -0.12, 95% CI [-0.20, -0.03]). Average annual healthcare costs in Canadian dollars were marginally higher among patients in the COPD clinical pathway (mean = $10 549, standard deviation [SD] =$18 149) than those in the contemporaneous control group ($8841, SD = $17 120), but comparable to the historical control group ($10 677, SD = $21 201). The COPD pathway provides better outcomes at about the same costs when compared to the historical controls, but only slightly better outcomes and at a marginally higher cost when compared to the contemporaneous controls.

Remote Delivery of Mindful Movement Within Healthcare Systems: Lessons Learned From the Veterans Health Administration.

Mindful Movement approaches have been a growing part of the Veterans Health Administration (VA). Innovations in tele-health technology had been an important initiative before the public health emergency to meet the needs of rural veterans as well as challenges in getting to a physical location for care. The onset of the COVID-19 pandemic accelerated this transition to tele-delivery of many practices including mindful movement. This paper aims to share lessons learned from virtual delivery of mindful movement as part of clinical and well-being programs in VA. Benefits of virtual care discussed include the convenience and decreased travel burden; accessibility for adaptive movement options; translation to home practice; and shifting the emphasis to interoceptive skills-building supportive of self-efficacy for exploring and identifying safe movement. Important challenges are also identified such as technology related barriers; teachers trained to meet the need of offering adaptations for a heterogenous population and supporting interoceptive skill-building; and supporting both physical and psychological safety. Examples are provided of medical groups incorporating virtual mindful movement within programs for diabetes and pain care to further explore the potential benefit of these practices being integrated within the care itself, rather than as a separate practice. It is hoped that the lessons learned will provide support for Veterans and staff, and the wider health care community, in what they need to participate in virtual care that is high quality, accessible, and meets the needs for greater health and well-being.

BENEFITS OF A CLINICAL PATHWAY IN TOTAL KNEE ARTHROPLASTY.

Demonstrate whether a multiprofessional Clinical Pathway Program in Total Knee Arthroplasty (CPPA) contributesto optimizing hospital care. Retrospective study of medical data of care indicators in 310 patients divided into two groups: A- who underwent arthroplasty in the last biennium before the introduction of the CPPA (n=144) and group B- who underwent TKA in the biennium after the introduction of the CPPA (n=166). Postoperative showed a significant difference in favor of group B over group A for hospitalization time in days 4.33 ± 2.79 and 5.4 ± 1.67 (p<0.001), time of prophylactic antibiotic in hours 28.13 ± 33.77 and 81.49 ± 40.91 (p<0.001), referral to the intensive care unit 40.9% and 73.4% (p<0.001), initiation of thromboprophylaxis within 24 hours 97.9% and 82.5% (p<0.001), use of elastic stockings and/or intermittent compression prescribed for thromboprophylaxis 89.5% and 31.2% (p<0.001), initiation of rehabilitation within 24 hours 90.1% and 66.1% (p<0.001), readmissions within 30 days 4.1% and 3% (p = 0.76), readmissions 90 days 2.7% and 6.6% (p = 0.183), transfusions 5.5% and 15.2% (p = 0.033). The implementation of a multiprofessional CPPA contributed to the implementation of care protocols, favoring greater patient safety. Level of Evidence III; Retrospective Comparative Study.

Biosimilars: From Production to Patient.

Biologic drugs are large, complex molecules produced through biotechnology. A biosimilar is a biologic product that is highly similar to an already approved biologic (reference product), with no clinically meaningful differences in purity, safety, or efficacy; as such, a biosimilar does not need to undergo the same level of study in a clinical trial program as the original reference product. Due to the potential impact of biosimilars on patient access and health care systems, the US Food and Drug Administration introduced an abbreviated pathway for approving biosimilars (351[k]) in 2009. There is strong evidence that switching from a reference product to a biosimilar does not reduce treatment effectiveness or increase the risk of adverse events. Biosimilars may reduce costs and increase patient access to biologic therapies. Biosimilar use in the United States has increased, as have the associated biosimilar cost savings, which are expected to reach $104 billion between 2020 and 2024. Yet, a need remains for increased knowledge among health care professionals and patients. Prescriber confidence is key to patient acceptance of biosimilars and minimizing the incidence of the nocebo effect. Infusion nurses are well positioned to help educate patients and to improve clinical outcomes across a range of diseases.

Qualitative assessment of expectations on the content, form and way of delivery of a prehabilitation programme in patients with lung resection surgery - A Swiss tertiary centre experience.

To assess the interest in a prehabilitation programme of patients awaiting lung resection and to identify expectations from such a programme. At present, in Switzerland, there are no multimodal clinical prehabilitation programmes for lung resection patients awaiting surgery. Semi-structured face-to-face interviews were conducted with patients who have had or were awaiting lung resection at a Swiss tertiary centre. Thematic analysis was performed to identify common prespecified themes. Twenty-two patients (45.5% female, age 70.6 ± 16.6 years) were interviewed. Seventy-seven percent were interested in a prehabilitation programme. Sixty-two percent, 67% and 90% were interested in endurance, strength and respiratory training, respectively. Six patients (27%) were active smokers, of whom two (one-third) were interested in a smoking cessation programme. Seventy-six percent were interested in nutrition counselling and 90% in receiving education on risk factor management. Forty percent preferred centre-based training/counselling sessions, 20% preferred home-based training/counselling and 30% found both forms acceptable. Patients were willing to perform prehabilitation activities on 2.6 days/week for a total of 162 min/week. Participating in peer groups was desired by only 25%. Patients with lung resection were highly interested in participating in prehabilitation, albeit only for a mean time cost of 2.7 h per week. Offering a prehabilitation programme with a combination of in-hospital group sessions and home-based training seems feasible.

Natural History of Colorectal Polyps Undergoing Longitudinal in Vivo CT Colonography Surveillance.

Background The natural history of colorectal polyps is not well characterized due to clinical standards of care and other practical constraints limiting in vivo longitudinal surveillance. Established CT colonography (CTC) clinical screening protocols allow surveillance of small (6-9 mm) polyps. Purpose To assess the natural history of colorectal polyps followed with CTC in a clinical screening program, with histopathologic correlation for resected polyps. Materials and Methods In this retrospective study, CTC was used to longitudinally monitor small colorectal polyps in asymptomatic adult patients from April 1, 2004, to August 31, 2020. All patients underwent at least two CTC examinations. Polyp growth patterns across multiple time points were analyzed, with histopathologic context for resected polyps. Regression analysis was performed to evaluate predictors of advanced histopathology. Results In this study of 475 asymptomatic adult patients (mean age, 56.9 years ± 6.7 [SD]; 263 men), 639 unique polyps (mean initial diameter, 6.3 mm; volume, 50.2 mm3) were followed for a mean of 5.1 years ± 2.9. Of these 639 polyps, 398 (62.3%) underwent resection and histopathologic evaluation, and 41 (6.4%) proved to be histopathologically advanced (adenocarcinoma, high-grade dysplasia, or villous content), including two cancers and 38 tubulovillous adenomas. Advanced polyps showed mean volume growth of +178% per year (752% per year for adenocarcinomas) compared with +33% per year for nonadvanced polyps and -3% per year for unresected, unretrieved, or resolved polyps (P < .001). In addition, 90% of histologically advanced polyps achieved a volume of 100 mm3 and/or volume growth rate of 100% per year, compared with 29% of nonadvanced and 16% of unresected or resolved polyps (P < .001). Polyp volume-to-diameter ratio was also significantly greater for advanced polyps. For polyps observed at three or more time points, most advanced polyps demonstrated an initial slower growth interval, followed by a period of more rapid growth. Conclusion Small colorectal polyps ultimately proving to be histopathologically advanced neoplasms demonstrated substantially faster growth and attained greater overall size compared with nonadvanced polyps. Clinical trial registration no. NCT00204867 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Dachman in this issue.

Assessment of a novel Ehlers-Danlos syndromes disability index.

The Ehlers-Danlos syndromes (EDS) are a group of inherited connective tissue disorders characterized by disruptions in collagen synthesis and processing. These disorders lead to various symptoms, including hypermobility, musculoskeletal conditions, and chronic pain that can significantly limit patients' daily living. In the absence of a curative treatment, an EDS specific disability index that tracks changes in patient-reported outcomes can facilitate the investigation of new treatment options and enhance the quality of life for EDS patients. An EDS-specific disability index was created using survey data and input from clinicians. A total of 222 EDS patients in a multidisciplinary clinical program completed the index during their initial visit. Exploratory and confirmatory factor analyses were conducted to determine the index's factor solution and assess its goodness-of-fit. Paired t-tests were performed with follow-up visit data collected over the course of one year. The exploratory and confirmatory factor analyses indicated a two-factor solution, accounting for 42.40% of the variance. The index demonstrated adequate fit to the data, supported by Tucker and Lewis's index (0.85) and root mean square error of approximation (0.1). Data from follow-up visits showed significant improvement in three symptom related variables and one function related variable in addition to the total score and the symptom subscale score when compared to the initial visit. The development of an EDS-specific disability index is a crucial step in creating a clinical tool that enables healthcare professionals to gain a deeper understanding of the impact EDS has on patients' lives and potentially identify new therapeutic interventions.

Effect of a Legal Clinic Program Within an Urban Primary Health Care Center on Social Determinants of Health: A Program Evaluation.

Individuals living in poverty often visit primary healthcare clinics for health problems stemming from unmet legal needs. We examined the impact of a medical-legal partnership on improving the social determinants of health (SDoH), health-related quality of life, and perceived health status of attendees of a Legal Clinic Program (LCP). This was a pre-post program evaluation of a weekly LCP established within an urban primary healthcare clinic to provide free legal consultation. Patients aged 18 years or older were either approached or referred to complete a screening tool to identify potential legal needs. Those identified with potential legal needs were offered an appointment with LCP lawyers who provided legal counsel, referrals, and services. For those who attended the LCP, changes in SDoH and health indicators were collected via a self-reported survey 6 months after they attended the LCP and compared to their baseline scores using paired t-tests, McNemar's test for paired proportions, and the Wilcoxon Signed Rank Test for related samples. During the 6-month evaluation period, 31 participants attended the LCP and completed both the baseline and 6-month surveys; 67.8% were female, 64.5% were white, 90.3% were not working full-time, and 61.3% had a household income of $700 to 1800 per month. At follow-up, 25.8% were receiving at least 1 new benefit and there was a statistically significant reduction in food insecurity (35.5% vs 9.7%, P < .05). Also, perceived health status using the visual analog scale (ranges from 0 to 100) significantly improved from 42.5 points (SD = 25.3) at baseline to 56.6 points (SD = 19.6) after 6 months (P < .05). The LCP has the potential to improve the health and wellbeing of patients in primary healthcare clinics by addressing unmet legal needs and SDoH.

Perceived racial discrimination, internalized racism, social support, and self-esteem among Black individuals in Canada: A moderated mediation model.

Black Canadians report experiencing various forms of racial discrimination disproportionately. This study aimed to: (a) examine the association between everyday racial discrimination and self-esteem; (b) test the mediating role of internalized racism and social support in the association between racial discrimination and self-esteem, and (c) test the moderating role of gender and age in this same relationship. A total of 860 participants (76.60% female) aged 15-40 (Mage = 24.96, SD = 6.31) completed questionnaires assessing racial discrimination, self-esteem, internalized racism, and social support. Descriptive and moderated mediation analyses were performed. A total of 65.33% of participants were categorized as endorsing low self-esteem, with no significant difference between males and females (66.67% and 62.20%, respectively; χ² = 1.56, p = .47). Participants aged 25-40 exhibited a higher prevalence of low self-esteem compared to those aged 15-24 (89.91% and 58.54%, respectively, χ² = 37.31, p < .001). The results showed a progressive increase in the prevalence of low self-esteem commensurate with increasing levels of reported racial discrimination. Internalized racism (β = -.09, SE = .01, p < .001) and social support (β = .10, SE = .01, p < .001) mediated the association between everyday racial discrimination and self-esteem; whereas gender moderated the latter association (β = .17, SE = .04, p < .001; being a woman). Results indicate a strong association between racial discrimination and low self-esteem. These findings provide a better understanding of the mechanisms underlying the development of self-esteem problems among Black individuals in Canada. They also have important relevance for the development of educational and clinical programs for prevention and intervention. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Association Between Smoking Status and the Efficacy and Safety of Tofacitinib in Patients with Ulcerative Colitis.

Tofacitinib is an oral Janus kinase inhibitor for the treatment of ulcerative colitis (UC). This analysis assessed the impact of cigarette smoking on tofacitinib efficacy and safety in the UC clinical program. Efficacy endpoints and adverse events (AEs) were evaluated by smoking status (ever smokers [current and ex-smokers] and never smokers) in the phase (P)2 induction study (baseline demographics and safety only), P3 studies (OCTAVE Induction 1&2, OCTAVE Sustain, OCTAVE Open), and P3/4b RIVETING study. This post hoc analysis included 1156 patients (ever smokers, n = 416 [36.0%; current smokers, n = 59 (5.1%); ex-smokers, n = 357 (30.9%)]; never smokers, n = 740 [64.0%]; median [range] treatment duration 654 [1-2712] and 615.5 [1-2850] days, respectively). Similar proportions of ever smokers and never smokers achieved efficacy endpoints. AEs were reported in 88.7% of ever smokers and 83.8% of never smokers. Overall, 60.6% of ever smokers had an infection (serious infections, 5.5%; herpes zoster [nonserious and serious], 10.8%; Clostridioides difficile infection, 12.0%; lower respiratory tract infection, 19.5%: corresponding values among never smokers were 53.1%, 3.9%, 6.8%, 8.5%, and 11.4%). Major adverse cardiovascular events were reported in 1.0% of ever smokers and 0.7% of never smokers and thromboembolism events (venous and arterial) in 1.0% of ever smokers and 0.9% never smokers. Deaths, malignancies (excluding non-melanoma skin cancer [NMSC]), and NMSC occurred infrequently in ever smokers (0.5%, 2.5%, and 3.7%, respectively) and never smokers (0.1%, 1.5%, and 1.0%, respectively). Colorectal cancer was reported in 0.6% of never smokers; no cases occurred in ever smokers. Efficacy and safety of tofacitinib were generally similar in ever smokers and never smokers. Overall, serious AEs and, as expected, infections were more frequent in ever smokers versus never smokers. This may inform treatment selection and monitoring strategies. NCT00787202;NCT01465763;NCT01458951;NCT01458574;NCT01470612;NCT03281304.

Ethical issues experienced by otolaryngologists: a conventional content analysis.

To deliver effective medical services and establish trust and psychological security in patients, care providers must prioritize ethical principles. Developing a comprehensive clinical education program for learners, along with specific ethical guidelines, and implementing managerial and executive interventions necessitates a thorough understanding of the ethical challenges within this field. This qualitative study aimed to elucidate the ethical issues faced by otolaryngologists. Sixteen otolaryngologists participated in the study, selected through purposive sampling. Data were gathered through semi-structured interviews, and the analysis, conducted through conventional content analysis, revealed eight main categories and 38 subcategories encapsulating the identified ethical issues. The primary categories encompassed ethical issues faced by otolaryngologists concerning patients and companions, education, communication with the treatment team, physicians' rights, medical tourism, medical advertising, cultural considerations, and managerial challenges. resources and treatment approaches in alignment with Iranian cultural norms, address conflicts between treatment and education, and implement sound management plans to uphold rights of the treatment team. Additionally, the study suggests the necessity of ethical advertising programs and the strategic promotion of therapeutic tourism.