Migrants and refugees face elevated risks for mental health problems but have limited access to services. This study compared two strategies for training and supervising nonspecialists to deliver a scalable psychological intervention, Group Problem Management Plus (gPM+), in northern Colombia. Adult women who reported elevated psychological distress and functional impairment were randomized to receive gPM+ delivered by nonspecialists who received training and supervision by: 1) a psychologist (specialized technical support); or 2) a nonspecialist who had been trained as a trainer/supervisor (nonspecialized technical support). We examined effectiveness and implementation outcomes using a mixed-methods approach. Thirteen nonspecialists were trained as gPM+ facilitators and three were trained-as-trainers. We enrolled 128 women to participate in gPM+ across the two conditions. Intervention attendance was higher in the specialized technical support condition. The nonspecialized technical support condition demonstrated higher fidelity to gPM+ and lower cost of implementation. Other indicators of effectiveness, adoption and implementation were comparable between the two implementation strategies. These results suggest it is feasible to implement mental health interventions, like gPM+, using lower-resource, community-embedded task sharing models, while maintaining safety and fidelity. Further evidence from fully powered trials is needed to make definitive conclusions about the relative cost of these implementation strategies.

5wPatients with end stage kidney disease (ESKD) who receive in-center hemodialysis are disproportionately vulnerable to extreme weather events, including hurricanes and heat waves, that may disrupt access to healthcare providers, and life-sustaining treatments. This current era of climate-driven compounding disasters is progressively elevating the level of threat to the health and well-being of patients with ESKD. This analysis brings together multi-disciplinary expertise to explore the contours of this increasingly complex risk landscape. Despite the challenges, important advances have been made for safeguarding this medically high-risk patient population. Hemodialysis services providers have devised innovative systems for preparing their patients and sustaining, or rapidly reestablishing, hemodialysis services in the aftermath of a disaster, and maintaining open lines of communication with their caseloads of ESKD patients throughout all phases of the event. A description of lessons learned along the path towards improved patient support in disasters, is provided. The article concludes with a detailed case example, describing dialysis providers’ effective response throughout Hurricane Ian’s passage across the State of Florida in 2022. Based on lessons learned, this analysis outlines strategies for protecting patients with ESKD that may be adapted for future climate-potentiated disaster scenarios.

The federal government is funding a sea change in health care by investing in interventions targeting social determinants of health, which are significant contributors to illness and health inequity. This funding power has encouraged states, professional and accreditation organizations, health care entities, and providers to focus heavily on social determinants. We examine how this shift in focus affects clinical practice in the fields of oncology and emergency medicine, and highlight potential areas of reform.

This study investigates antecedents of entrepreneurial intentions of young adults, the next generation of entrepreneurs. We determine whether aspiring entrepreneurs' positive and dark traits relate to entrepreneurial intentions. Results indicated that entrepreneurial fitness, a second-order construct comprised of multiple positive and bright traits, positively relates to entrepreneurial intention, while the dark traits of Machiavellianism and narcissism differentially relate to entrepreneurial fitness and intention. Narcissism positively relates to entrepreneurial fitness and intention both directly and indirectly. Though Machiavellianism positively and directly relates to entrepreneurial intention, it also negatively and indirectly relates to intention through a negative relationship with entrepreneurial fitness. However, overall, entrepreneurial fitness positively relates with entrepreneurial intention. Findings extend the core model of entrepreneurial intention by concurrently illuminating the adaptive and maladaptive aspects of the dark side of narcissism and Machiavellianism with the bright, positive antecedents of entrepreneurial intention with entrepreneurial fitness. Theoretical and practical implications are discussed.

We assessed the efficacy of a culturally competent outreach model with promotoras in raising the coronavirus disease 2019 (COVID-19) first-dose vaccination rates in Chicago’s at-risk ZIP codes from February through May 2021. Utilizing community members from within target communities may reduce barriers, increase vaccination rates, and enhance COVID-19 prevention.

Background: Standard of care treatment for adult intracranial ependymoma patients includes maximal safe surgical resection, while the role for adjuvant radiotherapy remains unclear with existing data from small retrospective series’. Accordingly, we built a multi-institutional cohort to assess the prognostic value of adjuvant radiotherapy and other clinical factors in these patients. Methods: Patients managed for adult intracranial ependymomas from 1968 onwards within the University Health Network in Toronto, The University of Oklahoma Health Sciences Center, and The Ottawa Hospital were identified. Multivariate models assessing the prognostic value of clinical factors were built using variables with known prognostic value and/or significance in univariate Cox models. Results: Of 122 ependymomas, 71% were infratentorial, 78% grade two, 55% gross/near-totally resected (GTR/NTR), and 65% treated with adjuvant radiotherapy. Multivariate analyses identified GTR/NTR (vs. subtotal resection; HR=0.2, 95%CI=0.1–0.4, p<0.0001) and cranial (HR=0.5, 95%CI=0.2–1.1) or craniospinal (HR=0.2, 95%CI=0.04–0.5) radiotherapy receipt (p=0.01) as independent statistically significant predictors of more favourable PFS. Grade II pathology (vs. grade III; HR=0.2, 95%CI=0.05–0.6, p=0.006) and GTR/NTR (vs. subtotal resection; HR=0.1, 95%CI=0.03–0.3, p=0.0001) were independent statistically significant predictors of better OS. Conclusions: This work confirms the importance of maximal safe resection for adult intracranial ependymomas and establishes that adjuvant radiotherapy improves progression-free survival in these patients.

Magnetism can greatly impact the evolution of stars. In some stars with OBA spectral types there is direct evidence via the Zeeman effect for stable, large-scale magnetospheres, which lead to the spin-down of the stellar surface and reduced mass loss. So far, a comprehensive grid of stellar structure and evolution models accounting for these effects was lacking. For this reason, we computed and studied models with two magnetic braking and two chemical mixing schemes in three metallicity environments with the mesa software instrument. We find notable differences between the subgrids, which affects the model predictions and thus the detailed characterisation of stars. We are able to quantify the impact of magnetic fields in terms of preventing quasi-chemically homogeneous evolution and producing slowly-rotating, nitrogen-enriched (“Group 2”) stars. Our model grid is fully open access and open source.

Physicians play a critical role in preventing and treating firearm injury, although the scope of that role remains contentious and lacks systematic definition. This piece aims to utilize the fundamental principles of medical ethics to present a framework for physician involvement in firearm violence. Physicians' agency relationship with their patients creates ethical obligations grounded on three principles of medical ethics — patient autonomy, beneficence, and nonmaleficence. Taken together, they suggest that physicians ought to engage in clinical screening and treatment related to firearm violence. The principle of beneficence also applies more generally, but more weakly, to relations between physicians and society, creating nonobligatory moral ideals. Balanced against physicians' primary obligations to patient agency relationships, general beneficence suggests that physicians may engage in public advocacy to address gun violence, although they are not ethically obligated to do so. A fourth foundational principle — justice — requires that clinicians attempt to ensure that the benefits and burdens of healthcare are distributed fairly.

This qualitative study describes the lived experience of physicians who work in communities that have experienced a public mass shooting. Semi-structured interviews were conducted with seventeen physicians involved in eight separate mass casualty shooting incidents in the United States. Four major themes emerged from constant comparative analysis: (1) The psychological toll on physicians: “I wonder if I'm broken”; (2) the importance of and need for mass casualty shooting preparedness: “[We need to] recognize this as a public health concern and train physicians to manage it”; (3) massive media attention: “The media onslaught was unbelievable”; and (4) commitment to advocacy for a public health approach to firearm violence: “I want to do whatever I can to prevent some of these terrible events.”

Firearm injury in the United States is a public health crisis in which physicians are uniquely situated to intervene. However, their ability to mitigate harm is limited by a complex array of laws and regulations that shape their role in firearm injury prevention. This piece uses four clinical scenarios to illustrate how these laws and regulations impact physician practice, including patient counseling, injury reporting, and the use of court orders and involuntary holds. Unintended consequences on clinical practice of laws intended to reduce firearm injury are also discussed. Lessons drawn from these cases suggest that physicians require more nuanced education on this topic, and that policymakers should consult front-line healthcare providers when designing firearm policies.

Brain metastases (BM) are the most common intracranial neoplasm and represent a major clinical challenge across many medical disciplines. The incidence of BM is increasing, largely due to improvements in primary disease therapeutics conferring greater systemic control, and advancements in neuroimaging techniques and availability leading to earlier diagnosis. In recent years, the landscape of BM treatment has changed significantly with the advent of personalized targeted chemotherapies and immunotherapy, the adoption of focal radiotherapy (RT) for higher intracranial disease burden, and the implementation of new surgical strategies. The increasing permutations of options available for the treatment of patients diagnosed with BM necessitate coordinated care by a multidisciplinary team. This review discusses the current treatment regimens for BM as well as examines the salient features of a modern multidisciplinary approach.

The national priority to advance early detection and intervention for children with autism spectrum disorder (ASD) has not reduced the late age of ASD diagnosis in the US over several consecutive Centers for Disease Control and Prevention (CDC) surveillance cohorts, with traditionally under-served populations accessing diagnosis later still. In this review, we explore a potential perceptual barrier to this enterprise which views ASD in terms that are contradicted by current science, and which may have its origins in the current definition of the condition and in its historical associations. To address this perceptual barrier, we propose a re-definition of ASD in early brain development terms, with a view to revisit the world of opportunities afforded by current science to optimize children's outcomes despite the risks that they are born with. This view is presented here to counter outdated notions that potentially devastating disability is determined the moment a child is born, and that these burdens are inevitable, with opportunities for improvement being constrained to only alleviation of symptoms or limited improvements in adaptive skills. The impetus for this piece is the concern that such views of complex neurodevelopmental conditions, such as ASD, can become self-fulfilling science and policy, in ways that are diametrically opposed to what we currently know, and are learning every day, of how genetic risk becomes, or not, instantiated as lifetime disabilities.