Investigating disparities in smoking cessation treatment for veterans with multiple sclerosis: A national analysis.

BACKGROUND AND AIMS: Smoking is a risk factor for multiple sclerosis (MS) development, symptom burden, decreased medication efficacy, and increased disease-related mortality. Veterans with MS (VwMS) smoke at critically high rates; however, treatment rates and possible disparities are unknown. To promote equitable treatment, we aim to investigate smoking cessation prescription practices for VwMS across social determinant factors. METHODS: We extracted data from the national Veterans Health Administration electronic health records between October 1, 2017, and September 30, 2018. To derive marginal estimates of the association of MS with receipt of smoking-cessation pharmacotherapy, we used propensity score matching through the extreme gradient boosting machine learning model. VwMS who smoke were matched with veterans without MS who smoke on factors including age, race, depression, and healthcare visits. To assess the marginal association of MS with different cessation treatments, we used logistic regression and conducted stratified analyses by sex, race, and ethnicity. RESULTS: The matched sample achieved a good balance across most covariates, compared to the pre-match sample. VwMS (n = 3320) had decreased odds of receiving prescriptions for nicotine patches ([Odds Ratio]OR = 0.86, p < .01), non-patch nicotine replacement therapy (NRT; OR = 0.81, p < .001), and standard practice dual NRT (OR = 0.77, p < .01), compared to matches without MS (n = 13,280). Men with MS had lower odds of receiving prescriptions for nicotine patches (OR = 0.88, p = .05), non-patch NRT (OR = 0.77, p < .001), and dual NRT (OR = 0.72, p < .001). Similarly, Black VwMS had lower odds of receiving prescriptions for patches (OR = 0.62, p < .001), non-patch NRT (OR = 0.75, p < .05), and dual NRT (OR = 0.52, p < .01). The odds of receiving prescriptions for bupropion or varenicline did not differ between VwMS and matches without MS. CONCLUSION: VwMS received significantly less smoking cessation treatment, compared to matched controls without MS, showing a critical gap in health services as VwMS are not receiving dual NRT as the standard of care. Prescription rates were especially lower for male and Black VwMS, suggesting that under-represented demographic groups outside of the white female category, most often considered as the "traditional MS" group, could be under-treated regarding smoking cessation support. This foundational work will help inform future work to promote equitable treatment and implementation of cessation interventions for people living with MS.

Birth Prevalence of Sickle Cell Disease and County-Level Social Vulnerability - Sickle Cell Data Collection Program, 11 States, 2016-2020.

Sickle cell disease (SCD) remains a public health priority in the United States because of its association with complex health needs, reduced life expectancy, lifelong disabilities, and high cost of care. A cross-sectional analysis was conducted to calculate the crude and race-specific birth prevalence for SCD using state newborn screening program records during 2016-2020 from 11 Sickle Cell Data Collection program states. The percentage distribution of birth mother residence within Social Vulnerability Index quartiles was derived. Among 3,305 newborns with confirmed SCD (including 57% with homozygous hemoglobin S or sickle ß-null thalassemia across 11 states, 90% of whom were Black or African American [Black], and 4% of whom were Hispanic or Latino), the crude SCD birth prevalence was 4.83 per 10,000 (one in every 2,070) live births and 28.54 per 10,000 (one in every 350) non-Hispanic Black newborns. Approximately two thirds (67%) of mothers of newborns with SCD lived in counties with high or very high levels of social vulnerability; most mothers lived in counties with high or very high levels of vulnerability for racial and ethnic minority status (89%) and housing type and transportation (64%) themes. These findings can guide public health, health care systems, and community program planning and implementation that address social determinants of health for infants with SCD. Implementation of tailored interventions, including increasing access to transportation, improving housing, and advancing equity in high vulnerability areas, could facilitate care and improve health outcomes for children with SCD.

Allostatic Load, Morbidity, and Mortality Among Older Adults: A Multi-Wave Analysis From the National Health and Aging Trends Study.

Although allostatic load (AL) is a key concept to reflect physiologic wear and tear from stress, older adults are underrepresented in AL-related research, especially the oldest old (≥80). Further, attenuative factors are often unaccounted for. This longitudinal analysis using data from National Health and Aging Trends Study investigated relationships of AL in 2017 and multi-wave (1) comorbidity accumulation using multilevel Poisson modeling and (2) mortality risk using survival analysis. By year five (2022), each incremental AL increase that older adults (n = 3614) experienced was associated with a 47% increase in comorbidity (p < .001), and a 33% increased mortality risk (p < .001). This research supports a shift to a more proactive, health promotion/risk mitigation paradigm through informing intervention research targeting AL, which is currently scarce. Identifying potentially modifiable and key driving factors influencing the relationship between AL and health among older adults is an important next step to inform intervention design.

Resilience, mental health, sleep, and smoking mediate pathways between lifetime stressors and Multiple Sclerosis severity.

Intro: Lifetime stressors (e.g., poverty, violence, discrimination) have been linked to Multiple Sclerosis (MS) features; yet mechanistic pathways and relationships with cumulative disease severity remain nebulous. Further, protective factors like resilience, that may attenuate the effects of stressors on outcomes, are seldom evaluated. Aim: To deconstruct pathways between lifetime stressors and cumulative severity on MS outcomes, accounting for resilience. Methods: Adults with MS (N=924) participated in an online survey through the National MS Society listserv. Structural Equation Modeling was used to examine the direct and indirect effect of lifetime stressors (count/severity) on MS severity (self-reported disability, relapse burden, fatigue, pain intensity and interference), via resilience, mental health (anxiety and depression), sleep disturbance, and smoking. Results: The final analytic model had excellent fit (GFI=0.998). Lifetime stressors had a direct relationship with MS severity (ß=0.27, p<.001). Resilience, mental health, sleep disturbance, and smoking significantly mediated the relationship between lifetime stressors and MS severity. The total effect of mediation was significant (ß=0.45). Conclusions: This work provides foundational evidence to inform conceptualization of pathways by which stress could influence MS disease burden. Resilience may attenuate effects of stressors, while poor mental health, smoking, and sleep disturbances may exacerbate their impact. Parallel with usual care, these mediators could be targets for early multimodal therapies to improve disease course.

Fatigue, pain interference, and psychiatric morbidity in multiple sclerosis: The role of childhood stress.

BACKGROUND: Multiple sclerosis (MS) is a progressive, autoimmune disease of the central nervous system that affects nearly one million Americans. Despite the existence of immunomodulatory therapies to slow physical and cognitive disability progression, interventions to ameliorate common symptoms of MS, including fatigue and pain, remain limited. Poor understanding of risk factors for these symptoms may contribute to treatment challenges. In recent years, childhood stress has been investigated as a risk factor for chronic autoimmune conditions including MS; yet remarkably few studies have investigated the relationship between childhood stressors and chronic MS symptoms. Our aim was to examine clusters of stressors and three key features of MS: fatigue, pain interference, and psychiatric morbidity. METHODS: Cross-sectional data were collected from a sample of People with MS (PwMS) via a national web-based survey that assessed the presence and type of childhood stressors and MS clinical features. Hierarchical block regression was used to assess associations among emotional, physical, and environmental childhood stressors and three clinical features commonly experienced by PwMS. RESULTS: N = 719 adults with MS (aged 21-85) completed the survey. Childhood emotional and physical stressors were significantly associated with overall presence of fatigue (p = 0.02; p<0.03) and pain interference (p<0.001; p<0.001) in adulthood, as well as the magnitude of both outcomes. Environmental stressors (p<0.001), in addition to emotional (p<0.001) and physical (p<0.001) stressors were significantly associated with psychiatric morbidity in PwMS. CONCLUSION: Childhood stress may predict fatigue, psychiatric morbidity, and pain in adults with MS. Further research is needed to show cause and effect; however, if an association exists, strategies to mitigate the impact of childhood stress could offer new pathways to reduce the severity of these symptoms. Broadly, this work adds to the body of evidence supporting upstream preventive measures to help address the stress on children and families.

Multimodal smoking cessation treatment combining transcranial magnetic stimulation, cognitive behavioral therapy, and nicotine replacement therapy in veterans with posttraumatic stress disorder: A feasibility randomized controlled trial protocol.

Tobacco-related deaths exceed those resulting from homicides, suicides, motor vehicle accidence, alcohol consumption, illicit substance use, and acquired immunodeficiency syndrome (AIDS), combined. Amongst U.S. veterans, this trend is particularly concerning given that those suffering from posttraumatic stress disorder (PTSD)-about 11% of those receiving care from the Department of Veterans Affairs (VA)-have triple the risk of developing tobacco use disorder (TUD). The most efficacious strategies being used at the VA for smoking cessation only result in a 23% abstinence rate, and veterans with PTSD only achieve a 4.5% abstinence rate. Therefore, there is a critical need to develop more effective treatments for smoking cessation. Recent studies have revealed the insula as integrally involved in the neurocircuitry of TUD, specifically showing that individuals with brain lesions involving this region had drastically improved quit rates. Some of these studies show a probability of quitting up to 5 times greater compared to non-insula lesioned regions). Altered activity of the insula may be involved in the disruption of the salience network's (SN) connectivity to the executive control network (ECN), which compromises that patient's ability to switch between interoceptive states focused on cravings to executive and cognitive control. Thus, we propose a feasibility phase II randomized controlled trial (RCT) to study a patterned form of repetitive transcranial magnetic stimulation (rTMS), intermittent theta burst stimulation (iTBS), at 90% of the subject's resting motor threshold (rMT) applied over a region in the right post-central gyrus most functionally connected to the right posterior insula. We hypothesize that by increasing functional connectivity between the SN with the ECN to enhance executive control and by decreasing connectivity with the default mode network (DMN) to reduce interoceptive focus on withdrawal symptoms, we will improve smoking cessation outcomes. Fifty eligible veterans with comorbid TUD and PTSD will be randomly assigned to two conditions: active-iTBS + cognitive behavioral therapy (CBT) + nicotine replacement therapy (NRT) (n=25) or sham-iTBS + CBT + NRT (n=25). The primary outcome, feasibility, will be determined by achieving a recruitment of 50 participants and retention rate of 80%. The success of iTBS will be evaluated through self-reported nicotine use, cravings, withdrawal symptoms, and abstinence following quit date (confirmed by bioverification) along with evaluation for target engagement through neuroimaging changes, specifically connectivity differences between the insula and other regions of interest.

Associations among stressors across the lifespan, disability, and relapses in adults with multiple sclerosis.

INTRODUCTION: Stress and adversity during childhood, adolescence, and adulthood could impact the present and future health and well-being of people with multiple sclerosis (PwMS); however, a lifespan approach and nuanced stressor data are scarce in this nascent area of research. Our aim was to examine relationships among comprehensively measured lifetime stressors and two self-reported MS outcomes: (1) disability and (2) relapse burden changes since COVID-19 onset. METHODS: Cross-sectional data were collected from a nationally distributed survey of U.S.-based adults with MS. Hierarchical block regressions were used to sequentially evaluate contributions to both outcomes independently. Likelihood ratio (LR) tests and Akaike information criterion (AIC) were used to evaluate additional predictive variance and model fit. RESULTS: A total of 713 participants informed either outcome. Most respondents (84%) were female, 79% had relapsing remitting multiple sclerosis (MS), and mean (SD) age was 49 (12.7) years. Childhood (R2  = .261, p < .001; AIC = 1063, LR p < .05) and adulthood stressors (R2  = .2725, p < .001, AIC = 1051, LR p < .001) contributed significantly to disability, above and beyond prior nested models. Only adulthood stressors (R2  = .0534, p < .001; AIC = 1572, LR p < .01) significantly contributed above the nested model for relapse burden changes since COVID-19. CONCLUSIONS: Stressors across the lifespan are commonly reported in PwMS and could contribute to disease burden. Incorporating this perspective into the "lived experience with MS" could facilitate personalized health care by addressing key stress-related exposures and inform intervention research to improve well-being.

Service Workers' Experience and Perceptions of Workplace Protective Measures During the Onset of COVID-19.

OBJECTIVES: The Coronavirus-2019 (COVID-19) pandemic presents a unique burden specifically for workers in service industries. However, limited research on service worker's experience during the onset of COVID-19 exists. We aimed to describe the experiences and concerns of service industry workers during the pandemic's onset. METHODS: This is a mixed-method study. Participants were recruited through social media and completed either a survey or a phone interview during May and June 2020. The survey and transcribed interview data were analyzed using the SPSS software and content analysis, respectively. RESULTS: Twenty-seven individuals completed audio-recorded phone interviews and 28 completed the survey. Participants were mostly women between 19 and 65 years old. Participants worked in food retail (n = 23), restaurant (n = 25), and hospitality (n = 7) industries. There was discordance in perceived threat level of COVID-19. Most participants reported that their workplace complied with their state's mandates for protection measures, while others reported lacking basic supplies such as soap, hand sanitizer, and masks. Job insecurity, change of job tasks, and work hours were the most common ways that COVID-19 affected the workers. Worker's assertiveness to self-protect while at work was influenced by their perceived severity of the pandemic. CONCLUSION/APPLICATION TO PRACTICE: This study highlights the vulnerability of service workers relating to job security and job tasks during the pandemic. Organizational processes are needed to promote safe work environments and facilitate access to resources for these workers. In addition, occupational health practitioners need to be aware of and address the emerging health risks and worker needs.

Relationships between childhood trauma and multiple sclerosis: A systematic review.

OBJECTIVE: Adverse Childhood Experiences (ACEs), such as physical, emotional, and sexual abuse trigger inflammatory changes and have been associated with many causes of morbidity and mortality, including autoimmune diseases. Although Multiple Sclerosis (MS) is a debilitating neurological autoimmune disease, literature linking ACEs and MS is understudied. The aim of this review was to examine the 1) state of the literature, and 2) relationships between childhood adversity and the prevalence and physical clinical features of MS (e.g., age at onset, relapses, pain, fatigue, disability). METHODS: A comprehensive search was preformed through five databases and by hand using the ancestry and descendancy approach for connections to papers published through January 20th, 2022. Studies were screened by independent reviewers using Rayyan.ai, and critically appraised for both quality and reporting transparency. RESULTS: Twelve studies examined relationships between any ACE(s) and the prevalence or physical clinical features of MS. There was considerable variance in the measurement of stressors, confounders, and categorization of MS; however most studies (n = 10) demonstrated an association between ACEs and MS (alone or grouped with other similar diagnoses), or physical clinical features. CONCLUSION: Although there are few studies in this area, it is of quickly growing interest. These results should be cautiously interpreted, yet highlight the need for continued work to disentangle and discern true associations.

Immigration-related stressors and health outcomes among low-wage immigrant hotel workers: A pilot study.

BACKGROUND: Immigrants comprise over 40% of the low-wage workforce. They are more likely to be employed in service industries, paid less, and experience more illness and injuries than their native counterparts. DESIGN/OBJECTIVE: The aim of this cross-sectional pilot study was to explore the relationship between immigrant workers' stressors and health. SAMPLE: Twenty-five female Mexican immigrant hotel workers. MEASUREMENTS: Surveys and blood samples were analyzed and compared to national data. Descriptive statistics and linear regression were used for analysis. RESULTS: Longer length of stay, older age at migration, and higher Demands of Immigration (DI) were significantly associated with more chronic conditions. Higher DI were significantly associated with more depressive symptoms. This is comparable to national data (n = 468) which shows a significant relationship between length of stay, Allostatic Load (AL), and chronic conditions (ß = 0.14, p = .043; ß = 0.13, p = .025). CONCLUSIONS: Immigrant-specific factors affect individuals' health. More studies are needed to further explore the relationship between DI and health among foreign-born workers.

The Impact of Pet Care Needs on Medical Decision-Making among Hospitalized Patients: A Cross-Sectional Analysis of Patient Experience.

Hospital-based protocols to support pet care needs for hospitalized patients may have potential to benefit patient health and wellbeing, but must be informed by experiences of hospitalized pet owners. The aim of this study was to determine the scope and need for pet care services among hospitalized patients. A panel of prior inpatients and their family members at a tertiary care center were surveyed about preferences, experiences, and need for assistance with pet care during hospitalization. Respondents (n = 113) expressed interest in a low/no-cost pet-boarding or foster program for adult patients struggling to find pet care assistance. The majority of respondents (n = 71; 63%) reported challenges securing pet care during a prior hospitalization, and/or knew someone who encountered similar challenges. Respondents also indicated that these challenges had a negative impact on health, recovery, or their own decision to receive medical care. Pet care challenges during hospitalization are likely common and have the potential to hamper medical decision-making and health outcomes of inpatients.

The importance of assessing life stress exposure in multiple sclerosis: A case report.

This case report describes associations between childhood adversity, adult stress exposure, and Multiple Sclerosis (MS) to highlight the intersection between mental health and neurological illness in persons with MS (PwMS). We focus on a high-adversity, high-resource patient who self-referred to mental health services for depression and suicidal ideation, without ever being screened for past or current stress exposure. MS and common comorbid symptoms (e.g., fatigue, depression, suicidality) may be affected by adversity and compounded by pandemic-related stressors, including socio-political and economic sequelae. This case illustrates the potential benefit of screening for lifetime stressors as a mechanism to improve case conceptualizations, enable referrals to mental health specialists to promote coping and resiliency, reduce future MS morbidity, and illuminate stress as an important research focus that deserves further exploration in PwMS.

COVID-19 and mental health of food retail, food service, and hospitality workers.

The coronavirus pandemic has taken a detrimental toll on the lives of individuals globally. In addition to the direct effect (e.g., being infected with the virus), this pandemic has negatively ravaged many industries, particularly food retail, food services, and hospitality. Given the novelty of the disease, the true impact of COVID-19 remains to be determined. Because of the nature of their work, and the characteristics of the workers, individuals in the food retail, food service, and hospitality industries are a group whose vulnerability is at its most fragile state during this pandemic. Through this qualitative study, we explored workers' perspectives on the impact of COVID-19 on their mental health and coping, including screening for post-traumatic stress disorder (PTSD) and alcohol use disorder symptoms. Twenty-seven individual interviews were conducted, audio-recorded, transcribed, and analyzed using qualitative content analysis. Four key themes emerged: being infected and infecting others, the unknown, isolation, and work and customer demands. Considering the many uncertainties of COVID-19, workers in these three industries were experiencing heightened levels of mental distress because of where they worked and the already existing disparities they faced on a daily basis before the pandemic started. Yet they remained hopeful for a better future. More studies are needed to fully understand the magnitude, short-term, and long-term effects of COVID-19. Based on this study's findings, programs are critically needed to promote positive coping behaviors among at-risk and distressed workers. Recommendations for employers, occupational health and safety professionals, and policy stakeholders to further support these service workers are discussed.