Cancer is a leading cause of disease burden worldwide and the first cause of mortality in Canada with 30.2% of deaths attributable to cancer. Given aging of the population and the improvement of prevention and treatment protocols, the number of cancer survivors is steadily increasing. These individuals have unique physical and mental health needs some of which can be addressed by integrating physical activity promotion into ongoing and long-term care. Despite the benefits of being active, delivery of PA programs for cancer patients in both clinical and community settings remains challenging. This knowledge-to-action protocol–called Kiné-Onco–aims to develop a practice guideline for the delivery, implementation, and scaling-up of cancer-specific physical activity promotion programs and services in clinical and community settings located in Québec, Canada.The Kiné-Onco project involves knowledge synthesis of scientific and grey literature to establish the benefits and added value of physical activity for cancer patients and survivors, describes current practices in delivering physical activity programs, analyses quantitative data from electronic health records (EHR) of patients participating in a novel hospital-based physical activity program, collects and analyses qualitative data from patients and healthcare providers interviews about lived experience, facilitators, and barriers to physical activity promotion, outlines deliberative workshops among multidisciplinary team members to develop implementation guidelines for physical activity promotion, and summarizes a variety of knowledge transfer and exchange activities to disseminate the practice guidelines.This paper describes the protocol for a knowledge-to-action project aimed at producing and sharing actionable evidence. Our aim is that physical activity promotion programs and services be scaled up in such a way as to successfully integrate physical activity promotion throughout cancer treatment and survivorship in order to improve the physical and mental health of the growing population of individuals having received a cancer diagnosis. Cancer is a leading cause of disease burden worldwide  and is tThe growing population of cancer survivors has unique physical and mental health needs , 6. For Physical activity (PA) is demonstrated to be an effective and safe strategy to improve physical and mental health in populations diagnosed with different cancers –21. SpecSince 2010, both regional (e.g. Cancer Care Ontario)  and inteDespite cancer-specific PA guidelines , 40, 41,An increasing number of studies –51, a meIntegrating PA promotion into ongoing and long-term care is a promising innovation for addressing the physical fitness and mental health needs of cancer patients. In this project, we aim to address the gaps between knowledge and evidence regarding the PA benefits, PA programs for cancer patients and survivors, and integration of PA promotion as a routine standard of care in cancer. Effective implementation of PA as a standard of cancer care requires easy access for health professionnals and patients to the most recent evidence on PA security and benefits, identification of patient characteristics associated with PA program involvement as well as factors contributing to satisfaction and a comprehensive understanding of the barriers and facilitators to PA practice and PA promotion within the clinical setting , 54. In Conceptual frameworks are recommended to translate evidence into actual health interventions  as they Institut national d’excellence en santé et en services sociaux (INESSS).The ultimate deliverable of this project is to assemble the knowledge required for the production of a practice guideline allowing for delivery and implementation of cancer-specific PA promotion in clinical and community settings located in Québec, Canada. The practice guideline deliverable and the project will be built to meet the requirements of the provincial agency that develops such guidelines, namely the The specific objectives are to:Provide a review of reviews of PA safety and added value for people diagnosed with cancer;Summarize PA recommendations for people diagnosed with cancer endorsed by provincial and national agencies;Identify and describe the range of PA programs for cancer patients and survivors currently offered in clinical and community settings in Canada as well as internationally;Gain insights into the sociodemographic and clinical profiles as well as the participation motives of cancer patients who took part in a kinesiology program offered in a hospital setting by examining HER information of patients;Examine barriers and facilitators identified by patients and health professionals to the implementation of PA promotion in routine cancer care and, more specifically, participation in cancer-specific PA programs by collecting qualitative data through individual interviews;Propose recommendations for the implementation and scaling-up of PA promotion and PA program participation for cancer patients and survivors in clinical and community settings in Québec by conducting interactive workshops;Assemble the foundations of a practice guideline that meets the requirements of the provincial Agency responsible for approving such guidelines (INESSS) and propose tools to facilitate dissemination.To achieve these objectives, knowledge synthesis, analysis of quantitative data from electronic health records (EHR), collection and analysis of qualitative data from patients and healthcare providers, and a variety of knowledge transfer and exchange activities will be conducted.Centre Hospitalier de l’Université de Montréal (CHUM) which is an academic hospital with quaternary cancer care teams. The Virage kinesiology programs attracted substantial interest as many patients gravitate towards the programs. Program leaders hence expressed interest in working with a team of researchers to assemble evidence in order to translate this initiative into a larger-scale organizational innovation which might be deployed in other hospital centres. A multidisciplinary team including kinesiologists, oncologists, public health and health services researchers, managers, and policy-makers was assembled (see author list).This project, henceforth called Kiné-Onco, emerged from collaborations with health professionals from the Virage Foundation (designated as Virage) offering kinesiology programs for oncology patients at the The CHUM is an international reference hospital centre for academic medicine and research. The CHUM welcomes annually over 8000 patients diagnosed with cancer making it the largest cancer centre in the province of Québec (Canada). The oncology healthcare team is equipped with state-of-the-art methods and instruments, provides comprehensive patient management that includes assessment, diagnosis, treatment, and support. The multidisciplinary team of the CHUM Integrated Cancer Center brings together 19 hemato-oncologists, 4 uro-oncologists, 13 surgeons , 23 nurse navigators, about 200 nurses as well as numerous other health professionals such as nutritionists, kinesiologists, and psychologists. Several foundations including Virage raise funds to offer a variety of support services to cancer patients. Starting in 2013, Virage offered a kinesiology program  and examining the grey literature to inventory current recommendations and practices in terms of PA promotion.With respect to the scientific literature, we are including reviews on exercise and PA undertaken before, during, and following cancer treatment by searching PubMed, Medline Google Scholar Databases, PROSPERO, and Cochrane Database of Systematic Reviews. The search strategy was applied at three different times: initially in October 2017, again in October 2018, and Spring 2020. The MeSH keywords and search strategy used in PubMed/Medline were: ) AND cancer treatment) AND . We are also applying the filters “last 10 years” and “Humans”. The search terms used in Cochrane Database and PROSPERO are “physical activity and cancer treatment” with the filter “in the last year”. All abstracts are screened for duplicates, only systematic reviews and meta-analysis are retained. Full texts are being downloaded and bibliography of selected publications are screened to identify other potentially relevant publications. All publications to be included in the final stage are being assessed with relevant items from the AMSTAR tool . This toTo summarize physical activity guidelines for people diagnosed with cancer (Objective 2), we are searching both scientific and grey literature and scrutinizing websites from national and international organizations from countries who provide recommendations to physicians and health professionals in oncology .Finally, a review of exercise programs in both hospital and community settings is being conducted (Objective 3). We are searching for programs developed across six countries  using directories available on national cancer organizations’ websites, programs’ websites, and published documentation . Information on the setting , cost , type of program , supervision , and content  are being extracted to provide a comprehensive review of program components and delivery context. In order to describe the PA programs offered in each setting, we are computing frequencies and proportions of each of the characteristics identified.To describe the profile of participants in the Virage kinesiology program (objective 4) and their “lived experience” of PA promotion, recommendations and guidance throughout their cancer experience and their participation in the program, we will perform quantitative analysis of data extracted from EHRs. Patient EHRs were populated twice by kinesiologists: once before the patient began the program (pre) and then after completion of the 8-week program (post). A smaller group of patients provided information by phone three months later which was added to data in the EHRs.Before commencing the kinesiology program, the kinesiologists collected data about the patients’ cancer history and treatments received, health conditions, cardiovascular disease risk factors, medication, and musculoskeletal problems. The kinesiologist also asked patients to share their objectives related to participation in the PA program; objectives included: improve or maintain functional abilities, aerobic capacity, energy level, flexibility, strength, balance, decrease waist circumference, weight control, maintain glucose levels, manage hypertension, decrease dyspnea, dyslipidemia, and facilitate return to work. Patients were asked to report on the frequency, intensity, duration, and type of all current PAs . Information regarding current knowledge about PA and preferences for the future were also collected. Finally, selected anthropometric  and health indicators  were recorded and physical and fitness tests  were conducted by the kinesiologist. Based on test results, the kinesiologist discussed recommendations with the patients and provided educational documentation if needed.The post intervention information included questions about current PA and anthropometric and health indicators. Physical fitness tests were performed among those willing to ascertain changes since commencing the program. We will compute descriptive statistics  to portray the sample as a function of demographics , cancer history and treatments , health conditions and comorbidities, and fitness level. Histograms and Q-Q plot will be used for data visualization to illustrate the distribution of continuous variables. Box Plots will also be used to identify potential aberrant or extreme values. Then, we will compute Shapiro Wilk tests to assess normality of distributions; if the p-value is larger than 0.05, we will assume a normal distribution. Using paired T-tests, we will compare PA practice, BMI, waist circumference, cardiac frequency, and blood pressure prior to and following participation in the Virage kinesiology program. Similar analyses will be performed to compare pre-and post PA program participation results for fitness tests. All analysis will be conducted with R, Software Version 4.1.3.To identify facilitators and barriers to PA promotion during the cancer treatment and survivorship, and participation in cancer-specific PA programs, we are collecting data through individual interviews with i) professionals  involved in cancer care, rehabilitation and PA services, hospital services administration, and public health and public policy and ii) cancer patients who participate in the PA program (objective 5).The interviews with professionals aim to:required and those representing ii) facilitators and iii) barriers to PA promotion in cancer are collected;Explore knowledge, attitudes, and behaviors of professionals working in the health / public health sector to promote or recommend PA for cancer patients and survivors. Specific information on knowledge, attitudes and behaviors i) Explore information / training needs for professionals working in the health / public health sector regarding i) benefits of physical activity in the cancer care pathway, ii) availability of resources  to promote the practice of physical activity in the course of cancer care, and iii) other strategies suggested by the participants to enhance and facilitate PA promotion in cancer;Identify structural facilitators or barriers  to the implementation of PA programs in cancer in i) hospital and ii) community settings;Identify the PA promotion strategy and self-management PA strategies to i) support cancer patients and survivors to adopt and maintain PA practice in the short and long term and ii) facilitate the transition from hospital-based PA programs to programs offered in private clinics or in the community.Interviews with cancer patients and survivors who participated in the Virage kinesiology programs between 2017 and 2019 aim at examining patient experience in transitioning from referral to the Virage kinesiology program towards home or community settings when patients undertake their PA practice autonomously. The interviews with patients aim to:Identify the positive and negative experiences of patients who participated in the Virage kinesiology program;Identify the facilitators and barriers  to which patients have been exposed within the PA program i) in the hospital environment and ii) in community settings;Identify self-management strategies spontaneously used by patients to maintain their physical activity both during participation in the Virage kinesiology program and after the end of the program.A total of 20 professionals  have been identified after consultation with the research team, and are being invited to participate in interviews. A random sample of 60 participants is being drawn from the participants involved in the Virage kinesiology program in 2017–2019. To obtain in-depth data presenting multiple perspectives from patients and healthcare professionals and managers, sample size for semi-structured interviews should range between 15 and 20 participants . A minimResearch staff is making initial contacts via email and/or by phone to invite identified participants to the interviews and arrange an interview appointment. For all participants , semi-structured individual interviews are performed by a trained research assistant in person, over the phone, or by video conference according to patients’ preferences. Participants receive the consent form by email using an online form or a form to print, sign, and scan; they have the opportunity to ask questions regarding the study and their participation and then provide consent before the interview. Digital audio recordings of the interviews are performed via a phone or computer recorder application and later downloaded on secured computers at the research centre. Phone recordings are then deleted. Recordings stored in secured computers will be transcribed verbatim.The team is using the comprehensive, integrated checklist of determinants of practice checklist (TICD Checklist) as a guide for deductive thematic analysis while allowing for unexpected themes to emerge during the coding process . AccordiIn light of the evidence gathered in the scientific and grey literature reviews, results from the data collected on patient medical record, and findings that will emerge from in-depth analysis of professionals and patients interviews, the multidisciplinary research team, including researchers, graduate students, oncologist, kinesiologist, hospital managers, and public health decision makers, will hold 2 to 4 half-day deliberative workshops to develop specific recommendations regarding PA promotion for patients through the cancer journey, in both clinical and community settings (objective 6 and 7).First, we propose to disseminate the resulting practice guideline and recommendations across Québec among healthcare organizations , physician-oncologists, health professionals, public health practitioners, cancer patients and survivors, and the general public. To this end, we will enlist patient partners to identify messages and tool formatting. Knowledge transfer activities will be achieved through reports, dissemination, exchanges, and production of the practice guide. Between January and June 2021, we will hold outreach events for clinicians, patients, kinesiologists, and public health actors who promote PA in communities by creating video clips of patients and health professionals and decision support tools from the study; organizing public forums on cancer and PA informed by our findings and scientific publications; publishing one or two brief "communiqués". Findings and recommendations from the current study will also be disseminated to the international scientific community through website simple language summaries and scientific publications in open access journals in French and English.The data collection procedures were approved by the CHUM Hospital Center Research Ethics Committee; ethical approval was received on April 12, 2018 (no 17.238). Patient medical record access was approved by the institution and all data are anonymized. Participants of qualitative interviews provided written informed consent and transcripts are also anonymized. The study design complies with institutional and national research ethics regulations and has been performed in accordance with the ethical standards as laid out in the 1964 Declaration of Helsinki and its later amendments.The data literature review started in September 2018; the EHR data extraction was completed in July 2019. At the time of submission, the research team was finalizing qualitative interviews with both professionals and patients, running analyses on data extracted from patient EHR, and developing the blueprint for the practice guideline.The COVID-19 pandemic affected health care systems globally. Worldwide, efforts to maintain and adapt usual health care were necessary although these transformations were not easy to implement due to limited time and resources. At the CHUM, the kinesiology team from the Virage Foundation rapidly transformed in-person PA sessions into virtual PA group sessions three times per week. To promote social interactions between participants, break social isolation, and foster social connectedness and support particularly needed in the context of COVID-19 confinement, the virtual room was available 30 minutes before and 30 minutes after PA sessions. This new virtual kinesiology service has generated great interest and increased participation from CHUM cancer patients into Virage PA programs. Although the current project was not initially planned to address this rapid transition to virtual services, it seems that there is much to learn from this rapid and so far, successful organizational transformation in the current COVID-19 context. To this end, data are being collected through the deliberation process with the multidisciplinary team to propose specific recommendations to promote PA and adapt kinesiology services in the exceptional context of a global pandemic.This paper describes the protocol for a knowledge-to-action project aimed at producing and sharing actionable evidence. Our hope is that PA promotion can be scaled up in such a way as to successfully integrate PA throughout cancer treatment and survivorship in order to improve the physical and mental health of the growing population of patients having received a cancer diagnosis.Our team recognizes that results obtained from participants mostly in one organization  would not reflect the diversity of perspectives from both patients and health professionals and managers across all regions and sites in Quebec. Given that PA programs are not widespread, it is challenging to identify individuals (both patients and caregivers) who have lived experience of either performing PA or promoting PA among cancer patients. As a result, we believe that data from this project represents a strength of the design as we capitalize on people’s lived experience to build and improve a nascent initiative. Finally, while we are in a single cancer center, the CHUM is the largest cancer center in the province of Quebec, and thus provides services and care to a broad spectrum of citizens. The size and complexity of the center provides an opportunity for understanding how different actors in the system spearheaded a variety of problems. Furthermore, we believe that working from a single, large university hospital is a good place to commence the exercise of scaling up.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.


Background: Blood flow restriction exercise (BFRE) has become a common method to increase skeletal muscle strength and hypertrophy for individuals with a variety of conditions. A substantial literature of BFRE in older adults exists in which significant gains in strength and functional performance have been observed without report of adverse events. Research examining the effects of BFRE in heart disease (HD) and heart failure (HF) appears to be increasing for which reason the Muscle Hypothesis of Chronic Heart Failure (MHCHF) will be used to fully elucidate the effects BFRE may have in patients with HD and HF highlighted in the MHCHF.Methods: A comprehensive literature review was performed in PubMed and the Cochrane library through February 2022. Inclusion criteria were: 1) the study was original research conducted in human subjects older than 18 years of age and diagnosed with either HD or HF, 2) study participants performed BFRE, and 3) post-intervention outcome measures of cardiovascular function, physical performance, skeletal muscle function and structure, and/or systemic biomarkers were provided. Exclusion criteria included review articles and articles on viewpoints and opinions of BFRE, book chapters, theses, dissertations, and case study articles.Results: Seven BFRE studies in HD and two BFRE studies in HF were found of which four of the HD and the two HF studies examined a variety of measures reflected within the MHCHF over a period of 8–24 weeks. No adverse events were reported in any of the studies and significant improvements in skeletal muscle strength, endurance, and work as well as cardiorespiratory performance, mitochondrial function, exercise tolerance, functional performance, immune humoral function, and possibly cardiac performance were observed in one or more of the reviewed studies.Conclusion: In view of the above systematic review, BFRE has been performed safely with no report of adverse event in patients with a variety of different types of HD and in patients with HF. The components of the MHCHF that can be potentially improved with BFRE include left ventricular dysfunction, inflammatory markers, inactivity, a catabolic state, skeletal and possibly respiratory muscle myopathy, dyspnea and fatigue, ANS activity, and peripheral blood flow. Furthermore, investigation of feasibility, acceptability, adherence, adverse effects, and symptoms during and after BFRE is needed since very few studies have examined these important issues comprehensively in patients with HD and HF. The “muscle hypothesis of chronic heart failure” (MHCHF) attributes the decreased exercise tolerance common in heart failure (HF) to skeletal muscle atrophy and metabolic inefficiency which stimulates a viscous cycle of dyspnea and fatigue; increased ventilation; sympathetic nervous system (SNS) excitation; increased afterload and reduced peripheral blood flow; and a catabolic state all of which worsen cardiac and skeletal muscle performance. . Many ofBlood flow restriction exercise (BFRE) has become a common method to increase skeletal muscle strength and hypertrophy for patients with a variety of orthopedic and other musculoskeletal disorders in whom limited activity, exercise, and workloads are common. . A substThe reduction in blood flow and subsequent hypoxia within exercising skeletal muscle during BFRE stimulates anaerobic metabolism and metabolite accumulation promoting rapid muscular fatigue, up-regulated muscle protein synthesis, systemic anabolic hormone release, and possibly angiogenesis. . HoweverOne such BFRE protocol is cuff release after one or more sets of BFRE since there is potential to elicit favorable effects on skeletal muscle and the vasculature including an increase in nitric oxide and endothelium dependent vasodilation due to vascular sheer stress. . In factThe purpose of this paper is to provide a comprehensive overview of the MHCHF and how BFRE may affect each component of the original and revised MHCHF and attenuate its viscous cycle. A systematic review of a growing literature of seven BFRE studies in HD and two BFRE studies in HF will follow in which the safety and beneficial effects of BFRE on the pathophysiological manifestations of HD and HF will be highlighted. . Recent Patients with HF suffer from marked dyspnea and fatigue because of the inability of the heart to pump blood adequately to peripheral tissues resulting in excessive blood volume in the chambers of the heart and insufficient blood flow to skeletal muscles. . InsuffiThe manner by which left ventricular dysfunction contributes to skeletal muscle weakness and many pathophysiological manifestations of heart failure have been keenly described in the MHCHF. This conceptual model outlines the major ramifications from HF on the body and identifies the major role that skeletal muscle weakness plays in worsening HF . As showIn view of the potential effects of BFRE on the vasculature and cardiovascular function, it is possible that BFRE may be a potential method to improve not only skeletal muscle strength and endurance and exercise tolerance, but possibly even the pumping ability of the heart in HF. .The three key mechanisms by which BFRE could potentially improve each area within the MHCHF include increasing skeletal muscle strength, decreasing venous return, and improving peripheral vasodilation . Since pAlso, although the MHCHF was specifically designed for patients with HF, many of the components outlined in the original and revised MHCHF may still be present in patients with HD and other disorders such as chronic obstructive pulmonary disease and cachexia. . Exampleblood flow restriction, heart disease, heart failure, physical function and skeletal muscle. The reference list of eligible studies was also screened to identify other potentially relevant publications.A comprehensive literature review was performed in PubMed and the Cochrane library through February 2022. A study had to meet the following criteria to be included in the systematic review: 1) the study was original research conducted in human subjects older than 18 years of age and diagnosed with either heart disease or heart failure, 2) study participants performed BFRE, and 3) post-intervention outcome measures of cardiovascular function, physical performance, skeletal muscle function and structure, and/or systemic biomarkers were provided. Exclusion criteria included review articles and articles on viewpoints and opinions of BFRE, book chapters, theses, dissertations, and case study articles. Studies were only considered for eligibility if they have been peer reviewed and published prior to the search. Study quality was assessed using two separate instruments including the TESTEX scale for randomized controlled trials (RCTs)  and the This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.The search identified a total of 227 papers of which 9 met our inclusion criteria (7 reports of BFRE in HD and 2 reports of BFRE in HF) . The ass59 Also observed by Passino were significant favorable decreases in end-systolic and diastolic volume after the 9-months program as well as an identical significant relationship between BNP and peak oxygen consumption.  and the other with less severe HF (LVEF = 65%). . A serieIn view of the above favorable changes in cardiac performance from BFRE in the patient with severe HF, chronic BFRE was performed via SLR without added resistance 2x/week for 3 weeks at 60% limb occlusion pressure. . Three sThe second study of BFRE in HF was performed by Groennebaek et al. in which 36 patients with reduced ejection fraction heart failure (LVEF = 35–37%) were randomized to BFRE, remote ischemic preconditioning (RIPC), or non-treatment control . Groenn BFRE andThree of the 7 studies of BFRE in HD were RCTs  and the The results of the above studies are shown in The two other studies of BFRE in HD were performed in Slovenia using the same patient population while using a pneumatic cuff that was placed at the medium portion of each thigh . The acu41-49 This is an important finding given that a variety of patients with HD  performed BFRE making the results of this systematic review more generalizable. However, the relatively small number of total subjects in this systematic review  and the carefully selected subjects with the HF subjects having mild to moderate HF based on BNP values highlights the need for further investigation of BFRE in HD and HF.It is important to note that BFRE was performed safely in all of the above studies without report of an adverse event.The results of the chronic BFRE by Nakajima et al. appear to be most promising for patients with HD in view of the significantly greater circumferential surface area in the quadriceps, hamstring, and adductor muscles, significant increases in leg strength, as well as submaximal and maximal exercise and cardiorespiratory capacity after 3 months of twice weekly BFR exercise performed at 20–30% 1 RM with an initial set of 30 repetitions followed by 3 sets of 15 repetitions and a 60 s rest between sets. . Thus, aThe results of the acute and chronic BFRE studies in HD are also important since plasma fibrinogen and fibrin degradation products were unchanged and after plasma volume correction, the D-dimer and CRP values were no longer statistically different than before BFR exercise highlighting the potential safety of BFRE in patients with HD. . FurtherAlthough no studies of BFRE in HD utilized aerobic exercise training, the results of BFRE in HF are promising especially since aerobic BFRE appears to elicit a less aggressive hemodynamic response. . FurtherIn summary, BFRE in HD and HF was performed safely and was observed to improve one or more of the following measures in the reviewed studies including skeletal muscle strength, endurance, and hypertrophy; cardiorespiratory performance; mitochondrial function; exercise tolerance; functional performance; immune humoral function; and possibly cardiac performance. . AlthougIn view of the above systematic review, BFRE has been performed safely with no report of adverse event in patients with a variety of different types of HD and in patients with HF. The available literature suggests that many components of the MHCHF are improved with BFRE which may attenuate its viscous cycle. The components of the MHCHF that can be potentially improved with BFRE include left ventricular dysfunction, inflammatory markers, inactivity, a catabolic state, skeletal and possibly respiratory muscle myopathy, dyspnea and fatigue, ANS activity, and peripheral blood flow. Although the currently available BFRE literature has demonstrated improvements in each of these components in patients with HD and HF, further investigation of the role BFRE may have in the management of HD and HF is needed.


To better understand life course influences affecting cognitive function and decline in later life, we explored sex and race/ethnicity differentials in the relationship between a history of psychiatric, emotional, or nervous problems and cognitive functioning in later life, while accounting for early life disadvantage and relevant covariates.Multi-level growth curve models examined associations between psychiatric history and cognitive functioning, and differences by sex and race/ethnicity (SRE), in 20,155 Health and Retirement Study (1995-2014) participants aged 65 or older, by estimating cognition scores and plotting trajectories of change with age by SRE.A history of psychiatric, emotional, or nervous problems was significantly related to cognition scores and rates of decline. Hispanic and Black participants had significantly lower cognition scores at age 75 and steeper rates of decline than White females, and Black race and the Hispanic race-sex interaction erased the protective effects of being female.Our findings indicate that members of minority groups with a history of psychiatric problems evidence lower cognitive function in later life, and as a result, have a greater need for community-based long-term care than their peers without this history. Future research should include longitudinal analyses of different components of cognitive function, specific psychiatric diagnoses, and life history data that capture socioeconomic and psychosocial experiences throughout the life course. Population level findings as reported here, along with aggregate findings from similar studies, can inform interventions and policies regarding support for populations that are vulnerable to mental illness and to subsequent cognitive decline.


Social determinants of health, such as food insecurity, contribute to chronic health conditions, decreased quality of life, and health disparities. Increasingly, healthcare systems seek to address social determinants of health by integrating medical and social care.Eskenazi Health Center Pecar is a Federally Qualified Health Center providing comprehensive primary care to vulnerable patients in Indianapolis, IN, USA. This health center, in coalition with community partners, established and continually developed an integrated food pantry model to address food insecurity, improve nutrition education, and support patient access to healthy food.Food insecurity and poor nutrition are common in primary care and contribute to the incidence and outcomes of chronic conditions such as obesity, hypertension, and diabetes. Long-term management of food assistance and nutrition programs requires substantial resources, partnerships, and leadership. We describe lessons learned in food pantry partnership, funding, logistics, and sustainability in a collaborative food access model integrated into healthcare. These lessons learned can be utilized by other health systems to scale up and accelerate strategies to better address food security and nutrition education. This paper articulates best practices for integrating a food pantry model within primary care with the goal of long-term sustainability and direct impact on patient health outcomes. According to the World Health Organization, social determinants of health account for 30–50% of health outcomes and have a major influence on health disparities . These s45678910111213141516Food pantries are an essential part of the food landscape for many communities and individuals who are food insecure. A food pantry can not only serve as an emergency source of nutrition but can also provide a significant portion of a participant’s dietary intake . Althoug23241428A comprehensive approach to addressing food insecurity addresses not only hunger, but also the full spectrum of poor nutrition leading to common chronic conditions. Paradoxically, food insecurity may lead to obesity by pushing families toward low-cost, high-calorie, low-nutritional value foods 31. Thus,By the end of its first year of operation in 2015, CCFP had served 5,284 household visits  and in 2019 that number grew to a total of 18,443 household visits served . With the SARS-CoV2 global pandemic, CCFP increased capacity to serve 24,186 household visits  in 2020, 25,877 household visits  in 2021 and is now projecting the number of household visits served for 2022 to far exceed these numbers. Additionally, when the clinical care teams implemented the integrated workflow process for food insecurity screening in 2019, the volume of Eskenazi Health Center Pecar specific patient referrals utilizing CCFP started to rapidly increase .TM questions. Prior research demonstrates these questions to be sensitive and specific for identifying households at risk for food insecurity [33A key sustainability feature of this model is a goal to embed the care processes for food access and nutrition within the current health system workflow. Annual screening was implemented in 2019 for patients receiving care at Eskenazi Health Center Pecar utilizing the two validated Hunger Vital Signsecurity 3334. TheTM” smart phone-based food access guide. The EHR captures these referrals and provides a visual reminder if a positive screen does not have an associated documented resource assistance referral. These EHR support tools help to assure follow-up to determine if the patient was able to access and utilize the recommended food resources. One final aspect of the EHR infrastructure includes support for a team-based approach to health care. As noted, our goal is to embed the workflow of care for social determinants within the same teams and workflow for other health conditions. This requires a communication platform that also supports a primary care culture that assigns responsibility, accountability, and resources to specific team members. Hospital inpatient, specialty care, emergency department, and mental health care teams also utilize the same EHR screening platform, so documentation is visible throughout the health system. A clear process and role for each clinical team member is necessary to effectively administer screening questions, review results, refer patients who need resources, and follow-up whether food access needs were met. For example, with about one-third of all patients screening positive for food insecurity, clinic-based social workers cannot meet the patients’ needs without a team approach. Additional EHR-based tools support providers’ electronic referral to other social care and nutrition services both within and outside Eskenazi Health. These may include internal referrals to social workers, dietitians, health coaches, application support for the US Supplemental Nutrition Assistance Program (SNAP), or financial counseling. Referrals may also include food pantry resources, free prepared meals, Supplemental Nutrition Program for Women, Infants and Children (WIC), SNAP, and other community food services that can be accessed on the Indy Hunger Network’s “Community CompassFood insecure patients receive a “Food is Medicine” paper referral to present for registration at the CCFP see . We highPatients can choose to enroll in other nutrition education programs that are an essential part of a comprehensive approach to food insecurity. CCFP includes a mobile education kitchen where groups of patients and their families can learn to cook with a health center registered dietitian and taste nutritious recipes or learn how to follow medically tailored diets. Health center dietitians also engage with patients with education about food preparation, cooking, nutrition and food label assessment, grocery shopping, and disease-specific nutrition guidance. This extensive nutrition education programming is made possible by the co-located food pantry in a health care center. Monthly food demonstrations by the registered dietitians at CCFP began in 2016 and continued until the “Food Is Medicine” group visits started in 2019. During this period, there were 29 food demonstrations for general shoppers, with an estimated 2175 clients attending. An additional outreach during senior shopping hours included 22 demonstrations with 770 attending. While nutrition programming continued to develop at CCFP, it also continued to drive the increase in individual dietitian patient visits at Eskenazi Health Center Pecar. The Eskenazi Health Center Pecar dietitians (1.5 full time employment) saw volumes more than double over the four-year time period . RegisteHouseholds register to shop at the co-located CCFP for nutritious food items twice a month as needed. Prior to the pandemic, CCFP clients utilized a “client choice” food pantry model with availability of a variety of fresh produce, frozen food items, eggs, milk, and other staple items partially based on family size. During the SARS-CoV2 pandemic CCFP distributed the same items to households in a drive -through system at the same health center site, but without the individual personal shopping choice experience. Households received about 80 pounds (average) of food with the initial “client choice” model and now with the drive through pantry model each household receives an average is about 140 pounds of food. This approximate 50% increase in food distributed in the drive -through model has allowed households to get more food without increasing number of pantry visits. Other resources from community-based organizations, community gardening efforts, and other food resources and social services are also provided to families with additional needs.The Crooked Creek Food Pantry is a separate 501c3 nonprofit corporation and is led by a volunteer Board of Directors with representation from the founding member organizations of Corteva Agriscience (formerly Dow Agroscience), Eskenazi Health, and St. Luke’s United Methodist Church, as well as other key community partners. It receives donations and purchased food from multiple food banks and local business partners in addition to Gleaners. CCFP also purchases at retail about 25% of the food it distributes. Individual volunteers represent one of the most important resources required for managing and sustaining a food pantry in a health facility. Currently CCFP is managed by one full-time volunteer Executive Director, two full-time paid managers, one part-time interpreter, one part-time truck driver, and about 120 volunteers per week. Total CCFP staff and volunteer work hours exceed 500 hours per week. Volunteer capacity, training, scheduling, and organization are significant tasks that are essential for a large food pantry to function at full capacity. For example, to support obtaining the quantities of food required for ample distributions of food to 2,850 households a month, CCFP facilitates up to 44 separate food pickups weekly. In addition to the work needed to organize the volunteers, we summarize the volunteer workforce needed to maintain pantry function and capacity as follows: 1) Unloading, boxing, and bagging volunteers total about 50 per week, 2) Food distribution volunteers total about 40 per week, 3) Registration and sign-in volunteers total about 10 per week, and 4) Cardboard and trash management and general cleanup requires 10 volunteers per week. Our partner organizations facilitate and encourage volunteer efforts, as well as financial donations, donation of other food resources, and infrastructure resources.We highlight four lessons learned to guide others seeking to integrate medical care and social care to address food insecurity: partnership, funding, logistics, and sustainability.Well-intentioned efforts without partnership with community-based organizations and the community served can exacerbate and amplify the harmful impacts of food insecurity. As health systems become more aware of the significant impact food insecurity has on individual health outcomes and health disparities, they often seek quick but unsustainable solutions. A common example of such a solution includes food closets supported through food donations from medical staff and their families. These food sources typically cannot provide a balanced source of nutrition or even enough low nutritional value calories to sustain food insecure families for weeks at a time. A small capacity food pantry with shelf-stable canned and dry food products that are high in sodium and carbohydrate content are often contrary to the dietary recommendations for patients with chronic health conditions. Another example of an inadequate response to individuals who are food insecure is the simple provision of names and contact information for food pantry organizations in the local community. As noted earlier, patients face multiple additional access hurdles without facilitated referrals to community-based food related partners. Finally, these smaller efforts often duplicate larger scale, more efficient  food pantry operations. When viewed from the perspective of the full range of social determinants of health, health systems must develop and manage partnerships with organizations whose capacity, efficiency, and expertise in any particular area  exceeds that of the health system.Partnerships also provide a foundational level of funding support both in terms of financial assistance from larger organizations and donations from individual donors. Notably, significant leadership effort and strategic planning is needed for sustainable funding of a large-scale food pantry. The community need for food access in the FQHC setting is high and funding a large food pantry takes a commitment from the health system and community partners. Initial funding for CCFP was obtained well in advance of the pantry opening and continues to evolve to meet the ongoing funding demands. Over the past six years funding sources include extramural grants, corporations, faith-based organizations, and individual philanthropy. Direct food donations are a large aspect of sustainability for CCFP. In 2015 CCFP had total expenses of $60,000 (US). In the first full year of operation in 2016 the donation amount breakdowns were as follows: Direct Food Donations $301,000, Individual Food Donations $22,000, Faith-Based Donations $93,000, and Corporate Donations $95,000, for a total of $511,000. Currently the annual budget exceeds $360,000 (US) which does not include the significant estimated retail value of donated food that now exceeds $2.5 million (US) annually. In any given year, annual expenses may exceed these figures as the number of clients served increases and as the program is awarded funding for capital expenditures, vehicles and/or other equipment.Additional funding sustainability was added in September 2019 when CCFP began to participate in The Emergency Food Assistance Program (TEFAP). TEFAP is a federal program that helps supplement the diets of low-income Americans by providing them with emergency food assistance at no cost. The United States Department of Agriculture (USDA) provides food and administrative funding to states to operate TEFAP . With thThe space needed for food storage and pantry shopping was also initially underestimated. In July 2018 CCFP doubled the original square footage for client shopping and inventory storage to approximately 2,500 square feet. Additional issues that required a larger space included increased space needed for clients waiting to shop in the food pantry, larger entry space for food pallet delivery, and additional pallet and shopping cart storage space. CCFP generated large volumes of cardboard and food packaging materials, as typically occurs with food pantries, which necessitated additional recycling and dumpster capacity.To highlight some of these logistical challenges, we specifically note the demand for refrigeration and freezer capacity. CCFP began operations in 2015 with a total of 230 cubic feet of refrigeration and freezer capacity. This cooling and freezer capacity proved inadequate. Over the following two years, CCFP expanded refrigeration to 400 cubic feet. This refrigeration and freezer capacity remained inadequate for the number of individuals served. The commitment to provide healthy food options that need refrigerator or freezer storage led the food pantry to eventually increase its cooling capacity over its first six years of operation from 230 cubic feet in 2015 to approximately 1,605 cubic feet.Since CCFP opened, there have been several adjustments in the food distribution approach to take into consideration the household size. Initially in 2015, virtually every category of food had a selection level based on the household size allowing more food for larger families. As the pantry volumes grew, it became apparent that it was difficult for volunteers to manage the pantry flow to include the variability in number of items to be allowed for each category based on household size. A shift was made to reduce the number of items that were household size sensitive. Another change to tailored distribution of food volumes for varying household sizes was necessitated by the SARS CoV2 pandemic. Currently all households receive larger but equal food distributions independent of household size. There will likely be further process adjustments necessitated as the pantry food distribution model continues to adapt to changes and constraints while still ensuring the community need for food pantry services is met. We highlight the value of partnerships with large organizations with substantial logistic expertise and workforce capabilities to underscore the importance of these partnerships in responding to change.As already noted, labor, funding, and logistic support represent major challenges to sustainability. However, within each of these areas, sustainability also requires innovative approaches to old problems and novel approaches to unanticipated or new problems. The COVID-19 pandemic disrupted operations; it also caused a large surge of food insecure individuals in the community. In order to further sustain sufficient food supply to meet the increased demand, CCFP utilized additional federal resources with The US Emergency Food Assistance Program TEFAP and the Coronavirus Food Assistance Program (CFAP) as described above in funding section. There was also an effort to greatly increase the network of retail and food bank donation partners as another approach to obtain sufficient food supply to meet the increasing demand for food pantry services.The sustainability of food insecurity screening and the social determinants of health workflow implementation has largely relied on significant health system investment in the built infrastructure, food resource partnership and staff development. It has been essential to streamline and decrease the human resource burden of screening and resource referral by supporting the process within existing workflows in the electronic medical record. A team-based care workflow approach to food insecurity screening and referral helps to reduce the burden on any individual health provider. Development of a dashboard for social determinants of health data collection allows for the incorporation of quality metrics such as food insecurity screening rates into individual performance goals as another approach to sustaining the workflow process and high screening rates. Investment in the social determinants of health system leadership structure and the integration of additional community outreach positions, such as community health workers and community weavers, has accelerated and sustained efforts to address community social health needs.Additionally, the sustainability of this food pantry model integrated into Eskenazi Health Center Pecar is enhanced by being part of a larger health system and a public entity of Health & Hospital Corporation (HHC) of Marion County. Each of the fourteen Eskenazi FQHC sites are a part of this larger FQHC co-applicant enterprise that provides access to additional resources that a typical independent FQHC may not be able to provide. For example, the larger Eskenazi Health and HHC system allowed access to additional food pantry staffing and other support needed during the SARS-CoV2 global pandemic. The “in kind” donation of health center space, utilities, and additional infrastructure support are all benefits of being a part of a larger health system. Another essential ingredient to the success and sustainability of this food access model is the understanding and unwavering support of the physician-led Eskenazi Health senior leadership and mission for a comprehensive approach to food as medicine, lifestyle medicine, and all the other social determinants of health.Chronic health conditions and long-term health outcomes are significantly impacted by nutrition, so it is imperative that every health system has a universal food insecurity screening infrastructure and process as well as a comprehensive food resource and nutrition education strategy. Despite the essential role that food pantry models serve in providing emergency nutrition resources, it is understood that as an isolated intervention they do not resolve many of the complexities of food insecurity and the associated risk of chronic disease. Addressing food access disparities is essential to improving the health and well-being of every individual in the community, yet most health systems have minimal experience or expertise in the implementation of a sustainable food access model integrated into primary health care. Health systems historically have grossly underestimated the large capacity and extensive partnerships necessary to sustain an effective food access strategy. High quality food resources and nutrition education that are comprehensive, culturally sensitive, patient-centered, accessible, and facilitated with community partnership in the health care setting are essential but exceedingly difficult for health systems to implement and sustain. Well-intentioned efforts by health systems to provide small pantry capacity, without consistent nutritious food options, may further perpetuate and worsen the poor health outcomes related to the inadequate nutrition of those who are food insecure. Eskenazi Health Center Pecar and Crooked Creek Food Pantry are successful examples of a healthcare and pantry partnership seeking to provide an initial solution for this key social determinant of health. It demonstrates that the linkage of a health center with a food pantry is a powerful and innovative way to begin to effect change in the health and well-being of a community. Health systems can utilize the lessons learned from the implementation of this large-scale, co-located food pantry partnership to avoid common pitfalls and unsustainable food access strategies.Further innovation and study of best practices in addressing food access and nutrition education are needed as health systems partner with communities to address health disparities and barriers related to food insecurity. Partnerships outside of the traditional healthcare establishment are essential with the recognition that many community-based partners have the extensive experience and expertise that healthcare systems typically lack in the management of food pantry and food access resources. Community food pantry partners value the health care systems’ ability to screen for food insecure individuals, understand the complexities of individuals health and social situation, provide expertise in nutrition-related disease management, and nutrition education. Effective partnership and integrated care will better address the impact of food insecurity on the health of individuals and communities for improved health outcomes and decreased nutritional-related health disparities.


Restorative sleep plays a critical role in maintaining physical and mental health. Sleep disturbances frequently co-occur with trauma or stress related disorder such as posttraumatic stress disorder (PTSD). It has long been thought that interventions focusing on trauma itself would eventually reduce disturbed sleep. However, accumulating evidence have shown that sleep disturbances play a central role in both the development and maintenance of PTSD and therefore require clinical attention. As well as traumatic stress, stressful experiences are also associated with sleep . Stress Lancel et al. introduced sleep disorders which have been suggested as predisposing, facilitating, and perpetuating factors of PTSD. This review also introduces non-pharmacological and pharmacological treatments for the four major sleep disorders commonly accompanying PTSD. Authors strongly recommended an initial comprehensive evaluation and timely treatment for comorbid sleep disorders for PTSD patients.In the current Research Topic, 1 review article and 1 original article on the association between PTSD and sleep were published. The review article by Denis et al., the relationship between sleep microarchitecture and symptom severity in trauma-exposed participants with and without PTSD were investigated. Contrary to previous studies, beta power was increased in trauma-exposed controls (TEC) compared to PTSD. Spectral power in the beta frequency was associated with reduced symptoms. Their results suggest an adaptive role of beta power during sleep for individuals exposed to trauma.In the article by Cleper et al. reported that the influence of COVID-19 work-related stressors on sleep in physicians and nurses working in designated COVID-19 wards. COVID-19 frontline health care workers were more likely to report sleep difficulties compared to non-COVID-19 health care workers in the same hospital. In particular, the negative experiences, mainly witnessing patient's physical suffering or death, partially explained the association between COVID-19 work and sleep disturbances.There are many stressful situations in hospital both for patients and health care workers, and these stressful situations can be associated with sleep. The current Research Topic covers the relationship between sleep and hospital-related stressful situations such as COVID-19, HIV infection, operation, and pregnancy. Yan et al.. PSQI was used to measure sleep quality 5 years after HIV diagnosis. Sleep disturbances were associated with less income, higher CD4 counts, antiretroviral treatment initiation, exercise, depression, and higher stress levels. Authors reported that the Chinese version of PSQI is feasible for use among people living with HIV considering its internal consistency and the construct validity.The reliability and validity of the Chinese version of Pittsburgh Sleep Quality Index (PSQI) in people living with HIV were assessed by Zeng et al.. Patients with preoperative insomnia were divided into two groups of intranasal DEX and normal saline (NS). Intranasal DEX shorten sleep latency and lengthen total sleep time compared to intranasal NS. The intranasal DEX application also reduced insomnia and drowsiness. They suggest that intranasal DEX can improve preoperative insomnia, especially for patients who are reluctant to take sleeping pills before surgery.Applicability of intranasal dexmedetomidine (DEX) in the treatment of preoperative insomnia was reported by Bao et al.. Poor sleep trajectories during the perinatal period were related to postpartum depression. Authors suggest that screening for prenatal sleep problems would be helpful for identifying the onset of perinatal depression. Bao et al. also reported that patients with prenatal depression showed poor sleep quality and decision-making function especially when they had suicidal ideation. This study suggests that sleep disturbance and impaired decision-making function may be risk factors for suicidal ideation in prenatal depression.Most women complained sleep disturbances during perinatal/postnatal period, which is associated with physiological and psychological change during pregnancy . Two papManzar et al. demonstrates that the interrelationship between psychological stress, poor sleep, inadequate sleep hygiene, and anxiety in university students. They suggest a need to address the various aspects of mental health and its diverse sleep correlates in university students.The current Research Topic also covers the association between sleep and common psychological stress of young adults. Barbeau et al. investigated the impact of recent troubling experiences on dream characteristics. Individuals who experienced a recent troubling event reported a higher frequency of nightmares and more emotionally negative dream. Nightmare and oneiric dream were more common in young adults. Authors suggest that dysphoric dreams might serve as potential proxies of mental health status and developmental stages.Taken together, this Research Topic covered several diverse of sleep disturbance and psychological trauma or stress, and can update readers with the latest research in the field of sleep medicine, psychosomatic medicine and psychiatry. These articles will provide insights to the clinicians and researchers, and help them to further explore the relationship between sleep and psychological trauma or stress with the goal of developing effective therapeutic strategies.The author confirms being the sole contributor of this work and has approved it for publication.This research was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. 2022R1A2C2008417), the Bio and Medical Technology Development Program of the National Research Foundation (NRF) funded by the Korean government (MSIT) (No. 2020M3E5D9080561), and a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI) funded by the Ministry of Health & Welfare, Republic of Korea (No. HR21C0885).The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Life course-informed theories of development suggest it is important to integrate information about positive and negative aspects of the social environment into studies of child and parental wellbeing, including both stressors that compromise health and resources that promote well-being. We recruited a sample of 169 pairs of caregivers and young children (birth to 5 years) from a community health clinic and administered survey questions to assess stressors and resources. We constructed inventories of stressors and resources and examined the relationships between these inventories and caregivers’ depressive symptoms, anxiety symptoms, and sleep problems, and young children’s medical diagnoses derived from electronic health records. Cumulative stressors and resources displayed bivariate and adjusted associations with caregivers’ depressive symptoms, anxiety symptoms, and sleep problems. For depressive and anxiety symptoms, these associations were evident in models that included stressors and resources together. Caregivers with high stressors and low resources displayed the highest levels of depressive and anxiety symptoms and sleep problems. In terms of children’s health outcomes, only modest trends were evident for developmental/mental health outcomes, but not other diagnostic categories. Future studies are needed to examine stressors and resources together in larger samples and in relation to prospectively assessed measures of child well-being. Social context affects the health and wellbeing of parents and children, including stressors that compromise health and resources that promote well-being . The intn = 40,302), adverse childhood experiences and positive childhood experiences interacted, whereby children who were exposed to high levels of adversity and low positive experiences had over 8 times the odds of depression compared to children with low adversity and high positive experiences [n = 489, ages 10–13 years at baseline), researchers found that the ratio of childhood adversities to protective factors was associated with a range of health outcomes nearly ten years later [Several recent studies have examined childhood stressors and resources together for health outcomes in children ,15 and aeriences . In anotrs later . Similarrs later . These srs later ,18,19,20Social scientists and health practitioners have developed a wide array of options for high-quality measures of distinct family processes, attributes, and events relevant for characterizing the lives of caregivers and young children. Validated measures for specific parent or family characteristics, experiences, or contexts are typically long , making it challenging to bring together multiple measures to characterize caregiver and young children’s social environments comprehensively within research or clinical contexts, and to incorporate multiple detailed, multi-item assessments into analyses. With the increasing interest in integrating information about positive and negative aspects of children’s social environment into research studies and clinical practices ,23,24,25Guided by an accumulation model , in the Our study team recruited 169 caregiver-child dyads from the waiting room of a single community health center in Massachusetts. Families were eligible for inclusion in this cross-sectional study if the adult was a primary caregiver to a young child (ages 0 to 5 years) present in the clinic for an appointment. If eligible, the primary caregiver completed an informed consent process and the survey in English, Spanish, Portuguese, or Haitian Creole . Caregivers completed the surveys via a tablet while at the clinic, with help from research assistants as needed. Following survey completion, the research assistant added the child’s medical record number to the survey record to make it possible to link the child’s electronic health record (EHR) to the survey responses. The Institutional Review Board at Cambridge Health Alliance approved the study.We collected information on a broad range of stressors and resources that can impact opportunities for healthy child development until five years of age. Experts from psychology, sociology, public health, and human development (some included in this authorship group) were asked to recommend brief yet validated questions for a range of stressors and resources recognized as central to parental wellbeing and child health. The overall goal was to create a survey with high-quality brief measures. The included constructs and associated measures were selected based on the current theories of early child development and research building on these models ,26,27,28We constructed a cumulative stressor inventory that included 16 dichotomous indicators (range 0–16), created from the items listed in The cumulative resources inventory included 11 indicators created from the items listed in To consider the co-occurrence of cumulative stressors and resources, we constructed a four-category variable to capture combinations of high and low scores on the cumulative stressors and resources inventories. For both inventories, we grouped quartiles 1 and 2 as “low” and quartiles 3 and 4 as “high” and created categories of (1) high stressors/low resources, (2) high stressors/high resources, (3) low stressors/low resources, and (4) low stressors/high resources.The survey included brief measures of the caregiver’s anxiety symptoms, depressive symptoms, and sleep difficulties. All three of these outcomes are important for sensitive and responsive parenting ,39,40. AWe abstracted children’s ICD-9- and ICD-10-based diagnoses from the electronic health record (EHR) and generated four dichotomous outcomes, including: (1) pediatric growth/nutrition ; (2) laboratory abnormalities ; (3) developmental/mental health ; (4) asthma-like symptoms . See t-tests and chi-square tests, respectively). As described above, we used quartile variables for the inventory scores (rather than continuous scores) to examine whether graded relationships exist and avoid assumptions of a linear relationship. Next, we applied regression models to estimate associations between caregiver symptoms and child health outcomes (dependent variables) and the continuous cumulative stressors and resources inventory quartiles (independent variables of interest), adjusted for socioeconomic and demographic characteristics. We used linear regressions to model associations for the caregiver outcomes , adjusted for the respondent’s age, sex, race/ethnicity, highest education in the household, and parental nativity. We did not apply adjusted models for the child outcomes given the sparse outcomes. Finally, we examined associations between the cumulative stressors and resources inventories as continuous scores, included individually and then together in models adjusted for the covariates described above. As a sensitivity analysis, we tested for multiplicative interactions between the continuous stressors and resources scores for the caregiver outcomes only.First, we generated descriptive statistics to summarize the sociodemographic characteristics of the study participants. To describe the bivariate relationship between the cumulative stressors and resources inventories and caregiver and child outcomes, we calculated mean scores by quartiles of the inventory scores, and for the four-category variable that combined across stressors and resources , the scores displayed independent associations with depressive and anxiety symptoms when included together (see Model 2), with the magnitudes of associations only slightly attenuated. In the model with sleep problems as the outcome, only the cumulative stressors score displayed a clear association, with greater stressors associated with more sleep problems, when the two scores were included together. In our sensitivity analyses, we did not find evidence for multiplicative interactions between the continuous stressors and resources scores for any of the outcomes in the adjusted models presented in Finally, in There are four key findings from our study. First, inventories of cumulative stressors and resources displayed strong associations with caregiver depressive symptoms, anxiety symptoms, and sleep problems, with cumulative stressors associated with worse outcomes, and cumulative resources associated with better outcomes. Second, the associations were evident in models that included stressors and resources together, for depressive and anxiety symptoms. Third, caregivers with high stressors and low resources displayed the highest levels of depressive and anxiety symptoms and sleep problems, indicating the value of considering stressors and resources together. Finally, with respect to children’s diagnoses, we did not observe associations between the cumulative stressors or resources indices and the child outcomes, except for developmental/mental health outcomes, which showed some evidence for associations, although they were not robust. Taken together, our results indicate that our measure of cumulative stressors and resources was related to a range of caregiver outcomes, whereas this was not the case for diagnostic conditions in young children.The observed associations for the caregiver outcomes are consistent with a broad literature documenting cumulative impacts of stressors and resources for adult mental health . The lacThe current study builds on a variety of studies that have examined individual types of parental or family characteristics in relation to outcomes in young children and their parents  may not be captured by most pediatric assessments or diagnoses. Third, the survey information was linked to the child’s EHR, which contains diagnoses since birth, meaning our analyses cannot document temporal ordering for either child or adult health outcomes. Fourth, all measures of stressors and resources relied on relatively brief caregiver self-reports, and negative experiences may be under-reported, or positive experiences or attributes could be inflated. Fifth, given the design for this pilot study, which relied on convenience sampling, the sample is small and susceptible to selection bias. Finally, we conducted multiple tests because we had three caregiver outcomes and four child outcomes; however, given the sample size of this pilot study, we were not able to adjust for multiple comparisons.Notably, this study also has several strengths, including (1) the unique community health clinic sample primarily comprised of racial/ethnic minorities and immigrants; (2) the translation of the survey into four languages to facilitate inclusion of non-English speaking families; and (3) the inclusion of numerous reliable and valid brief measures to comprise comprehensive inventories of stressors and resources, in line with the accumulation model, which is supported by the child development literature. In future research, it is important to examine the utility of this measure and other measures of cumulative stressors and resources, within longitudinal study designs that include repeated measures of child development. In addition, it will be informative to consider a broader range of outcomes in young children, beyond diagnostic conditions, including sleep , potentiIn conclusion, our study has documented clear associations between stressors and resources and parental outcomes, and these results are complemented by other studies showing the importance of parental wellbeing for optimal child development . Future


Disparity in cancer survival across countries has been linked to variation in cancer policy delivery but there is lack of empirical evidence for this association. We traced the evolution of cancer policies in 20 jurisdictions in Australia, Canada, Denmark, Ireland, Norway, New Zealand and the UK since 1995 and present the findings of an exploratory analysis linking cancer policy consistency to cancer survival.We systematically searched and analysed national/regional cancer plans and strategies, mapping timelines of cancer policy evolution. For 10 jurisdictions, evidence was synthesised into five categories: oversight function; cancer plan; implementation plan; budget for plan implementation; and evaluation. We assigned scores evaluating whether a category was present or absent, and weighted scores for consistency. Summed scores were correlated with trends in survival from seven cancers between 1995-2014.All ten jurisdictions had implemented a high-level structure overseeing, steering or delivering cancer control policies (1995 - 2014); all had also published at least one major cancer plan. There was great variation in oversight mechanisms, ranging from institutionalising cancer control  to cancer steering groups or taskforces . Frequency and consistency of cancer plans also varied, from a succession of plans that build on each other  to the publication of isolated plans . We found a positive, albeit weak, correlation of cancer policy consistency and improvements in survival over time for six of the seven cancers.Jurisdictions that have implemented consistent cancer control policies over time tended to be more successful in improving survival for a wide range of cancers. Our findings can help guide policymakers seeking approaches and frameworks to improve cancer services and, ultimately, cancer outcomes.• Sustained and consistent strategic cancer planning and investment are crucial for ensuring better patient outcomes, and this requires strong and sustained commitment at all levels.• The findings can help guide policymakers seeking approaches and frameworks to improve cancer services and, ultimately, cancer outcomes.


Image fusion of CT, MRI, and PET with endoscopic ultrasound and transabdominal ultrasound can be promising for GI malignancies as it has the potential to allow for a more precise lesion characterization with higher accuracy in tumor detection, staging, and interventional/image guidance. We conducted a literature review to identify the current possibilities of real-time image fusion involving US with a focus on clinical applications in the management of GI malignancies. Liver applications have been the most extensively investigated, either in experimental or commercially available systems. Real-time US fusion imaging of the liver is gaining more acceptance as it enables further diagnosis and interventional therapy of focal liver lesions that are difficult to visualize using conventional B-mode ultrasound. Clinical studies on EUS guided image fusion, to date, are limited. EUS–CT image fusion allowed for easier navigation and profiling of the target tumor and/or surrounding anatomical structure. Image fusion techniques encompassing multiple imaging modalities appear to be feasible and have been observed to increase visualization accuracy during interventional and diagnostic applications. The accurate diagnosis and staging of gastrointestinal malignancies can be further enhanced through the use of image fusion involving ultrasound (US). Medical image fusion refers to the integration and merging of visual information from various imaging modalities. Image fusion involving US incorporates the dynamic imaging technique of transabdominal ultrasound (TUS) or endoscopic ultrasound (EUS) fused with computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET). The major advantages of combining various imaging techniques include the ability to compare findings from one modality to another and the overall improved visualization of target lesions for diagnosis and image-guided interventions. The fusion of these modalities for clinical use has increased in recent years and has extended the diagnostic and therapeutic capabilities of US, enabling physicians to have a more precise assessment of target lesions ,2,3,4. FImage fusion of CT, MRI, and PET with US can be promising for GI malignancies as it has the potential to allow for a more precise lesion characterization with higher accuracy in tumor detection, staging, and interventional/image guidance. Here, we conducted a literature review to present an overview of the current possibilities of real-time image fusion involving US with a focus on clinical applications in the management of GI malignancies.The literature search was performed in PubMed and Web of Science using the terms “ultrasonography” or “endoscopic ultrasound” and “image fusion” and “gastrointestinal” or “digestive” and “cancer” or “malignancies”. The reference lists of the retrieved articles were hand-searched for further references.Precise image guidance is necessary for managing GI malignancies but can be challenging due to the possible small size of tumors, overall poor visualization, and deformable nature of the surrounding tissue.CT imaging is one of the main pillars of image-guided procedures for GI tumors due to its high spatial resolution and the ability to image all vital structures. However, it is limited by the lack of real-time feedback, radiation exposure, and need for contrast for tumor visualization . Similarly, MRI is a common diagnostic imaging modality for organs such as the liver or pancreas due to its ability to obtain superior tissue contrast resolution and high-resolution images without ionizing radiation. Real-time MRI guidance is available, but it requires a prolonged procedure time; the images are susceptible to motion artifact  and the additional equipment is expensive and cumbersome. MRI also poses safety concerns for patients with contraindications such as the presence of electronic medical devices or metal implants.On the other hand, US is widely available, portable, and less costly. Therefore, improvement in US technology and utilization through the integration of image fusion could have a global impact on improving the quality of care of patients with GI malignancies. US allows real-time visualization and does not have the same issues of radiation exposure, as with CT, or the safety risks and training required, as with MRI. Therefore, one can appreciate the advantage of US guidance to target GI tumors and adjacent tissues by fusing diagnostic quality MRI/CT images. With image fusion, the practicability of real-time US guidance is combined with the high resolution of baseline CT/MRI datasets. Furthermore, image fusion incorporating endoscopic US (EUS) with CT/MRI imaging can provide real-time, high-resolution visualization of liver lesions and pancreato-biliary and esophageal lesions through multiple viewing planes ,6. EUS iPerhaps the most well-known fusion application in diagnostic imaging is the use of functional FDG-PET with CT for anatomic localization. PET/CT is a powerful tool for the assessment of metabolic activity of lesions suspected of malignancy and whole-body oncologic staging ,11. HoweThe combination of these imaging modalities to enhance visualization of the tumor and to provide dynamic feedback would extend the standard of care for GI malignancy staging, diagnosis, and interventional therapies and could reduce the risks for adverse events and toxicity to surrounding vital abdominal structures. This is especially true when trying to assess treatment response from radiotherapy (RT) for pancreatic tumors where CT provides limited data and increased SUV on PET could be due to inflammation as opposed to residual disease. Recently, texture patterns and changes observed on CT before and after RT appear to correlate with the clinical outcomes of pancreatic ductal adenocarcinoma . CorrelaFusion of two imaging modalities requires a spatial co-registration to ensure that the real-time dynamic imaging data match the exact anatomy and spatial volume data of the reference imaging modality . AchieviDuring the image fusion set up, two or more sets of co-registered images are co-displayed. This process can be done manually by an operator, who matches points and/or landmarks on both sets of images, or automatically by an algorithm, which matches pixels to voxels of two imaging datasets . Semi-auElectromagnetic (EM) navigation is used to track the movement and position of the imaging devices within the region of the target lesion. This is accomplished by placing an electromagnetic field generator in close proximity to the patient and incorporating electromagnetic sensor coils within the interventional or sonographic imaging device . These sThere are many challenges that present with image fusion technologies. In reality, many of the imaging data points collected are constantly being changed by tissue deformation caused by body movement such as respiration and gastrointestinal lumen contractions ,3,16,17.Place the EM tracking and field generator system in close proximity to or under the patient and connect it to the computer running the fusion imaging (FI) software;Place one or more active marker disks on the patient’s xiphoid process;Place the EM sensor inside the navigation catheter in the working channel of the endoscope/echoendoscope;Load the pre-procedure CT scans in the FI software;Create a 3D model of the patient anatomy;Co-register the EUS patient space with the CT space;Identify and navigate towards the target using dual visualization of the EUS image and its corresponding virtual section through the CT volume;Make fine adjustments to the registration if necessary;Once the target is reached, the EUS is fixed in place; the navigation catheter is retracted and replaced with a FNA (fine needle aspiration) needle for biopsy collection.A typical image fusion session combines the EM field generator, external physical markers, and the image fusion software in the following steps :Place thRegarding the role of image fusion in the management of GI malignancies, liver applications have been the most extensively investigated, either in experimental or commercially available systems. Real-time US fusion imaging of the liver is gaining more acceptance as it enables further diagnosis and interventional therapy of focal liver lesions that are difficult to visualize using conventional B-mode ultrasound .Studies have shown that image fusion allows for a better detection and characterization of focal liver lesions. The detection rate of small hepatocellular carcinomas (<3 cm) with US increased from 78.8% to 90.5% after using real-time US fused with CT or MR images . Jung etConsidering the results of these aforementioned studies, image fusion enables more accurate identification of hepatic tumors and, therefore, it can offer important advantages for targeting liver lesions during minimally invasive procedures such as biopsies and percutaneous ablations or for radiation treatment planning.During the past two decades, imaging-guided tumor ablation using either chemical or thermal energy has emerged as one of the most effective loco-regional treatment modalities for small malignant hepatic tumors . Among tThe usefulness of real-time fusion imaging for RFA of hepatic tumors has been evaluated in clinical practice. Several studies have shown that image fusion techniques resulted in better feasibility of US-guided percutaneous RFA for HCCs with poor conspicuity on conventional B-mode US ,27,28. MImage fusion can also help monitor RFA procedural adverse events. Potential complications and adjacent organ injury that arises after RFA might be avoided since fusion imaging can show the relationship between the ablation zone and vital structures, including the bile duct and large portal vein as well as adjacent organs.Fusion imaging techniques can also accurately evaluate the ablation margins of RFA for liver metastasis or HCC. Usually, the ablative margin cannot be precisely evaluated on B-mode US and/or CE-US immediately after RFA because gas bubbles (due to the ablation) hide the tumor and the surroundings. The development of image fusion has made it possible to visualize the ablative margin on US. By an overlay of preoperative and postoperative US, the tumor image could be projected onto the white ablation zone in real time. Therefore, US–US overlay image fusion could show the ablative margin during the RFA procedure . US–US iPromising results were obtained for imaging guided microwave ablation of HCC undetectable by conventional ultrasound ,33. AnotEUS has provided gastroenterologists a tool to generate real-time high-resolution images of target organs for accurate diagnosis and staging of abdominal and thoracic malignancies. However, EUS is still not widely utilized by many gastroenterologists because of a difficult learning curve and challenging navigation techniques that accompany the small viewing plane ,37. TherEUS-guided interventions and staging are heavily dependent on the skills and experience of the endoscopists; therefore, fusion of CT, MRI, or PET/CT with EUS can provide more anatomical information to facilitate the navigation of the endoscope, as well as provide enhanced EUS evaluations due to better visualization of the target lesions, including evaluation of treatment response, and normal adjacent structures ,41.Image fusion with EUS uses the same technical preparation as mentioned previously, which includes an electromagnetic (EM) field generator with an EM tracking system, the fusion imaging navigation software, and a tracking electrode placed on the patient’s chest (xiphoid process). In addition, a miniature EM sensor attached to the end of the echoendoscope probe or a navigation catheter equipped with an EM sensor can replace the biopsy needle in the echoendoscope such that the EUS probe and suction can still function ,2,42.To date, clinical studies on EUS-guided image fusion have been limited, but promising results have been seen in two feasibility studies that analyzed efficacy, accuracy, image registration errors, total time to reach lesions, and precision of reaching the target lesion ,42. EUS–Obstein et al.  had noteOne additional limitation with EUS–CT imaging fusion was with the co-registration’s failure to accurately adjust for various physiological movements such as breathing, endoscopic manipulation, and patient movement ,16,17,43Our group is currently developing a software platform (EUS/CT image fusion) with the following functions: automatic processing of pre-procedure CT for 3D rendering and segmentation; automatic nodule detection and procedure planning; automatic organ/tumor segmentation; automatic registration of patient’s CT for endoscopy procedures; localization and tracing of the position of therapeutic devices using electromagnetic or optical tracking technologies; virtual visualization of the medical instruments on the pre-procedure CT stack; augmented reality for virtual visualization of the patient’s anatomy over intraprocedural video. A prototype of the software has been tested on a custom-made pig organ model a. InitiaReal-time US fusion imaging (CT/MR) allows for a better detection and characterization of focal liver lesions;Image fusion can offer important advantages for targeting liver lesions during minimally invasive procedures such as biopsies and percutaneous ablations or for radiation treatment planning;EUS–CT image fusion allows for easier navigation and profiling of the target tumor and/or surrounding anatomical structure;EUS–CT image fusion can lower the learning curve for understanding and navigating EUS.Image fusion techniques encompassing multiple imaging modalities appear to be feasible and have been observed to increase visualization accuracy during interventional and diagnostic applications. The standard of care of GI malignancies can be enhanced by integrating image fusion so that better tumor diagnosis, staging, and multi-disciplinary treatment planning can be accomplished. These preliminary developments in the clinical application of image fusion involving CT/MRI/PET with EUS/US have shown great promise in facilitating diagnosis of small tumors and guidance of biopsies and interventional ablations. Further clinical research is needed to overcome current limitations before the widespread use of fusion imaging in managing GI malignancies can be achieved. Among them, the challenge of fusing images with large anatomical variation due to organ deformation should be the focus of future investigations to evaluate the benefit and accuracy of deformable image registration for this application.