PSYCHOSOCIAL FACTORS AND MOBILE HEALTH INTERVENTION: IMPACT ON LONG-TERM OUTCOMES AFTER LUNG TRANSPLANTATION

Identifying and intervening on modifiable risk factors may improve outcomes in lung transplantation (LTx), which, despite recent improvements, remain suboptimal. Evidence suggests that two modifiable risk factors, psychiatric disorders and nonadherence, may improve LTx outcomes in the short-term; however, neither has been explored in the long-term. Therefore, the overarching goal of this dissertation was to determine the long-term impact of these modifiable risk factors and intervention to attenuate them. First, we examined the relationship of pre- and early post-transplant psychiatric disorders on LTx-related morbidity and mortality for up to 15 years post-LTx. Our sample included 155 1-year LTx survivors enrolled in a prospective study of mental health post- LTx. We found that depression during the first year post-LTx increased risk of BOS, mortality and graft loss by nearly twofold, and that pre-transplant depression and pre- and post-transplant anxiety were not associated with clinical outcomes. Next, we examined the impact of a mobile health intervention designed to promote adherence to the post-LTx regimen, PocketPATH, on long-term LTx-related morbidity, mortality and nonadherence. We conducted two follow-up studies to the original yearlong randomized controlled trial in which participants assigned to PocketPATH showed improved adherence to the regimen, relative to usual care. Among the 182 LTx recipients (LTxRs) who survived the original trial, we found that PocketPATH had a protective indirect effect on mortality by promoting LTxRs’ communication with the LTx team during the first year. Among the 104 LTxRs who completed the follow-up assessment, we found that PocketPATH’s adherence benefits over the first year were not sustained into the long-term, although LTxRs assigned to PocketPATH were more likely than LTxRs assigned to usual care to perform the home self-care tasks of the regimen at follow-up. Median time since LTx for participants in both follow-up studies was 4.2 years (range, 2.8-5.7 years). This dissertation presents an important first step toward identifying and intervening on modifiable risk factors to improve long-term LTx outcomes. Mobile health technologies offer limitless potential to target these risk factors and others. More work is needed to determine specific features and long-term patient engagement strategies that will optimize and sustain intervention effectiveness

Quality of recipient-caregiver relationship and psychological distress are correlates of self-care agency after lung transplantation

Self-care behaviors are crucial for following the complex regimen after lung transplantation, yet little is known about recipients’ levels of self-care agency (the capability and willingness to engage in self-care behaviors) and its correlates. We examined levels of self-care agency and recipient characteristics (socio-demographics, psychological distress, quality of relationship with primary lay caregiver, and health locus of control) in 111 recipients. Based on Perceived Self-Care Agency scores, recipients were assigned to either the low or high self-care agency comparison group. Characteristics were compared between groups to identify characteristics likely to be associated with lower self-care agency. Mean (S.D.) score for self-care agency (scale range 53–265) was 223.02 (22.46). Recipients with lowest self-care agency scores reported significantly poorer quality of caregiver relationships (p < .001) and greater psychological distress (p < .001). After controlling for psychological distress, the quality of the recipient-caregiver relationship remained significantly associated with self-care agency. Every one-point decrease in the quality of caregiver relationship increased the risk of low self-care agency by 12%. Recipients with poorer caregiver relationships and greater psychological distress may need additional support to perform the self-care behaviors expected after lung transplantation

An Intervention Fidelity Framework for Technology-Based Behavioral Interventions

Despite the proliferation of health technologies, descriptions of the unique considerations and practical guidance for evaluating intervention fidelity of technology-based behavioral interventions are lacking

Clinical trials of health information technology interventions intended for patient use: Unique issues and considerations

BACKGROUND: Despite the proliferation of health information technology (IT) interventions, descriptions of the unique considerations for conducting randomized trials of health IT interventions intended for patient use are lacking. PURPOSE: Our purpose is to describe the protocol to evaluate Pocket PATH (Personal Assistant for Tracking Health), a novel health IT intervention, as an exemplar of how to address issues that may be unique to a randomized controlled trial (RCT) to evaluate health IT intended for patient use. METHODS: An overview of the study protocol is presented. Unique considerations for health IT intervention trials and strategies are described to maintain equipoise, to monitor data safety and intervention fidelity, and to keep pace with changing technology during such trials. LESSONS LEARNED: The sovereignty granted to technology, the rapid pace of changes in technology, ubiquitous use in health care, and obligation to maintain the safety of research participants challenge researchers to address these issues in ways that maintain the integrity of intervention trials designed to evaluate the impact of health IT interventions intended for patient use. CONCLUSIONS: Our experience evaluating the efficacy of Pocket PATH may provide practical guidance to investigators about how to comply with established procedures for conducting RCTs and include strategies to address the unique issues associated with the evaluation of health IT for patient use

Culture, Altruism, and Conflict Between Ancestors and Descendants

Anthropologists often recorded the typical amount of kinship altruism – that is, the altruism between individuals who identify one another as kin -- they observed in what they referred to as tribal or traditional societies (e.g., Murdock 1949; Keesing 1975; Fortes 1969; Evans-Pritchard 1940). This altruism, they noted, was extended to very distant kin. This altruism toward distant kin, as several scholars have pointed out (E. O. Wilson, D.S. Wilson), is fundamentally inconsistent with the predictions of kin selection. In this paper, we present a possible solution to this puzzle, and one that does not reply on group selection. To do this we introduce a new evolutionary concept called “ancestor-descendant conflict” and the mathematical formula upon which it is based. The concept of “ancestor-descendant conflict” is a multi-generational diachronic extension of Trivers’ concept of “parent-offspring conflict.” It leads to an extension and revision of Hamilton’s rule “

Improving Understanding and Detection of Postpartum Anxiety

Background: Maternal mental health conditions are the most common complications in the postpartum period (Luca et al., 2019; US Preventive Services Task Force et al., 2019). Recognition that postpartum anxiety (PPA), anxiety during the post-partum period, is more prevalent than postpartum depression (PPD), and its significant impacts on maternal and infant outcomes, has raised interest in improving its detection (Accortt & Wong, 2017; Fairbrother et al., 2016; Fawcett et al., 2019). Yet, detection challenges remain including lack of diagnostic criteria for PPA (Jordan & Minikel, 2019; Zappas et al., 2020), difficulties differentiating between levels of anxiety (e.g., adaptive worry after childbirth, generalized anxiety, and postpartum-specific anxiety) (Howard & Khalifeh, 2020; Lorenzo, 2022; Zappas et al., 2020), and lack of consensus for a PPA-specific screening tool (Thorsness et al., 2018; Zappas et al., 2020). A better understanding of the course and temporal patterns of PPA, such as severity and influencing factors over time, is warranted to improve detection of PPA. Also, more descriptive research is needed to expand understanding of anxiety in postpartum contexts which may help to further delineate postpartum-specific anxiety from generalized anxiety and aid in detection and clinical management of the condition. Purpose: To describe the prevalence, stability, trends, and context of anxiety from the 3rd trimester of pregnancy (e.g., 27 to 40 weeks of pregnancy) to eight-weeks postpartum using multiple measurement modalities. Modalities included questionnaires to assess mood and ecological momentary assessments (mEMA) asking participants to rate daily anxiety levels and respond to open-ended mEMA questions guided by the Theory of Becoming a Mother (Mercer, 2004). Qualitative findings were compared between those with and without anxiety at eight-weeks postpartum and integrated with quantitative findings in a narrative synthesis. Sample and Setting: A convenience sample of 73 birthing people who planned to give birth to their infants at a large academic tertiary center in the Mid-Atlantic U.S. were enrolled. Study activities were performed remotely between August 2021 to March 2022. Methods: The study used a prospective, mixed-methods, cohort design for the purpose of development (i.e., mEMA daily anxiety ratings were used to develop a stratified sampling plan for the qualitative mEMA responses), and for the purpose of expansion (i.e., anxiety questionnaires were used to develop categories of participants by presence of anxiety). The State Trait Anxiety Inventory, State Scale (STAI-S) and Postpartum Specific Anxiety Scale (PSAS) were administered at baseline (3rd trimester, STAI-S only), one-, and eight-weeks postpartum. mEMA prompts were sent to participants to rate their daily anxiety on a scale of 0, “not at all” to 10, “very much so” and respond to open-ended questions regarding perceived stress, social support, role adjustment, environment, and source of daily anxiety. Established cut-off scores for anxiety on the STAI-S and PSAS were used to determine anxiety prevalence at each study timepoint using descriptive statistics. Stability of the STAI-S and PSAS was evaluated with a dependent samples t-test and repeated measures analysis of variance. Linear mixed modeling was used to evaluate trends in individuals’ daily anxiety ratings. The mode and variance of daily anxiety ratings for participants who returned ≥ 50% of mEMA prompts were used to stratify participants into four groups, from which 50% of the cases in each group were randomly selected for subsequent qualitative analysis (N = 34). Qualitative data were analyzed using qualitative descriptive methods and a theory-driven coding framework. Participants’ responses were organized into thematic-categories and major concepts. Eight-week STAI-S and PSAS scores were used to categorize participants by presence of anxiety based on established cut-off scores for anxiety (> 40 and > 112), respectively. Thematic-categories between anxiety classifications were compared using matrices, a joint display, and narrative synthesis to expand understanding. Findings: In our sample of mostly white (81%), partnered (90.4%), and highly educated (≥ graduate degree, 75%) people, mean STAI-S anxiety scores were significantly higher [F(1.85, 129.18) = 4.305, p = 0.018] at one week postpartum (36.4 11.0) than at eight-weeks postpartum (33.4 9.6). Mean PSAS scores were significantly higher [ t(70) = 3.047, p = 0.003] at eight-weeks postpartum (93.9 20.7) than at one-week (88.6 19.6). The proportion of the sample above the cut-off for anxiety on the STAI-S (> 40) in descending order was greatest at one-week postpartum (28.8%), lower at eight weeks (23.9%), and lowest at baseline (3rd pregnancy trimester) (21.9%). The proportion above the cut-off for anxiety on the PSAS (> 112) in descending order was greatest at eight-weeks (21.1%) and lowest at one-week postpartum (12.3%). The proportion who met anxiety thresholds on either the STAI-S or PSAS was greater at eight-weeks (35.2%) than one-week postpartum (31.5%). Only 33% of the sample’s responses for daily anxiety ratings between one- to eight-weeks postpartum (968/2936) indicated no level of daily anxiety (e.g., 0). Aggregated mean daily anxiety ratings were highest at two-weeks, declined and stabilized, then trended upward toward week eight postpartum, t(65.56) = 2.15, p = 0.036, 95% CI, [0.000034, 000944]. Individuals who met cut-offs for anxiety at eight-weeks postpartum described feeling more overwhelmed, having less support, experiencing more relationship conflict, difficulty adjusting to maternal roles, and having less positive environmental influences than those without anxiety. Further, there were qualitative differences between participants with anxiety per the STAI-S and anxiety per the PSAS. Specifically, participants with anxiety per the PSAS alternated between feeling able to “manage” their responsibilities and “overwhelmed” by their responsibilities over the study period. Alternatively, participants with anxiety per the STAI-S consistently reported feeling overwhelmed. Regarding support, participants with anxiety per the PSAS reported task-related support in the early weeks postpartum that declined as the time from birth lengthened, while participants with anxiety per the STAI-S consistently described lack of support. Further, individuals with anxiety per the PSAS reported relationship conflict more often and described daily sources of anxiety (e.g., infant-related concerns and return to the workplace) that were different than daily sources of anxiety per the STAI (e.g., self-health, finances, and partner work/travel). Participants with anxiety based on either questionnaire shared similar response patterns for perceived stress, social support, and role adjustment. Regarding environmental influences, participants with anxiety per the STAI-S often mentioned the negative influences of fatigue, deficient support systems, infant temperaments, and/or other children’s needs. Alternatively, participants with anxiety per the PSAS reported similarly negative environmental influences from relationship conflict and deficient support as those with anxiety per the STAI-S or both the STAI-S and PSAS, but also recounted more positive influences from socialization opportunities that the other categories of anxiety did. Conclusions: Our study found that mean anxiety scores decreased from one- to eight-weeks postpartum per the STAI-S, but increased from one- to eight-weeks postpartum per the PSAS. These findings suggest postpartum-specific anxiety may worsen as the time from birth lengthens. Our findings also corroborate reportedly high anxiety prevalence at eight-weeks postpartum, where per the STAI-S, 23.9% of the sample had anxiety and per the PSAS, 21%. Although more participants met the cut-off for anxiety per the STAI-S at eight-weeks postpartum, consideration should be given to the potential that STAI-S scores were falsely inflated, as instrument items were developed to measure somatic symptoms in general and not postpartum populations (Infante-Gil et al., 2022; Meades & Ayers, 2011; Spielberger et al., 1983). Daily anxiety ratings showed that anxiety is a shared experience across the postpartum; for most peaking at two-weeks, declining and stabilizing, then trending upward toward week eight postpartum. However, for some, daily anxiety ratings increase more dramatically as the time from birth lengthens. Responses to theory-driven mEMA questions offered qualitative validation for existing assumptions regarding relationships between high perceived stress, low social support, relationship conflict, and maternal role adjustment and provide possible new directions for anxiety detection strategies (e.g., assessing presence of relationship conflict, negative environmental influences, or sources of anxiety). Future studies should explore the course and stability of anxiety beyond eight-weeks postpartum, the influence of other participant characteristics on anxiety (e.g., demographics, obstetrical history, presence of pregnancy or birth-related complication), and the relationship between postpartum-specific anxiety and generalized anxiety in postpartum populations

The interventional magnetic resonance imaging suite: Experience in the design, development, and implementation in a pre-existing radiology space and review of concepts

Background Intraoperative magnetic resonance imaging (ioMRI) has led to significant advancements in neurosurgery with improved accuracy, assessment of the extent of resection, less invasive surgical alternatives, and real-time confirmation of targeting as well delivery of therapies. The costs associated with developing ioMRI units in the surgical suite have been obstacles to the expansion of their use. More recently, the development of hybrid interventional MRI (iMRI) units has become a viable alternative. The process of designing, developing, and implementing operations for these units requires the careful integration of environmental, technical, and safety elements of both surgical and MR practices. There is a paucity of published literature providing guidance for institutions looking to develop a hybrid iMRI unit, especially with a limited footprint in the radiology department. Methods The experience of designing, developing, and implementing an iMRI in a preexisting space for neurosurgical procedures at a single institution in light of available options and the literature is described. Results The development of the unit was accomplished through the engagement of a multidisciplinary team of stakeholders who utilized existing guidelines and recommendations and their own professional experience to address issues including physical layout, equipment selection, operations planning, infection control, and oversight/review, among others. Conclusion Successful creation of an iMRI program requires multidisciplinary collaboration in integrating surgical and MR practice. The authors' aim is that the experience described in this article will serve as an example for facilities or neurosurgical departments looking to navigate the same process