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Importance: Algorithms are commonly incorporated into health care decision tools used by health systems and payers and thus affect quality of care, access, and health outcomes. Some algorithms include a patient's race or ethnicity among their inputs and can lead clinicians and decision-makers to make choices that vary by race and potentially affect inequities. Objective: To inform an evidence review on the use of race- and ethnicity-based algorithms in health care by gathering public and stakeholder perspectives about the repercussions of and efforts to address algorithm-related bias. Design, Setting, and Participants: Qualitative methods were used to analyze responses. Responses were initially open coded and then consolidated to create a codebook, with themes and subthemes identified and finalized by consensus. This qualitative study was conducted from May 4, 2021, through December 7, 2022. Forty-two organization representatives (eg, clinical professional societies, universities, government agencies, payers, and health technology organizations) and individuals responded to the request for information. Main Outcomes and Measures: Identification of algorithms with the potential for race- and ethnicity-based biases and qualitative themes. Results: Forty-two respondents identified 18 algorithms currently in use with the potential for bias, including, for example, the Simple Calculated Osteoporosis Risk Estimation risk prediction tool and the risk calculator for vaginal birth after cesarean section. The 7 qualitative themes, with 31 subthemes, included the following: (1) algorithms are in widespread use and have significant repercussions, (2) bias can result from algorithms whether or not they explicitly include race, (3) clinicians and patients are often unaware of the use of algorithms and potential for bias, (4) race is a social construct used as a proxy for clinical variables, (5) there is a lack of standardization in how race and social determinants of health are collected and defined, (6) bias can be introduced at all stages of algorithm development, and (7) algorithms should be discussed as part of shared decision-making between the patient and clinician. Conclusions and Relevance: This qualitative study found that participants perceived widespread and increasing use of algorithms in health care and lack of oversight, potentially exacerbating racial and ethnic inequities. Increasing awareness for clinicians and patients and standardized, transparent approaches for algorithm development and implementation may be needed to address racial and ethnic biases related to algorithms.

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OBJECTIVE: The construct of perfectionism has long been related to Obsessive-Compulsive Personality Disorder (OCPD), though research has not considered how OCPD could distinguish individuals with elevated perfectionism. The aim of this study was to evaluate clinical differences between those with and without OCPD in a sample of individuals with elevated perfectionism. METHODS: Seventy-four university students with elevated perfectionism completed a diagnostic assessment and several self-report measures of clinical characteristics and were randomly assigned to complete an exposure-based treatment for perfectionism or waitlist. Thirty-four (45.95%) participants met DSM-IV diagnostic criteria for OCPD. RESULTS: Compared to those without OCPD, individuals with OCPD had higher levels of general and specific domains of perfectionism and higher levels of social anxiety. OCPD diagnosis was also associated with higher rates of current anxiety disorder. Importantly, those with and without OCPD showed comparable benefits from treatment. CONCLUSIONS: This study provides novel evidence of the role of OCPD in perfectionism and demonstrates the efficacy of a perfectionism-oriented treatment in individuals with OCPD.Key pointsWe examined the role of obsessive-compulsive personality disorder (OCPD) in a high perfectionism sample.OCPD was associated with higher perfectionism and personal standards.OCPD was also associated with higher social anxiety and higher rates of current anxiety disorder.Those with and without OCPD had comparable responses to an exposure-based treatment for perfectionism.

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BACKGROUND AND OBJECTIVES: Loneliness is an important factor in mental and physical health. People with social anxiety disorder (SAD) often report high levels of loneliness, which may be maintained by difficulties with intimacy. Building Closer Friendships (BCF) is a technology-based intervention we developed to reduce loneliness through reducing fear of intimacy in individuals with SAD. METHODS: A sample of individuals with current SAD (N = 55), were randomized to BCF or waitlist control conditions and completed self-report assessments of loneliness, fear of intimacy, social anxiety and other outcomes throughout the study. An in vivo conversation task was also administered at post-treatment to assess distress and perceived disclosure, warmth, and friendliness of participants when interacting with a stranger. RESULTS: In the intent-to-treat analyses, the BCF group reported lower fear of intimacy at post-treatment compared to the control group. Among completers, BCF led to lower fear of intimacy at post-treatment and follow-up, and lower loneliness and depression at follow-up compared to the waitlist control. No treatment effects were found in the conversation task or for other symptom outcomes, including social anxiety. Analyses of treatment components revealed that the frequency of emotional check-ins with friends was associated with reductions in loneliness and depression. LIMITATIONS: The study was limited by the sample of primarily undergraduate college students, and use of self-report measures. CONCLUSIONS: This preliminary study found modest support for BCF as a computerized intervention to reduce fear of intimacy and loneliness in individuals with SAD.

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Rapid advances in precision medicine promise dramatic reductions in morbidity and mortality for a growing array of conditions. To realize the benefits of precision medicine and minimize harm, it is necessary to address real-world challenges encountered in translating this research into practice. Foremost among these is how to choose and use precision medicine modalities in real-world practice by addressing issues related to caring for the sizable proportion of people living with multimorbidity. Precision medicine needs to be delivered in the broader context of precision care to account for factors that influence outcomes for specific therapeutics. Precision care integrates a person-centered approach with precision medicine to inform decision making and care planning by taking multimorbidity, functional status, values, goals, preferences, social and societal context into account. Designing dissemination and implementation of precision medicine around precision care would improve person-centered quality and outcomes of care, target interventions to those most likely to benefit thereby improving access to new therapeutics, minimize the risk of withdrawal from the market from unanticipated harms of therapy, and advance health equity by tailoring interventions and care to meet the needs of diverse individuals and populations. Precision medicine delivered in the context of precision care would foster respectful care aligned with preferences, values, and goals, engendering trust, and providing needed information to make informed decisions. Accelerating adoption requires attention to the full continuum of translational research: developing new approaches, demonstrating their usefulness, disseminating and implementing findings, while engaging patients throughout the process. This encompasses basic science, preclinical and clinical research and implementation into practice, ultimately improving health. This article examines challenges to the adoption of precision medicine in the context of multimorbidity. Although the potential of precision medicine is enormous, proactive efforts are needed to avoid unintended consequences and foster its equitable and effective adoption.

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Reusable respiratory protective devices called elastomeric respirators have demonstrated their effectiveness and acceptability in well-resourced healthcare settings. Using standard qualitative research methods, we explored the feasibility of elastomeric respirator use in low- and middle-income countries (LMIC). We conducted interviews and focus groups with a convenience sample of health workers at one clinical center in Mali. Participants were users of elastomeric and/or traditional N95 respirators, their supervisors, and program leaders. Interview transcripts of participants were analyzed using a priori constructs from the Health Belief Model (HBM) and a previous study about healthcare respirator use. In addition to HBM constructs, the team identified two additional constructs impacting uptake of respirator use (system-level factors and cultural factors). Together, these framed the perceptions of Malian health workers and highlighted both facilitators of and barriers to respirator use uptake. As needs for respiratory protection from airborne infectious hazards become more commonly recognized, elastomeric respirators may be a sustainable and economic solution for health worker protection in LMIC.

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Background: Dissemination and implementation (D&I) research is a key factor in the uptake and use of evidence-based cancer control interventions. National Cancer Institute (NCI)-designated cancer centers are ideal settings in which to further D&I knowledge. The purpose of this study was to summarize the characteristics of NCI-funded D&I science grants in the nation's cancer centers to understand the nature, extent, and opportunity for this key type of translational work. Methods: We used the National Institutes of Health Research Portfolio Online Reporting Tool to identify active NCI-funded grants in D&I science at NCI clinical cancer centers (n = 13) and comprehensive cancer centers (n = 51) as well as their academic affiliates. Active projects were eligible for inclusion if they 1) were awarded directly to an NCI cancer center or an academic or research affiliate, and 2) identified D&I content in the abstract. Portfolio data were collected in February 2021. Results: We identified 104 active NCI-funded D&I research or training grants across the 64 cancer centers; 57.8% of cancer centers had at least 1 NCI-funded D&I grant. Most awards (71.1%) were for research grants. Training grants constituted 29.1% of D&I-focused grants. Overall, 50.0% of grants (n = 52) concentrated on specific cancers. Almost two-thirds of grants (n = 68, 65.4%) had a stated health equity focus. Conclusions: More than one-half of NCI-designated cancer centers have active funding in D&I science, reflecting a substantial investment by NCI. There remains considerable room for further development, which would further support NCI's translational mission.

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BACKGROUND: Colorectal cancer (CRC) rates are increasing in individuals below the age of 50 and this trend has been projected to continue for the foreseeable future. Health officials are calling for increased awareness of rising rates in affected populations to promote discussion and early detection. METHODS: In May 2018, we surveyed an online purposive sample of adults below the age of 50 (N = 624). We conducted an exploratory analysis examining knowledge of current CRC screening guidelines, knowledge of available CRC screening methods, perceived risk of CRC, and perceived importance of screening for CRC by gender, race, and previous CRC screening activity. RESULTS: The sample was 56% female, averaged 36 years of age, largely identified as Caucasian (84%), married (48%), and well educated (70% with some college or a college degree). 36% correctly identified the current age of recommended CRC screening initiation. Few (8%) correctly identified all CRC screening options presented. Genetics was thought to be the most relevant determinant of CRC. African American or black participants perceived themselves to be at lower risk of CRC, while women rated the importance of screening significantly lower than men. CONCLUSION: We identified a lack of CRC knowledge in individuals below the age of 50. Interventions should correct perceptions of risk of CRC and highlight the importance of screening. Complete knowledge of the range of screening options may reduce barriers to screening while a greater knowledge of modifiable risk factors of CRC can promote healthy behaviors.

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BACKGROUND: Social support has been identified as a protective factor against suicidal thoughts and behaviors. Research has not conclusively identified the component of social support most implicated in suicidal thoughts and behaviors: (1) frequency of social contact or (2) closeness of relationships. This study examined the relationships between these facets of social support and suicidal thoughts and behaviors in two nationally representative samples, as well as subsamples with social anxiety disorder (SAD). METHODS: Study 1 variables for lifetime and past-year suicide ideation and attempt, social contact frequency, and closeness were calculated and examined within the National Comorbidity Survey-Replication (NCS-R). Study 2 examined the independent contributions of social contact frequency and closeness to only lifetime suicide attempt in the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). RESULTS: In the NCS-R, lower social closeness but not contact frequency was uniquely associated with suicidal ideation and attempt in the general sample and those with SAD. In the NESARC-III, both components of social support were associated with lifetime suicide attempt in the general sample, while only social closeness was uniquely associated with suicide attempt in the SAD subsample. LIMITATIONS: This study utilized cross-sectional data and was limited in the validity and specificity of the variables assessed. DISCUSSION: Lower social closeness was more strongly associated with suicidality than social contact frequency and merits attention as a potential target for suicide-related interventions. Social closeness may be especially relevant in populations experiencing high rates of suicidal thoughts and behaviors and decreased social support.

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BACKGROUND: Adaptations to evidence-based practices (EBPs) are common but can impact implementation and patient outcomes. In our prior research, providers in routine care made a fidelity-inconsistent adaptation to an EBP that improved health outcomes in people with serious mental illness (SMI). The purpose of this study was to characterize the process and reasons for the adaptation using a framework for reporting adaptations and modifications to EBPs, with a focus on equity. METHODS: This study used qualitative data collected during a national implementation of the InSHAPE EBP addressing obesity in persons with SMI. We reviewed transcripts from five behavioral health organizations that made a successful fidelity-inconsistent adaptation to a core component of InSHAPE that was associated with cardiovascular risk reduction. We coded the data using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) with an emphasis on exploring whether the adaptation addressed inequities in using the EBP related to social determinants of health. RESULTS: Across the five agencies, the fidelity-inconsistent adaptation was characterized as unplanned and reactive in response to challenges InSHAPE teams experienced delivering the intervention in community fitness facilities as intended. In all cases, the goal of the adaptation was to improve intervention access, feasibility and fit. Social and economic disadvantage were noted obstacles to accessing fitness facilities or gyms among participants with SMI, which led agencies to adapt the program by offering sessions at the mental health center. CONCLUSIONS: Findings from this study show the advantages of applying a health equity lens to evaluate how obstacles such as poverty and discrimination influence EBP adaptations. Recommendations can also assist researchers and community partners in making proactive decisions about allowable adaptations to EBPs.

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Background: Social anxiety has been associated with higher levels of and more problematic marijuana use. Research suggests that safety behaviors may play a role in the development and maintenance of marijuana problems. However, the safety behaviors that are most commonly associated with social anxiety have not been investigated, nor has the potential moderating role of gender on this relationship. Method: A diverse sample of regular marijuana users (N = 279) completed measures of social anxiety, safety behaviors related to social situations, and marijuana use problems. Results: Social anxiety and safety behavior use were both positively correlated with marijuana use problems. These relationships were stronger in men than in women. Among men only, tendencies to use safety behaviors to cope with social situations accounted for the relationship between social anxiety symptoms and marijuana-related problems. Discussion: The avoidant coping style that characterizes safety behaviors in social anxiety may also underlie problematic patterns of marijuana use, particularly for men. The present study is the first to report an association between safety behaviors in social situations and marijuana use problems and suggests the importance of examining the effect of reducing safety behaviors in social situations, in regular marijuana users with comorbid social anxiety.

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BACKGROUND: Most measures of anxious avoidance are limited to disorder-specific mechanisms and ignore the measurement of courage/approach responding in confronting fearful situations. AIMS: The purpose of the present study was to construct and validate a self-report assessment of the tendency towards avoidant or approach responding in fearful situations, the Response to Fearful Situations Scale (RFSS). METHOD AND RESULTS: In Study 1 (n = 241), exploratory factor analysis resulted in two factors, avoidance and approach. Study 2 (n = 423) replicated the two-factor structure and established test-re-test reliability. In Study 3 (n = 44), the RFSS demonstrated predictive validity on a behavioural avoidance task. In Studies 4 (n = 253) and 5 (n = 256), the RFSS was associated with clinical symptoms above existing measures of avoidance. DISCUSSION: These results validate the use of the RFSS as a transdiagnostic measure of avoidance and approach.

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OBJECTIVE: Cognitive models of social anxiety disorder propose that maladaptive safety behaviors (SBs; i.e., behaviors intended to avoid, prevent, or manage threat) play an important maintaining role in the disorder. Though targeting these behaviors for elimination is one component of contemporary cognitive-behavioral therapies for social anxiety, it has rarely been examined as a specific treatment strategy, and, to our knowledge, it has not yet been examined in isolation as an intervention for social anxiety. The current study evaluated an SB reduction intervention for social anxiety that consisted of brief text message reminders. METHOD: Individuals with elevated social anxiety (N = 94) were recruited from across the United States and randomized to receive one of two 1-month text message interventions consisting of 16 text message reminders to avoid SBs or focus on the present. Symptoms were assessed at pre- and posttreatment, as well as at 1-month follow-up. RESULTS: Both treatments were associated with substantial symptom reduction. Compared to the present-focused text message condition, SB elimination led to lower SB frequency at posttreatment (sr² = .044, p = .048) and lower social anxiety at follow-up (sr² = .096, p = .005). CONCLUSIONS: These preliminary findings provide novel evidence for the importance of SBs in social anxiety and suggest text message SB reduction may be an effective, highly accessible intervention for individuals with social anxiety. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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BACKGROUND: High rates of suicidal ideation in those with social anxiety disorder (SAD) have been attributed to feelings of thwarted belongingness and perceived burdensomeness, but most work has been in non-clinical samples. We assessed the contributions of thwarted belongingness and perceived burdensomeness to suicidal ideation severity, over clinical covariates, in individuals diagnosed with SAD. METHODS: Participants were 58 adult outpatients (mean age 25.62 years, 69% female) with SAD. Hierarchical linear regression assessed contributions of thwarted belongingness and perceived burdensomeness to suicidal ideation, before and after covarying other potential explanatory variables (depression, agitation, brooding rumination). RESULTS: Perceived burdensomeness was significantly positively related to suicidal ideation severity (p < .001) above thwarted belongingness, which was not incremental (p = .791). The same pattern was found after inclusion of additional covariates (perceived burdensomeness p = .006; thwarted belongingness p = .757). Greater agitation also uniquely accounted for more severe suicidal ideation (p = .001). LIMITATIONS: This study was cross-sectional, did not assess all potential confounding variables, and utilized a treatment-seeking sample. CONCLUSIONS: Results suggest perceived burdensomeness is independently related to suicidal ideation severity in SAD, over thwarted belongingness and other clinical features. Future work should seek to replicate these findings and evaluate causal, longitudinal relationships among perceived burdensomeness, agitation, and severity of suicidal ideation in those with SAD in order to determine whether these may be clinically-relevant mechanisms.

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INTRODUCTION: Colonoscopy screening is an effective method of detecting and preventing colorectal cancer. Standard procedure for most colonoscopies (98%) is to use conscious sedation, which can cause short-term cognitive impairment postprocedure, including communication difficulties. In this study, we explored providers' (gastroenterology doctors and nurses) perceptions of the barriers to optimal communication with patients immediately following colonoscopy. METHODS: We conducted interviews with 61 providers across 5 clinical configurations. Interviews were transcribed and coded with NVivo version 11 software. RESULTS: Themes emerged regarding barriers to optimal provider-patient communication postcolonoscopy: patient barriers (sedation and patient characteristics), caregiver barriers, and system characteristics. CONCLUSIONS: Providers' perceived barriers to communication are an important topic to study. They endorsed, in particular, interventions that target the postcolonoscopy time frame when patients may still be sedated, but providers must convey important discharge and follow-up instructions.

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In sterile neuroinflammation, a pathological role is proposed for microglia, whereas in viral encephalitis, their function is not entirely clear. Many viruses exploit the odorant system and enter the CNS via the olfactory bulb (OB). Upon intranasal vesicular stomatitis virus instillation, we show an accumulation of activated microglia and monocytes in the OB. Depletion of microglia during encephalitis results in enhanced virus spread and increased lethality. Activation, proliferation, and accumulation of microglia are regulated by type I IFN receptor signaling of neurons and astrocytes, but not of microglia. Morphological analysis of myeloid cells shows that type I IFN receptor signaling of neurons has a stronger impact on the activation of myeloid cells than of astrocytes. Thus, in the infected CNS, the cross talk among neurons, astrocytes, and microglia is critical for full microglia activation and protection from lethal encephalitis.

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OBJECTIVE: The objective of this paper is to demonstrate the utility of the CFIR framework for evaluating broad-scale change by discussing the challenges to be addressed when planning the assessment of broad-scale change and the solutions developed by the evaluation team to address those challenges. The evaluation of implementation of Patient-centered Care and Cultural Transformation (PCC&CT) within the Department of Veterans Affairs (VA) will be used as a demonstrative example. Patient-Centered Care (PCC) is personalized health care that considers a patient's circumstances and goals. The Department of Veterans Affairs (VA) is working towards implementing PCC throughout its healthcare system, comprised of multiple interventions with a singular long-term goal of cultural transformation, however little is known about the factors influencing its implementation. This paper discusses the issues that arose using CFIR to qualitatively assess the factors influencing implementation of cultural transformation. RESULTS: Application of CFIR to this broad-scale evaluation revealed three strategies recommended for use in evaluating implementation of broad-scale change: (1) the need for adapted definitions for CFIR constructs (especially due to new application to broad-scale change), (2) the use of a mixed deductive-inductive approach with thematic coding to capture emergent themes not encompassed by CFIR, and (3) its use for expedited analysis and synthesis for rapid delivery of findings to operational partners. This paper is among the first to describe use of CFIR to guide the evaluation of a broad-scale transformation, as opposed to discrete interventions. The processes and strategies described in this paper provide a detailed example and structured approach that can be utilized and expanded upon by others evaluating implementation of broad-scale evaluations. Although CFIR was the framework selected for this evaluation, the strategies described in this paper including: use of adapted definitions, use of mixed deductive-inductive approach, and the approach for expedited analysis and synthesis can be transferred and tested with other frameworks.

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BACKGROUND: Management of severe and persistent mental illness is a complex, resource-intensive challenge for individuals, their families, treaters, and the health care system at large. Community-based rehabilitation, in which peer specialists provide support for individuals managing their own condition, has demonstrated effectiveness but has only been implemented in specialty centers. It remains unclear how the peer-based community rehabilitation model could be expanded, given that it requires significant resources to both establish and maintain. OBJECTIVE: Here, we describe the results from a study of one such program implemented within Waverley Place, a community support program at McLean Hospital, emphasizing psychiatric rehabilitation for individuals with severe and persistent mental illness, as well as describing the challenges encountered during the implementation of the program. Key questions were whether the patients could, and would, successfully use the app. METHODS: The smartphone app offered multiple features relevant to psychiatric rehabilitation, including daily task lists, activity tracking, and text messaging with peer specialists. A 90-day program of activities, goals, and content specific to the community support program was created on the basis of a prior pilot, in collaboration between members of the app development team (WellFrame), and peers, clinical, and research staff associated with the program. Hospital research staff recruited patients into the study, monitored peer and patient engagement, and handled all raw data acquired from the study. RESULTS: Of 100 people approached for the study, a total of 13 provided consent, of which 10 downloaded and used the app. Two patients were unable to complete the app installation. Five used the app regularly as part of their daily lives for at least 20 days of the 90-day program. We were unable to identify any specific factors (eg, clinical or demographic) that affected willingness to consent or engage with the app platform in the very limited sample, although the individuals with significant app use were generally satisfied with the experience. CONCLUSIONS: Smartphone apps may become a useful tool for psychiatric rehabilitation, addressing both psychiatric and co-occurring medical problems. Individualizing functions to each patient and facilitating connection with a certified peer specialist may be an important feature of useful apps. Unlike prior reports emphasizing that patients with schizophrenia will adopt smartphone platforms, we found that implementation of digital tools into existing community support programs for severe and persistent mental illness has many challenges yet to be fully overcome to realize the potential benefits such apps could have to promote systematization and cost reduction for psychiatric rehabilitation.

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Genomic imprinting confers parent-of-origin-specific gene expression, thus non-equivalent and complementary function of parental genomes. As a consequence, genomic imprinting poses an epigenetic barrier to parthenogenesis in sexual organisms. We report aberrant imprinting in Boechera, a genus in which apomicts evolved from sexuals multiple times. Maternal activation of a MADS-box gene, a homolog of which is imprinted and paternally expressed in the sexual relative Arabidopsis, is accompanied by locus-specific DNA methylation changes in apomicts where parental imprinting seems to be relaxed.

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OBJECTIVES: Gamma oscillation is important for cortico-cortical coordination and the integration of information across neural networks. The 40 Hz auditory steady-state response (ASSR), which reflects neural synchrony in the gamma band (30-100 Hz), is abnormal in patients with schizophrenia (SZ). The present study used the ASSR at multiple frequencies to examine (1) gamma dysfunction in patients with SZ, schizoaffective (SA), and bipolar disorder (BD) compared with controls, (2) the relationship between ASSR measures and clinical symptom severity, and (3) the relationship between ASSR measures and real-life community functioning. METHODS: EEG was recorded from 75 controls, 52 SZ, 55 SA, and 89 BD patients during 20-30-40-Hz binaural click trains. ANCOVA was used to compare ASSR measures between groups controlling for age, sex, and education. Associations between ASSR measures, symptom severity, and community functioning were examined using linear regression and Pearson partial correlations. RESULTS: ASSR deficits at gamma frequency were observed in all patient groups. SA patients showed additional specific deficit in the 20 Hz ASSR. Severity of manic, depressive, and anxiety symptoms mediated ASSR deficits. Severity of hallucinatory symptom and community functioning, particularly independent living/meaningful activity, were significantly and independently associated with the 40 Hz ASSR. CONCLUSIONS: SZ, SA and BD patients are likely to share the same abnormalities in neural processes that generate gamma oscillations. 40 Hz ASSR are associated with community functioning across patients and may serve as a biomarker for predicting functional outcome.

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