A comparative analysis of non-invasive prenatal testing in Ontario and Quebec: the role of governing style in health technology innovation & adoption.

BACKGROUND: While processes of adoption and the impacts of various health technologies have been extensively studied by health services and policy researchers, the influence of policy makers' governing styles on these processes have been largely neglected. Through a comparative analysis of non-invasive prenatal testing (NIPT) in the Canadian provinces of Ontario and Quebec, this article examines how decisions about this technology were shaped by contrasting political ideologies, resulting in vastly different innovation and adoption strategies and outcomes. METHODS: A comparative qualitative investigation comprising of a document analysis followed by semi-structured interviews with key informants. Interview participants were researchers, clinicians, and private sector medical laboratory employees based in Ontario and Quebec, Canada. Interviews were conducted both in person and virtually- owing partly to the COVID-19 pandemic - to garner perspectives regarding the adoption and innovation processes surrounding non-invasive prenatal testing in both provinces. All interviews were recorded and transcribed verbatim and data were analyzed using thematic analysis. RESULTS: Through an analysis of 21 in-depth interview transcripts and key documents, the research team identified three central themes: 1) health officials in each province demonstrated a unique approach to using the existing scholarly literature on NIPT; 2) each provincial government demonstrated its own preference for service delivery, with Ontario preferring private and Quebec preferring public; and finally, 3) both Ontario and Quebec's strategies to NIPT adoption and innovation was contextualized within each province's unique financial positioning and concerns. These findings illustrate how both Quebec's nationalist focus and use of industrial policy and Ontario's 'New Public Management' style had implications for how this emerging healthcare technology was made available within each province's publicly-financed health system. CONCLUSIONS: Our study reveals how these governments' differing approaches to using data and research, public versus private service delivery, and financial goals and concerns resulted in distinct testing technologies, access, and timelines for NIPT adoption. Our analysis demonstrates the need for health policy researchers, policy makers, and others to move beyond analyses solely considering clinical and health economic evidence to understand the impact of political ideologies and governing styles.

Promoting Judicious Primary Care Referral of Patients with Chest Pain to Cardiology: A Quality Improvement Initiative.

OBJECTIVE: To decrease referrals to cardiology of patients ages 7 to 21 years with low-probability cardiac pathology who presented to primary care with chest pain by 50% within 24 months. STUDY DESIGN: A multidisciplinary team designed and implemented an initiative consisting of 1) a decision support tool (DST), 2) educational sessions, 3) routine feedback to improve use of referral criteria, and 4) patient family education. Four pediatric practices, comprising 34 pediatricians and 7 nurse practitioners, were included in this study. We tracked progress via statistical process control charts. RESULTS: A total of 421 patients ages 7 to 21 years presented with chest pain to their pediatrician. The utilization of the DST increased from baseline of 16% to 68%. Concurrently, the percentage of low-probability cardiology referrals in pediatric patients ages 7 to 21 years who presented with chest pain decreased from 17% to 5% after our interventions. At a median follow-up time of 0.9 years (interquartile range, 0.3-1.6 years), no patient had a life-threatening cardiac event. CONCLUSION: Our health care improvement initiative to reduce low-probability cardiology referrals for children presenting to primary care practices with chest pain was feasible, effective, and safe.

#Testathome: Implementing 2 Phases of a HIV Self-Testing Program Through Community-Based Organization Partnerships in New York City.

BACKGROUND: Access to human immnodeficiency virus (HIV) testing in New York City (NYC) has increased, but disparities in testing rates still exist among most communities impacted by HIV. HIV self-tests (HIVSTs) present an opportunity to address testing barriers, but HIV-affected communities experience difficulties accessing HIVSTs, including lack of awareness and cost. To support increased access to HIVSTs, the NYC Health Department launched a partnership with select organizations to pilot distribution of free HIVSTs in 2 phases among priority populations across NYC. METHODS: Organizations that were diverse in their missions, experiences, capacities and populations served were recruited through a formal application process. The program initially launched with 10 organization partners (phase 1); as the pilot continued, partners identified necessary revisions to the program and launched a second phase in year 2. Both phases included outreach to NYC priority populations, HIVST distribution/redemption, and a follow-up survey. RESULTS: From March 2017 to August 2019, organizations distributed 75 HIVSTs during phase 1 and 252 during phase 2. All intended priority populations were reached, notably, those who had never tested before: 35% in phase 1 and 12% in phase 2. Over half of the follow-up survey respondents reported testing sooner. Respondents reported liking the HIVST because it did not require a visit to a clinic (84%) and preferred an HIVST to testing in a clinic (92%). CONCLUSIONS: Through 2 phases of implementation, this innovative partnership was able to reach and offer HIVSTs to priority populations across NYC. This program supports the feasibility of distributing HIVSTs through close partnerships with diverse organizations.

Spirituality and Multiple Dimensions of Religion Are Associated with Mental Health in Gay and Bisexual Men: Results From the One Thousand Strong Cohort.

The purpose of this study was to determine the association between religion, spirituality, and mental health among gay and bisexual men (GBM). A U.S. national sample of 1,071 GBM completed an online survey that measured demographic characteristics, religiosity, religious coping, spirituality, and four mental health constructs (i.e., depressive symptoms, rejection sensitivity, resilience, and social support). Hierarchal linear regressions determined the associations between each mental health construct, demographic variables, and the spirituality and religion variables. Controlling for demographic characteristics, spirituality was negatively associated with depression and rejection sensitivity, and positively associated with resilience and social support (all p < .001). Religiosity was positively associated with rejection sensitivity (p < .05) and negatively associated with resilience (p < .01). Religious coping was positively associated with depression (p < .001) and rejection sensitivity (p < .05) and negatively associated with resilience (p < .05) and social support (p < .05). The interaction of spirituality with religion was significantly associated with all mental health variables. In general, religious GBM with higher levels of spirituality had better mental health outcomes. Spirituality was significantly positively associated with positive mental health outcomes and negatively associated with negative ones. Religion-solely expressed through behaviors and lacking the functional components of spirituality such as meaning-making and connection to the sacred-was associated with mental health problems among GBM. Public health interventions and clinical practice aimed at decreasing negative mental health outcomes among GBM may find it beneficial to integrate spirituality into their work.

Pain control following tonsillectomy in children: A survey of patients.

OBJECTIVE: This prospective study aimed to survey pediatric patients and their parents after tonsillectomy to assess their pain management utilization and satisfaction. INTRODUCTION: Tonsillectomy is the second most common surgical procedure performed in pediatric patients. Postoperative recovery is often associated with high levels of pain and severe functional limitations. There is currently no consensus on pain control regimens. Additionally, a recent FDA Black Box Warning on narcotic use has caused more uncertainty in appropriate pain control regimens. METHODS: 111 pediatric patients (≤18 years) included in this study underwent tonsillectomy with or without adenoidectomy between October 2013 and August 2015. Postoperatively, each patient/parent was counseled to alternate on an over-the-counter regimen of acetaminophen and ibuprofen and given an additional as-needed acetaminophen with hydrocodone prescription. A survey was administered during the patient's 2-week follow-up that included questions regarding pain levels, worst post-op pain day, pain medications taken during recovery, and patient/parental perceived satisfaction of having the acetaminophen with hydrocodone prescription. RESULTS: 84 patients/parents (75.7%) felt that OTC medications were not adequate for pain control and used hydrocodone at least once. Between those who took hydrocodone versus those who did not, there was no significant difference in mean age (6.7 ± 2.9 vs. 6.0 ± 2.4 years), percentage of patients with severe pain (36.9% vs. 22.2%) and worst post-op pain day (4.3 ± 1.5 vs. 3.9 ± 1.9 days) (p > 0.05). However, regardless of pain control regimen followed, the majority of patients/parents found it valuable to have the hydrocodone prescription (p = 0.004). CONCLUSION: Post-tonsillectomy patients and their parents find being provided with an acetaminophen-hydrocodone prescription is therapeutically valuable, and many find it necessary in their postoperative pain management. However, further studies are needed to determine patient factors that influence narcotic utilization.

Race, ethnicity, religious affiliation, and education are associated with gay and bisexual men's religious and spiritual participation and beliefs: Results from the One Thousand Strong cohort.

OBJECTIVES: This study examined the rates of spirituality, religiosity, religious coping, and religious service attendance in addition to the sociodemographic correlates of those factors in a U.S. national cohort of 1,071 racially and ethnically diverse HIV-negative gay and bisexual men. METHOD: Descriptive statistics were used to assess levels of spirituality, religiosity, religious coping, and religious service attendance. Multivariable regressions were used to determine the associations between sociodemographic characteristics, religious affiliation, and race/ethnicity with four outcome variables: (1) spirituality, (2) religiosity, (3) religious coping, and (4) current religious service attendance. RESULTS: Overall, participants endorsed low levels of spirituality, religiosity, and religious coping, as well as current religious service attendance. Education, religious affiliation, and race/ethnicity were associated with differences in endorsement of spirituality and religious beliefs and behaviors among gay and bisexual men. Men without a 4-year college education had significantly higher levels of religiosity and religious coping as well as higher odds of attending religious services than those with a 4-year college education. Gay and bisexual men who endorsed being religiously affiliated had higher levels of spirituality, religiosity, and religious coping as well as higher odds of religious service attendance than those who endorsed being atheist/agnostic. White men had significantly lower levels of spirituality, religiosity, and religious coping compared to Black men. Latino men also endorsed using religious coping significantly less than Black men. CONCLUSIONS: The implications of these findings for future research and psychological interventions with gay and bisexual men are discussed. (PsycINFO Database Record

Social support, psychological vulnerability, and HIV risk among African American men who have sex with men.

Previous research has suggested a need to understand the social-psychological factors contributing to HIV risk among African American men who have sex with men (MSM). We conducted individual in-depth interviews with 34 adult African American MSM to examine their personal experiences about: (i) sources of social support, (ii) psychological responses to the presence or absence of social support and (iii) influences of social support on sexual behaviours. The majority of participants described limited positive encouragement and lack of emotional support from family, as well as few meaningful personal relationships. Feelings of isolation and mistrust about personal relationships led many participants to avoid emotional intimacy and seek physical intimacy through sexual encounters. Findings highlight a need for multilevel interventions that enhance social support networks and address the social-psychological, emotional and interpersonal factors that contribute to HIV risk among African American MSM.

DNA methylation and expression of KCNQ3 in bipolar disorder.

OBJECTIVES: Accumulating evidence implicates the potassium voltage-gated channel, KQT-like subfamily, member 2 and 3 (KCNQ2 and KCNQ3) genes in the etiology of bipolar disorder (BPD). Reduced KCNQ2 or KCNQ3 gene expression might lead to a loss of inhibitory M-current and an increase in neuronal hyperexcitability in disease. The goal of the present study was to evaluate epigenetic and gene expression associations of the KCNQ2 and KCNQ3 genes with BPD. METHODS: DNA methylation and gene expression levels of alternative transcripts of KCNQ2 and KCNQ3 capable of binding the ankyrin G (ANK3) gene were evaluated using bisulfite pyrosequencing and the quantitative real-time polymerase chain reaction in the postmortem prefrontal cortex of subjects with BPD and matched controls from the McLean Hospital. Replication analyses of DNA methylation findings were performed using prefrontal cortical DNA obtained from the Stanley Medical Research Institute. RESULTS: Significantly lower expression was observed in KCNQ3, but not KCNQ2. DNA methylation analysis of CpGs within an alternative exonic region of KCNQ3 exon 11 demonstrated significantly lower methylation in BPD, and correlated significantly with KCNQ3 mRNA levels. Lower KCNQ3 exon 11 DNA methylation was observed in the Stanley Medical Research Institute replication cohort, although only after correcting for mood stabilizer status. Mood stabilizer treatment in rats resulted in a slight DNA methylation increase at the syntenic KCNQ3 exon 11 region, which subsequent analyses suggested could be the result of alterations in neuronal proportion. CONCLUSION: The results of the present study suggest that epigenetic alterations in the KCNQ3 gene may be important in the etiopathogenesis of BPD and highlight the importance of controlling for medication and cellular composition-induced heterogeneity in psychiatric studies of the brain.

"We're going to have to cut loose some of our personal beliefs": barriers and opportunities in providing HIV prevention to African American men who have sex with men and women.

In the United States, there is an urgent need to provide HIV prevention services to African American men who have sex with men and women (MSMW) but who do not identify as gay or homosexual. Engaging these men in HIV prevention has historically been challenging. This study used qualitative methodology to explore the beliefs and experiences from community-based service providers (n = 21) and from African American MSMW (n = 21) regarding the provision of HIV prevention education and counseling to these men. Data analysis revealed that (a) African American MSMW who do not identify as gay can challenge service providers' assumptions about sexual behavior and sexual identity; (b) service providers' attitudes toward these men can be affected by ambivalent or negative beliefs that pervade the general community; (c) African American MSMW need safe and nonjudgmental spaces that offer HIV risk reduction, but they also might experience anxiety about disclosing same-sex behaviors to counselors. Findings highlighted the complexities related to culture, masculinity, and sexuality as determinants of HIV risk in African American MSMW, and findings also revealed tensions between these factors that may affect the quality of HIV prevention services. Service providers may need additional training to provide appropriate and non-judgmental HIV prevention counseling and education.

Moving beyond "the down low": a critical analysis of terminology guiding HIV prevention efforts for African American men who have secretive sex with men.

HIV continues to affect African American populations in the United States at disproportionate levels. Recent reports have described potentially high-risk behaviors of African American men who identify as heterosexual but who engage in secretive sex with other men. These men have been referred to as being "on the Down Low," and this terminology has been used to label subgroups of African American men and explain sexual risks for HIV infection in the African American community. In this paper, we argue that an uncritical use of this terminology for guiding public health and HIV prevention strategies can be problematic and counterproductive because it (a) stigmatizes and exoticizes secretive same-sex sexuality as a unique issue among African American men, and (b) ignores the social conditions under which HIV transmission occurs. We explore some historical roots contributing to current perspectives on African American men's sexuality, describe the use of the term "on the Down Low" and its application to same-sex behavior among African American men, and explain how this term can both clarify and potentially ambiguate efforts to address HIV risk among African American men. Recommendations for research and HIV prevention strategies are also provided.