Digging Deeper: What Can We Really Learn about Dementia from History?

In response to Finch and Burstein's provocative argument that the advanced dementias may result from environmental toxins and lifestyle factors associated with post-industrial societies, we call for a more rigorous historical approach, emphasizing the importance of situating ancient texts more fully in their historical and cultural context. Such an approach would also entail consideration of the declining relative rates of dementia in Western countries, which have been linked to population health-level factors and policies that appear to have reduced the risk of dementia by directly and indirectly influencing the social determinants of brain health.

The transformative power of participating in Opening Minds Through Art (OMA), an expressive arts program for medical students

Opening Minds Through Art (OMA) is a standardized expressive arts-based program that improves student attitudes toward persons living with dementia. Understanding how this change occurs is important for both educators and clinicians. In this study, narrative analysis was used to explore the impact of OMA on participating medical students. 111 students at six medical schools accepted an invitation to be part of OMA during the 2018-2020 academic years. After completing the program, participants were asked to write briefly about the impact of their OMA experience on their work as future physicians. These narratives were analyzed to identify themes relevant to the impact of the program. Students described appreciating both pragmatic and novel creative experiences in OMA, which differed from their traditional studies. Themes from the evaluation included: Inter and Intrapersonal Connection and Growth; Mastery of Anticipated Challenges; Acquisition of Knowledge and Skills; and Appreciation of Health Care Team Members. Teaching students to embrace clinical work with challenging and perceived "difficult" patients is often unaddressed in the medical school curriculum. This study suggests that the combination of medical knowledge and artistic expression can be used to benefit both students and persons living with dementia.

Association between diseases of despair and atherosclerotic cardiovascular disease among insured adults in the USA: a retrospective cohort study from 2017 to 2021

OBJECTIVES

To assess associations between diseases of despair (DoD) and incident atherosclerotic cardiovascular disease (ASCVD) among insured adults in the USA.

DESIGN

Retrospective cohort study.

SETTING

Highmark insurance claims data in the USA from 2017 to 2021.

PARTICIPANTS

Adults with at least 10 months of continuous insurance enrolment, no record of ASCVD in the 2016 baseline year and no missing data on study variables.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cox proportional hazard regression was used to calculate crude and adjusted hazard ratios (HR) and 95% confidence intervals (CI) to assess risk of ASCVD (composite of ischaemic cardiomyopathy, non-fatal ischaemic stroke, peripheral arterial disease or non-fatal acute myocardial infarction) by baseline DoD overall, and by the component conditions comprising DoD (alcohol-related disorders, substance-related disorders, suicidality) individually and in combination.

RESULTS

The DoD-exposed group had an age-adjusted rate of 20.5 ASCVD events per 1000 person-years, compared with 11.7 among the unexposed. In adjusted models, overall DoD was associated with increased risk of incident ASCVD (HR 1.42, 95% CI 1.36 to 1.47). Individually and in combination, component conditions of DoD were associated with higher risk for ASCVD relative to no DoD. Substance-related disorders were associated with 50% higher risk of incident ASCVD (HR 1.5, 95% CI 1.41 to 1.59), alcohol-related disorders and suicidality/intentional self-harm were associated with 33% and 30% higher risk, respectively (HR 1.33, 95% CI 1.26 to 1.41; HR 1.30, 95% CI 1.11 to 1.52). Co-occurring DoD components conferred higher risk still. The highest risk combination was substance-related disorders+suicidality (HR 2.01, 95% CI 1.44 to 2.82).

CONCLUSIONS

Among this cohort of insured adults, documented DoD was associated with increased ASCVD risk. Further research to understand and address cardiovascular disease prevention in those with DoD could reduce costs, morbidity and mortality. Further examination of overlapping structural factors that may be contributing to concurrent rises in ASCVD and DoD in the USA is needed.

What Can the Health Humanities Contribute to Our Societal Understanding of and Response to the Deaths of Despair Crisis?

Deaths of Despair (DoD), or mortality resulting from suicide, drug overdose, and alcohol-related liver disease, have been rising steadily in the United States over the last several decades. In 2020, a record 186,763 annual despair-related deaths were documented, contributing to the longest sustained decline in US life expectancy since 1915-1918. This forum feature considers how health humanities disciplines might fruitfully engage with this era-defining public health catastrophe and help society better understand and respond to the crisis.

Hospital-Based Community Gardens as a Strategic Partner in Addressing Community Health Needs

As part of community health needs assessments, US nonprofit hospitals are identifying a high prevalence of chronic diseases associated with poor diets. Institutions have responded by establishing nutrition-related initiatives such as farmers' markets and community gardens. There is public health value in demonstrating how these partnerships can help hospitals address identified community health needs. Here we describe diverse strategies undertaken by a hospital-based community garden at Penn State Milton S. Hershey Medical Center, explore implications for US hospitals, and provide implementation guidance. (Am J Public Health. 2023;113(9):939-942. https://doi.org/10.2105/AJPH.2023.307336).

Ancient Roots of Today's Emerging Renaissance in Psychedelic Medicine

An international ban on psychedelics initiated by the United Nations' Convention on Psychotropic Substances in 1971 restricted the clinical use of these ancient psychoactive substances. Yet, in an era marked by rising mental health concerns and a growing "Deaths of Despair" epidemic (i.e., excess mortality and morbidity from suicide, drug overdose, and alcoholism), the structured psychedelic use that has long been a part of ritual healing experiences for human societies is slowly regaining credibility in Western medicine for its potential to treat various mental health conditions. We use a historical lens to examine the use of psychedelic therapies over time, translate ancient lessons to contemporary clinical and research practice, and interrogate the practical and ethical questions researchers must grapple with before they can enter mainstream medicine. Given the COVID-19 pandemic and its contributions to the global mental health burden, we also reflect on how psychedelic therapy might serve as a tool for medicine in the aftermath of collective trauma. Ultimately, it is argued that a "psychedelic renaissance" anchored in the lessons of antiquity can potentially help shift healthcare systems-and perhaps the broader society-towards practices that are more humane, attentive to underlying causes of distress, and supportive of human flourishing.

The bystander effect: Impact of rural hospital closures on the operations and financial well-being of surrounding healthcare institutions

INTRODUCTION

There is presently a rural hospital shortage in the United States with 180 closures since 2005 and hundreds of institutions in financial peril. Although the hospital closure phenomenon is well-established, less is known about the spillover impact on the operations and financial wellbeing of surrounding hospitals. This preliminary study quantified how discrete rural hospital closures impact institutions in their regional proximity, finding a significant increase in inpatient admissions and emergency department visits for these "bystander hospitals".

METHODS

Using a repository of rural hospital closures collected by the UNC Sheps Center for Health Services Research, we identified closures over the past 15 years. Criteria for inclusion were hospitals that had been fully closed between 2005-2016 and with >25-bed capacity. We then designated surrounding hospitals within a 30-mile radius of each closed hospital as "bystander hospitals." We examined the average rate-of-change for inpatient admissions and emergency department visits in surrounding hospitals both two years before and after relevant hospital closures.

RESULTS

We identified 53 hospital closures and 93 bystander hospitals meeting our criteria during the study period. With respect to geographic distribution, 66% of closures were in the Southern US, including 21% in Appalachia. Average emergency department visits increased by 3.59% two years prior to a hospital's closure; however, at two years post-closure the average rate of increase rose to 10.22% (F (4,47) = 2.77, p = 0.0375). Average bystander hospital admissions fell by 5.73% in the two years preceding the hospital closure but increased 1.17% in the two years after (F (4,46) = 3.05, p = 0.0259).

CONCLUSION

These findings predict a daunting future for rural healthcare. While previous literature has described the acute effects hospital closures have on communities, this study suggests a significant spillover effect on hospitals within the geographic region and a cyclical process at play in the rural healthcare sector. In the absence of significant public health assistance in regions affected by closures, poor health outcomes, including "diseases of despair," are likely to continue proliferating, disproportionately affecting the most vulnerable. In the COVID-19 era, it will be especially necessary to focus on hospital closures given increased risk of maintaining solvency due to delayed and deferred care atop already tight margins.

Strategies to Help Health Care Organizations Execute Their Food System Leadership Responsibilities

Food systems influence environmental sustainability and health. The fact that our current food production and distribution practices neither support nor promote planetary or human health raises ethical concerns. Since health organizations offer food to patients, community members, and employees, they are situated at key intersections among food systems, agricultural policies and practices, and public health. This article considers the nature and scope of health care organizations' local food system leadership responsibilities and describes how health care organizations' food practices can help improve health outcomes and motivate equity.

Evaluating the Impact of Community Gardening on Sense of Purpose for Persons Living with Dementia: A Cluster-Randomized Mixed Methods Pilot Study

Background:

Gardening has been shown to have positive effects on persons living with dementia, but no studies have explored the effects of gardening on sense of purpose.

Objective:

Explore how gardening may influence sense of purpose for people with dementia.

Methods:

Ten residents with dementia diagnoses living in a skilled care facility participated in hour-long gardening sessions twice weekly at outdoor raised beds over a two-month duration. One group (n = 5) donated vegetables to a food pantry while the other (n = 5) harvested produce for personal use. Semi-structured interviews with participants and their caregivers conducted post-intervention were analyzed for themes.

Results:

Participants and caregivers reported biopsychosocial benefits of gardening, identifying four main themes: 1) Gardening outdoors provided specific physical benefits that improved quality of life; 2) Working on a project in a group setting improved mood and fostered a sense of community; 3) Gardening promoted reminiscence and reinforced a sense of self; 4) Gardening provided participants with a sense of purpose and pride.

Conclusion:

Gardening has biopsychosocial benefits for persons living with dementia, and there appears to be additive benefit linked to improved sense of purpose via charitable giving.

Making the Case for Accelerated Withdrawal of Aducanumab

The controversial approval in June 2021 by the Food and Drug Administration (FDA) of aducanumab (marketed as Aduhelm), Biogen’s monoclonal antibody for patients with Alzheimer’s disease, raises significant concerns for the dementia field and drug approval process, considering its lack of adequate evidence for clinical efficacy, safety issues, and cost. On 15 December 2021, an international group of clinicians, basic science experts, psychological and social science researchers, lay people with lived experience of dementia, and advocates for public health met to discuss making a recommendation for whether aducanumab’s approval should be withdrawn. Attendees considered arguments both in favor of and in opposition to withdrawal and voted unanimously to recommend that the FDA withdraw its approval for aducanumab and to support the Right Care Alliance’s filing of a formal Citizen Petition to this effect.

Effects of a Personalized Music Intervention for Persons with Dementia and their Caregivers

Background: Given the challenges of developing disease-modifying treatments for Alzheimer’s disease and related disorders, non-pharmacological interventions represent an increasingly promising approach in long-term care settings. Music-based interventions have been effective in improving the quality of life by influencing biopsychosocial factors that play a role in the progression of illnesses such as depression and anxiety. However, approaches have tended to focus exclusively on the person with dementia rather than integrating caregivers. Objective: This study aimed to determine the impact of a music-based intervention on the quality of life of persons with dementia and their caregivers. Methods: A mixed-methods study was conducted with seven dyads consisting of residents (aged 76–92) with diagnoses of dementia and their caregivers (aged 53–84) at a skilled nursing facility in Pennsylvania. Eight music intervention sessions were completed in the presence of the resident and caregiver using personalized playlists created for the dyad. Pre- and post-intervention questionnaires were administered during each session, and observational data for both residents and caregivers were collected. Results: Caregivers reported feeling less overwhelmed after the intervention with a mean difference of –0.24±0.14, p = 0.016. Mean difference in the other 5 responses showed that listening to music had a beneficial impact for resident/caregiver dyads. Observations of interpersonal behavior supported the benefit of the intervention for these dyads. Conclusion: Quantitative analysis of a personalized music intervention for residents/caregivers showed positive trends in increasing personal connection, and qualitative data identified greater appreciation of the relationship and increased bonding.

Bisexual Women's Invisibility in Health Care

Invisibility of racial and ethnic inequity in clinical research means many important features of disease etiology and symptom presentation are often unaccounted for. Similarly, binary (ie, gay or straight) definitions of sexuality render bisexual women's experiences invisible, and this invisibility has 2 important consequences for minority groups' members' health, which this article considers.

Perceptions of Diseases of Despair by Members of Rural and Urban High-Prevalence Communities: A Qualitative Study

IMPORTANCE

Diseases of despair (ie, mortality or morbidity from suicidality, drug abuse, and alcoholism) were first characterized as increasing in rural White working-class populations in midlife with low educational attainment and associated with long-term economic decline. Excess mortality now appears to be associated with working-class citizens across demographic and geographic boundaries, but no known qualitative studies have engaged residents of rural and urban locales with high prevalence of diseases of despair to learn their perspectives.

OBJECTIVE

To explore perceptions about despair-related illness and potential intervention strategies among diverse community members residing in discrete rural and urban hotspots.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, high-prevalence hotspots for diseases of despair were identified from health insurance claims data in Central Pennsylvania. Four focus groups were conducted with 60 community members in organizations and coalitions from 3 census block group hotspot clusters in the health system between September 2019 and January 2020. Focus groups explored awareness and beliefs about causation and potential intervention strategies.

MAIN OUTCOMES AND MEASURES

A descriptive phenomenological approach was applied to thematic analysis, and a preliminary conceptual model was constructed to describe how various factors may be associated with perpetuating despair and with public health.

RESULTS

In total, 60 adult community members participated in 4 focus groups (44 women, 16 men; 40 White non-Hispanic, 17 Black, and 3 Hispanic/Latino members). Three focus groups with 43 members were held in rural areas with high prevalence of diseases of despair, and 1 focus group with 17 members in a high-prevalence urban area. Four themes emerged with respect to awareness and believed causation of despair-related illness, and participants identified common associated factors, including financial distress, lack of critical infrastructure and social services, deteriorating sense of community, and family fragmentation. Intervention strategies focused around 2 themes: (1) building resilience to despair through better community and organizational coordination and peer support at the local level and (2) encouraging broader state investments in social services and infrastructure to mitigate despair-related illness.

CONCLUSIONS AND RELEVANCE

In this qualitative study, rural and urban community members identified common factors associated with diseases of despair, highlighting the association between long-term political and economic decline and public health and a need for both community- and state-level solutions to address despair. Health care systems participating in addressing community health needs may improve processes to screen for despair (eg, social history taking) and codesign primary, secondary, and tertiary interventions aimed at addressing factors associated with distress. Such actions have taken on greater urgency with the COVID-19 pandemic.

Opening Minds through Art: A preliminary study evaluating the effects of a creative-expression program on persons living with dementia and their primary care partners

For people living with dementia and their care partners, a decline in the ability to effectively communicate can cause significant distress. However, in recent decades, the arts have emerged as an effective care modality in fostering communication and expression for those with declining verbal skills and memory loss. Opening Minds through Art (OMA) is a national initiative that empowers people living with dementia by facilitating creative expression and social engagement through art-making in partnership with trained college student volunteers. Research has demonstrated that participation in the program benefits quality of life for those living with dementia and also improves student attitudes toward dementia. To date, however, no research has involved primary care partners. We implemented an OMA program at three residential care homes in State College, Pennsylvania, with residents cocreating artwork alongside primary care partners (i.e., a family member or primary medical personnel) over the course of four art-making sessions. We evaluated the effects of participation on quality of life and care partner burnout through pre-post use of "emotional thermometers" (measuring levels of distress, anxiety, depression, anger, and perceived quality of life), the National Institute of Health NIH emotional support scale, and the NIH caregiver assessment (care partner burnout). For people living with dementia, participation significantly increased perceived quality of life while decreasing distress, anxiety, depression, and anger (p < .01; n = 12) after each class; however, the intervention did not significantly impact perceived emotional support. For care partners, participation significantly lowered post-intervention measures of burnout and self-rated stress (p < .01; n = 9). This preliminary study suggests that a structured art-based activity appears to positively impact acute mood for patients and, importantly, decrease care partner burnout. Future research can bring more robust methods to bear in determining how to use OMA and other arts interventions to optimize social support for people living with dementia and their care partners.

Dermanyssus gallinae and chicken egg production: impact, management, and a predicted compatibility matrix for integrated approaches

The poultry red mite, Dermanyssus gallinae, is a worldwide threat to egg production and animal and human welfare. This mite is also a potential vector for several significant diseases. EU regulation that forbids the use of conventional cages for egg-laying hens may favour the growth of D. gallinae, a species known to thrive in more complex housing systems. Current control measures emphasize the use of chemical acaricides, which may have limited efficacy on D. gallinae considering its temporary blood-feeding behaviour. In integrated pest management (IPM), two or more compatible measures targeting physical, environmental, and/or biological aspects could be judiciously combined to enhance the effectiveness against D. gallinae infestation. To inform current and future IPM for D. gallinae, a compatibility matrix is proposed to guide the selection of control measures for field application.

Prolonged functional cerebral asymmetry as a consequence of dysfunctional parvocellular paraventricular hypothalamic nucleus signaling: An integrative model for the pathophysiology of bipolar disorder

Approximately 45 million people worldwide are diagnosed with bipolar disorder (BD). While there are many known risk factors and models of the pathologic processes influencing BD, the exact neurologic underpinnings of BD are unknown. We attempt to integrate the existing literature and create a unifying hypothesis regarding the pathophysiology of BD with the hope that a concrete model may potentially facilitate more specific diagnosis, prevention, and treatment of BD in the future. We hypothesize that dysfunctional signaling from the parvocellular neurons of the paraventricular hypothalamic nucleus (PVN) results in the clinical presentation of BD. Functional damage to this nucleus and its signaling pathways may be mediated by myriad factors (e.g. immune dysregulation and auto-immune processes, polygenetic variation, dysfunctional interhemispheric connections, and impaired or overactivated hypothalamic axes) which could help explain the wide variety of clinical presentations along the BD spectrum. The neurons of the PVN regulate ultradian rhythms, which are observed in cyclic variations in healthy individuals, and mediate changes in functional hemispheric lateralization. Theoretically, dysfunctional PVN signaling results in prolonged functional hemispheric dominance. In this model, prolonged right hemispheric dominance leads to depressive symptoms, whereas left hemispheric dominance correlated to the clinical picture of mania. Subsequently, physiologic processes that increase signaling through the PVN (hypothalamic-pituitaryadrenal axis, hypothalamic- pituitary-gonadal axis, and hypothalamic-pituitary-thyroid axis activity, suprachiasmatic nucleus pathways) as well as, neuro-endocrine induced excito-toxicity, auto-immune and inflammatory flairs may induce mood episodes in susceptible individuals. Potentially, ultradian rhythms slowing with age, in combination with changes in hypothalamic axes and maturation of neural circuitry, accounts for BD clinically presenting more frequently in young adulthood than later in life.

A Systematic Scoping Review of How Healthcare Organizations Are Facilitating Access to Fruits and Vegetables in Their Patient Populations

BACKGROUND

There is compelling evidence on the impact of diet as preventative medicine, and with rising health care costs healthcare organizations are attempting to identify interventions to improve patient health outcomes.

OBJECTIVES

The purpose of this systematic scoping review was to characterize existing healthcare organization-based interventions to improve access to fruits and vegetables (F&V) for their patient populations. In addition, we aimed to review the impact of identified interventions on dietary intake and health outcomes.

METHODS

Titles and abstracts were searched in PubMed® (MEDLINE®), Embase®, CINAHL®, and the Cochrane Library® from 1 January 1990 to 31 December 2019. To be selected for inclusion, original studies must have included a healthcare organization and have had a programmatic focus on increasing access to or providing fresh F&V to patients in an outpatient, naturalistic setting. The Effective Public Health Practice Project tool was used to assess study quality in 6 domains (selection bias, study design, confounders, blinding, data collection methods, and withdrawals and dropouts).

RESULTS

A total of 8876 abstracts were screened, yielding 44 manuscripts or abstracts from 27 programs. Six program models were identified: 1) a cash-back rebate program, 2) F&V voucher programs, 3) garden-based programs, 4) subsidized food box programs, 5) home-delivery meal programs, and 6) collaborative food pantry-clinical programs. Only 6 of 27 studies included a control group. The overall quality of the studies was weak due to participant selection bias and incomplete reporting on data collection tools, confounders, and dropouts. Given the heterogeneity of outcomes measured and weak study quality, conclusions regarding dietary and health-related outcomes were limited.

CONCLUSIONS

Healthcare-based initiatives to improve patient access to F&V are novel and have promise. However, future studies will need rigorous study designs and validated data collection tools, particularly related to dietary intake, to better determine the effect of these interventions on health-related outcomes.

Trends in the diagnosis of diseases of despair in the United States, 2009-2018: a retrospective cohort study

BACKGROUND AND OBJECTIVE

Increasing mortality and decreasing life expectancy in the USA are largely attributable to accidental overdose, alcohol-related disease and suicide. These 'deaths of despair' often follow years of morbidity, yet little is known about trends in the clinical recognition of 'diseases of despair'. The objective of this study is to characterise rates of clinically documented diseases of despair over the last decade and identify sociodemographic risk factors.

DESIGN

Retrospective study using a healthcare claims database with 10 years of follow-up.

SETTING

Participants resided nationwide but were concentrated in US states disproportionately affected by deaths of despair, including Pennsylvania, West Virginia and Delaware.

PARTICIPANTS

Cohort included 12 144 252 participants, with no restriction by age or gender.

OUTCOME MEASURES

Diseases of despair were defined as diagnoses related to alcohol misuse, substance misuse and suicide ideation/behaviours. A lookback period was used to identify incident diagnoses. Annual and all-time incidence/prevalence estimates were computed, along with risk for current diagnosis and patterns of comorbidity.

RESULTS

515 830 participants received a disease of despair diagnosis (58.5% male, median 36 years). From 2009 to 2018, the prevalence of alcohol-related, substance-related and suicide-related diagnoses respectively increased by 37%, 94%, and 170%. Ages 55-74 had the largest increase in alcohol/substance-related diagnoses (59% and 172%). Ages <18 had the largest increase in suicide-related diagnoses (287%). Overall, odds for current-year diagnosis were higher among men (adjusted OR (AOR) 1.49, 95% CI 1.47 to 1.51), and among those with Affordable Care Act or Medicare coverage relative to commercial coverage (AOR 1.30, 1.24 to 1.37; AOR 1.51, 1.46 to 1.55).

CONCLUSIONS

Increasing clinical rates of disease of despair diagnoses largely mirror broader societal trends in mortality. While the opioid crisis remains a top public health priority, parallel rises in alcohol-related diagnoses and suicidality must be concurrently addressed. Findings suggest opportunities for healthcare systems and providers to deploy targeted prevention to mitigate the progression of morbidities towards mortality.

Growing Healthy Hearts: Gardening Program Feasibility in a Hospital-Based Community Garden

OBJECTIVE

To assess feasibility in terms of acceptability, demand, and participant willingness to engage in gardening activities during an intervention delivered at a hospital-based community garden for patients at risk for cardiovascular disease (CVD).

METHODS

In a pre-post study design, 15 adults with ≥1 CVD risk factor attended 5 education sessions over 12 weeks, tended garden beds, and completed questionnaires related to program acceptability and future gardening intentions. Interviews were used to identify areas for programmatic improvement.

RESULTS

Most participants rated the intervention as good or excellent (93%), and 73% indicated that it was likely that they would garden next season. Areas for programmatic improvement included creating opportunities for group discussion, providing online materials, and offering more cooking and gardening content.

CONCLUSIONS AND IMPLICATIONS

Gardening as an intervention for adult patients with CVD risk factors is feasible. Assessment of the effect of gardening on health outcomes and dietary intake is warranted.

Considering a Potential Role of Linalool as a Mood Stabilizer for Bipolar Disorder

Epidemiologic studies suggest that the lifetime prevalence of bipolar spectrum disorders ranges from 2.8 to 6.5 percent of the population. To decrease morbidity and mortality associated with disease progression, pharmacologic intervention is indicated for the majority of these patients. While a number of effective treatment regimens exist, many conventional medications have significant side effect profiles that adversely impact patients' short and long-term well-being. It is thus important to continue advancing and improving therapeutic options available to patients. This paper reviews the limitations of current treatments and examines the chemical compound Linalool, an alcohol found in many plant species, that may serve as an effective mood stabilizer. While relatively little is known about Linalool and bipolar disorder, the compound has been shown to have antiepileptic, anti-inflammatory, anxiolytic, anti-depressive, and neurotrophic effects, with mechanisms that are comparable to current bipolar disorder treatment options.

Association Between Subjective Cognitive Decline and Social and Emotional Support in US Adults

Subjective cognitive decline (SCD) has been linked to Alzheimer's Disease in the literature. However, little is known about whether SCD is associated with social/emotional support (SES). To investigate this association, this study utilized the 2015 and 2016 Behavioral Risk Factor Surveillance System data. A study population of 17206 participants aged 45 years and older who responded to both the Emotional Support and Life Satisfaction survey module and the Cognition Decline survey module were included. Of this study population, 11.22% had SCD, and 21.83% reported insufficient SES. A much higher percentage of those with insufficient SES experienced SCD compared to those with sufficient SES (21.15% vs 8.45%, P < .0001). Insufficient SES was significantly associated with SCD (odds ratio = 1.68, 95% confidence interval: 1.37-2.06), after controlling for other factors. Furthermore, this study found certain demographic groups such as female, white, or married groups were more likely to receive sufficient SES.

A Collaborative Response to Provocative Comments in a Medical School

This article was migrated. The article was marked as recommended. In 2018, anonymous online provocative comments were submitted to student leaders of a Syrian Refugee Initiative (SRI) at the Penn State College of Medicine. This triggered a series of actions with students and medical school leaders aimed at identifying the person who submitted the comments, trying to understand mutual perspectives, and managing the impact of the event on the student body.We describe the history of our college's commitment to humanism and how the SRI was a direct outgrowth of that culture. Voices of the student leaders who were directly impacted by the provocative comments and educational leaders who worked to resolve the crisis are presented. We also describe a collaborative process that involved engaging cybersecurity experts to identify the perpetrator, and share how the students and educational leaders were able to develop trust despite initial skepticism by students over the leadership's avowed commitment to taking the hate speech seriously.While the perpetrator was never identified and opportunities for improvement were identified along the way, by including student leaders in the process, students and administrators were able to develop trust and reach reasonable closure on this disturbing event. Take home messages are presented to guide other institutions in navigating instances of provocative comments or speech.

Use of a Graphic Memoir to Enhance Clinicians' Understanding of and Empathy for Patients with Parkinson Disease

CONTEXT

Parkinson disease (PD) can be physically, emotionally, and financially burdensome. Understanding its impact from the patient's perspective is an important way to sensitize clinicians to the challenges of living with PD.

OBJECTIVE

To evaluate whether a book-length graphic memoir (an illness story in comic form) can help clinicians appreciate PD from the patient's perspective.

DESIGN

A convergent mixed-methods study of clinicians working in a multidisciplinary movement disorders clinic. Participants read My Degeneration and completed preintervention and post-intervention questionnaires. They also attended a book group discussion. Quantitative findings were compared before and after the intervention, and qualitative data were analyzed for themes.

MAIN OUTCOME MEASURES

Clinicians': 1) confidence in understanding patients' experiences with PD, 2) knowledge about PD, and 3) empathy toward patients and families.

RESULTS

After reading the book, participants' confidence in understanding patients' experiences with PD increased significantly in the areas of stigma and disease impact on patients and families. Clinical knowledge was unchanged. Qualitative analysis revealed 3 main themes: 1) the book provides a meaningful way for clinicians to learn about the experience of living with PD; 2) the medium of comics engages clinicians in ways different from other mediums; and 3) benefits of the book may extend beyond the clinical team.

CONCLUSION

Clinicians who read My Degeneration gained insight into the psychosocial effects of PD on patients and their loved ones. The book helped facilitate deeper understanding of patients' experiences living with PD and fostered greater empathy and self-reflection.

Opportunities for Growth: Evaluating the Feasibility of a Community Gardening Intervention Pairing Adolescent and Young Adult Cancer Survivors with Experienced Gardeners

We evaluated the feasibility of a mentored gardening intervention for adolescent and young adult (AYA) cancer survivors in a hospital-based community garden as a way to improve diet and physical activity, using qualitative data to assess the challenges, facilitators, and areas for future programmatic improvement and replication. Over the course of growing season 2018, AYA cancer survivors tended a garden plot in a community garden under the mentorship of an experienced (master) gardener. AYA cancer survivors were successful in planting and harvesting vegetables from the garden in partnership with their mentors. Qualitative results and future directions for the project are discussed.

"Prevention Produce": Integrating Medical Student Mentorship into a Fruit and Vegetable Prescription Program for At-Risk Patients

INTRODUCTION

Fruit and vegetable prescription (FVRx) programs provide increased access to produce to food-insecure, at-risk populations, yet many lack the educational and social components to support long-term disease prevention.

OBJECTIVES

To address these barriers, students at Penn State College of Medicine designed "Prevention Produce"-a modified FVRx program that integrated a community-based, month-long educational curriculum-and undertook preliminary evaluation.

METHODS

Nine families deemed by clinicians as at risk of chronic disease and food insecurity received weekly $40 "prescriptions" for produce at partnering farmers markets. Participants were paired with medical student mentors who delivered weekly nutrition education modules and assisted in produce shopping. Preprogram and postprogram surveys were administered, categorizing perceptions and practices of healthy eating. All participants were interviewed by phone 3 years later to assess long-term impact. Medical students provided written reflections via online survey.

RESULTS

Postprogram fruit and vegetable consumption increased, and more patients expressed efforts to include produce in every meal. More participants strongly agreed that fruits and vegetables prevented chronic diseases. In reflective interviews, participants praised the program's ease of use, mentor-patient relationship, and increased access to produce. Student mentors expressed gratitude for one-on-one interaction and felt empowered to learn and deliver nutrition education.

CONCLUSION

Integration of an FVRx program with education, mentorship, and community-based focus may increase produce consumption and improve opinions about healthy eating. This program serves as a model for integrating preventive strategies within larger health care systems. Additionally, the model can facilitate early clinical interventions that may benefit medical trainees' professional development.

Evaluating the Benefits of the TimeSlips Creative Storytelling Program for Persons With Varying Degrees of Dementia Severity

OBJECTIVES

To evaluate the benefits of TimeSlips, a group creative storytelling intervention used in residential care settings, on quality of life (QOL), interactions with caregivers, and Mini-Mental State Examination (MMSE) scores for persons with varying degrees of dementia severity.

DESIGN

A mixed-methods approach was used weekly over a 6-month period to measure QOL and resident-caregiver relationships.

SETTING

A dementia care unit in Pennsylvania.

PARTICIPANTS

Twenty-two residents with mild-to-severe dementia.

MEASUREMENTS

Dementia severity and QOL were assessed using the MMSE and Greater Cincinnati Chapter Well-Being Observational Tool. Resident-caregiver interactions were analyzed using a modified version of the Quality of Interactions Schedule. Semistructured interviews were conducted upon the study's conclusion.

RESULTS

Quantitatively, participants initially classified with mild-moderate dementia were significantly more likely to experience positive benefits compared to those initially classified with severe dementia. There were no significant changes in dementia severity over time. There was also no change in QOL or resident-caregiver relationships for those with mild-moderate dementia over time, although there was a decrease in certain measures of QOL and resident-caregiver relationships for those with severe dementia. Qualitative analysis identified consistent benefits for residents with both mild-moderate and severe dementia over time.

CONCLUSIONS

Mixed-methods analyses helped identify benefits of TimeSlips for persons at all levels of dementia severity, but particularly for those with milder dementia. Such an observation helps demonstrate how arts-based programs like TimeSlips can uniquely benefit people with advanced memory impairments and thereby support QOL.

Evaluating the Benefits of Hospital Room Artwork for Patients Receiving Cancer Treatment: A Randomized Controlled Trial

We examined whether placing a painting in the line of vision of a hospitalized patient improves patient outcomes and satisfaction and whether having patients choose their paintings offers greater benefit. From 2014 to 2016, we enrolled 186 inpatients with cancer diagnoses from Pennsylvania State University Cancer Institute and randomly assigned them to 3 groups: those who chose paintings displayed in rooms, those whose paintings were randomly selected, and those with no paintings. We assessed anxiety, mood, depression, quality of life, perceptions of hospital environment, sense of control and/or influence, self-reported pain, and length of stay and compared patients with paintings versus those without paintings, as well as those with an artwork choice versus those with no choice. There were no differences in psychological and/or clinical outcomes across the groups, but patients in the 2 groups with paintings reported significantly improved perceptions of the hospital environment. Integrating artwork into inpatient rooms may represent one means of improving perceptions of the institution.

Engineering Online and In-Person Social Networks for Physical Activity: A Randomized Trial

BACKGROUND

Social networks can influence physical activity, but little is known about how best to engineer online and in-person social networks to increase activity.

PURPOSE

The purpose of this study was to conduct a randomized trial based on the Social Networks for Activity Promotion model to assess the incremental contributions of different procedures for building social networks on objectively measured outcomes.

METHODS

Physically inactive adults (n = 308, age, 50.3 (SD = 8.3) years, 38.3 % male, 83.4 % overweight/obese) were randomized to one of three groups. The Promotion group evaluated the effects of weekly emailed tips emphasizing social network interactions for walking (e.g., encouragement, informational support); the Activity group evaluated the incremental effect of adding an evidence-based online fitness walking intervention to the weekly tips; and the Social Networks group evaluated the additional incremental effect of providing access to an online networking site for walking as well as prompting walking/activity across diverse settings. The primary outcome was mean change in accelerometer-measured moderate-to-vigorous physical activity (MVPA), assessed at 3 and 9 months from baseline.

RESULTS

Participants increased their MVPA by 21.0 min/week, 95 % CI [5.9, 36.1], p = .005, at 3 months, and this change was sustained at 9 months, with no between-group differences.

CONCLUSIONS

Although the structure of procedures for targeting social networks varied across intervention groups, the functional effect of these procedures on physical activity was similar. Future research should evaluate if more powerful reinforcers improve the effects of social network interventions.

TRIAL REGISTRATION NUMBER

The trial was registered with the ClinicalTrials.gov (NCT01142804).

Medical Students as Systems Ethnographers: Exploring Patient Experiences and Systems Vulnerabilities in the Emergency Department

OBJECTIVES

The objectives were 1) to design systems ethnography roles for first-year medical students that could enhance student learning with regard to healthcare systems, ethnography, and systems thinking and 2) to describe strategies for other education programs seeking to implement systems ethnography roles in clinical settings.

METHODS

Fourteen medical students were educated about ethnography and systems thinking and linked with patients in the emergency department (ED) for 12 to 15 hours to observe patient experiences and clinical processes. Students submitted written assignments, participated in a debriefing exercise with ED and medical education leadership, and completed an electronic survey regarding educational benefits and perceived clinical value conferred to the ED using 5-point Likert-scale questions. Qualitative methods were used to analyze both students' assignments and notes taken during the debriefing session, including small-group report-outs and discussions, and to identify vulnerabilities in the patient experience.

RESULTS

Students identified one overarching theme of the patient experience-prolonged waiting in close proximity to the fast-paced, hectic "world" of the ED. Four key categories of systems vulnerabilities were identified through student observations: 1) patient experience; 2) communication and collaboration; 3) processes, physical space, and resources; and 4) professionalism. Students reported improved appreciation for challenges experienced by patients (3.92/5), importance of communication between providers and patients (3.92/5), and improved understanding of the patient experience while receiving care (3.77/5).

CONCLUSIONS

These results demonstrate how innovative systems ethnography experiences for medical students can provide unique educational opportunities while at the same time adding value by highlighting shortcomings in the care environment that can be used for system improvement.