Advisory Boards and Usability Testing of an E-Training Program for End-of-Life Care in Prisons

Advisory Boards and Usability Testing of an E-Training Program for End-of-Life Care in Prisons

The 14th Annual Academic and Health Policy Conference on Criminal Justice Health, hosted by the Academic Consortium on Criminal Justice Health, was held virtually on April 8-10, 2021. Susan J. Loeb, PhD, RN, FGSA, FAAN, from the Penn State College of Nursing gave two presentations on research conducted in collaboration with Klein Buendel Senior Scientist, Valerie Myers, PhD. The presentations were titled, “Planning, Maximizing, and Sustaining Advisory Boards to Inform and Facilitate Research in Prisons” and “Usability Testing of an E-Training Package to Enhance Geriatric and End-of-Life Care in Prisons.” 

Planning, Maximizing, and Sustaining Advisory Boards to Inform and Facilitate Research in Prisons 

Dr. Susan J. Loeb discussed working with Advisory Boards for research in prisons. Advisory Boards are comprised of targeted stakeholders who collaborate with researchers to promote cultural awareness, consideration of environmental facilitators and constraints, and the upholding of ethical responsibilities to keep the best interests of research participants at the forefront. 

Effective partnering with Advisory Boards can promote entrée and execution of corrections research and enhance the credibility, relevance, and translation of study findings. The team systematically considered stakeholders who were engaged on Advisory Boards across four previous NIH-funded studies to assess how to promote stability, infuse fresh perspectives, refine the focus of consultation, and extend the array of research settings during an era when in-person meetings were not feasible due to a pandemic. 

Adopting multiple advisory boards with unique foci and constituted by people possessing expertise in a focused area, allows for laser-focused videoconference meetings. While virtual meetings may not afford the same intensive opportunities for relationship building that on-site meetings do, the former does lessen travel-related budgetary, logistical, and time burdens. 

The research team concluded that teaming with and sustaining a diverse array of community stakeholders is a key strategy for generating science that is tailored to address the health needs and promote health equity for people living in prisons. 

Usability Testing of an E-Training Package to Enhance Geriatric and End-of-Life Care in Prisons 

Dr. Susan J. Loeb presented on usability testing and best practices of a full-scale media-rich interactive computer-based learning system for corrections staff in response to the growing population needing geriatric and end-of-life (EOL) care in prisons, which are not consistently adopted. The training is called, Enhancing Care of the Aged and Dying in Prisons (ECAD-P). 
 
The research team conducted face- to- face usability testing of the 6-module ECAD-P training with corrections staff in two rounds at two correctional facilities in different states. The System Usability Scale (SUS) was administered to assess usability and acceptability of ECAD-P. Full scale testing included 173 participants at seven state prisons who completed cognitive and posttest measures and the SUS. 
 
The mean SUS score was 75.10 in the face-to-face usability testing, which indicated a high level of acceptability and usability since a score of 68 is above average. For the large-scale testing, cognitive posttest scores were significantly higher than cognitive pretest scores. At posttest, affective measures were significantly higher than at pretest. The mean SUS score for the full-scale testing was 69.34. 

The corrections environment is not technology-rich; however, prison administration and staff are accustomed to and receptive of computer-based learning (a frequently used delivery platform for mandatory training sessions). Therefore, the research team concluded the ECAD-P product is acceptable, feasible, and usable in corrections.  

The research presented at ACCJH was funded by multiple SBIR/STTR grants to Klein Buendel from the National Institute on Aging (AG049570; AG057239; Dr. Susan J. Loeb and Dr. Valerie Myers, Multiple Principal Investigators). Collaborators on the two presentations also included Dr. Erin Kitt-Lewis, Sherif Olanrewaju, and Katherine Fiochetta from Penn State University; and Jeannyfer Reither and Savanna Olivas from Klein Buendel. 

Working with Advisory Boards for Research in Prisons

Working with Advisory Boards for Research in Prisons

Susan Loeb, PhD, RN, FGSA, FAAN, from the Penn State College of Nursing presented research conducted in collaboration with Klein Buendel Senior Scientist, Valerie Myers, PhD, at the 33rd Annual (Virtual) Scientific Sessions of the Eastern Nursing Research Society on March 25 and 26, 2021. This year’s conference theme was Generating Nursing Science to Meet the Needs of a Diverse Society. Dr. Loeb’s poster was entitled, “Planning, Maximizing, and Sustaining Advisory Boards to Promote Equitable Care for Diverse Populations.”  

The poster reported the exploration of effective ways to partner with Advisory Boards to promote successful entrée into prisons to (1) conduct and execute study aims; (2) enhance credibility, relevance, and translation of research; and (3) promote equitable health and health care for diverse populations. The specific study utilizing Advisory Boards was designed to engage carefully vetted men and women who are incarcerated to assist in caring for their older or sicker peers, and provide them with consistent high quality peer caregiving training. Trained peers contribute to a pressing health care need in our nation’s prisons.

In order to maximize Advisory Board effectiveness, the research team:

  • Reflected on past experiences and considered key stakeholders engaged on Advisory Boards across four previous NIH-funded studies in this area of research;
  • Deliberated on what worked well and challenges encountered;
  • Identified enthusiastic leaders and staff at prior research location with a focus on broadening the array of disciplines represented;
  • Bolstered representation of people who were previously incarcerated; and
  • Appraised budgetary capacity.

As a result, Advisory Board meetings were shortened and focused, representation by Departments of Corrections was expanded, relationship building and networking opportunities were achieved, virtual events reduced budgetary and logistical burdens associated, and cost savings allowed for more frequent Advisory Board engagement.

Building commitment of representative Advisory Boards facilitates access to hard-to-reach and often overlooked research populations. Advisory boards of invested and representative stakeholders are key to generating nursing science that addresses health needs and promotes health equity for people living in prison.

The research presented was funded by the following SBIR/STTR grants to Klein Buendel from the National Institute on Aging at the National Institutes of Health (AG049570; AG049570; AG057239; AG057239; Dr. Susan Loeb and Dr. Valerie Myers, Multiple Principal Investigators). Collaborators on this poster also included Dr. Erin Kitt-Lewis, Sherif Olanrewaju, and Katherine Fiochetta from Penn State University; and Jeannyfer Reither and Savanna Olivas from Klein Buendel.

Curbing College Drinking and Risky Sexual Behavior Using Dynamic Feedback

Curbing College Drinking and Risky Sexual Behavior Using Dynamic Feedback

Two-thirds of college students are current drinkers of alcoholic beverages. One in three college students report past month binge drinking (five or more drinks in a row), and one in ten report high intensity drinking (ten or more drinks in a row). Greater student alcohol consumption and heavy drinking on a given day are linked to increased sexual activity and risky sexual behavior, such as unprotected sex and sex with casual partners. This puts students at risk for negative health outcomes, such as sexually-transmitted infections, and other harmful consequences, such as sexual victimization.

Klein Buendel is collaborating with Dr. Anne Ray at the University of Kentucky on a new research project designed to curb drinking and risky sexual behavior by first-year college students. The new study will assess the impact of a brief, personalized intervention utilizing an innovative, cross-tailored, dynamic feedback component. The intervention will purposefully integrate content on the relationship between alcohol use and risky sexual behavior. The intervention will leverage technology to incorporate daily assessments of student behavior and deliver weekly dynamic feedback. Participating students will be asked to complete four diary entries each week for three months.

A hybrid effectiveness-implementation design will allow the investigators to evaluate the effectiveness of the integrated personalized feedback intervention with 600 first-year college students at two college sites in a randomized controlled trial. In addition, formative evaluation with local and national stakeholders (students and student affairs staff) will help to better understand factors that influence implementation and ensure its success and sustained use.   

This research project is funded by the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health (Dr. Anne Ray, Principal Investigator). Collaborators include Dr. David Buller from Klein Buendel. KB’s Creative Team will develop the web-based program for college students.

Collaborator Spotlight:
Dr. Abby King

Collaborator Spotlight:
Dr. Abby King

Abby C. King, Ph.D., is a Professor of Health Research and Policy (Epidemiology) and a Professor of Medicine at Stanford University. She received her Ph.D. in Clinical Psychology from Virginia Polytechnic Institute and State University. Her past research has focused on investigating the development, evaluation, and translation of public health interventions to reduce chronic disease in the U.S. and globally. Her current research focuses on expanding the reach and generalizability of evidence-based interventions through the use of state-of-the-art communication technologies, community-based participatory research perspectives, and policy-level approaches to health promotion.

Presently, Dr. King is a Co-Investigator on the SBIR Phase II research project with Dr. Valerie Myers from Klein Buendel called “¡Caminemos Juntas!”. The project proposes to connect Latinas with one another in order to improve walking habits by increasing social support and decreasing perceived barriers through the use of a smartphone app. It is funded by the National Institute of Minority Health and Health Disparities at the National Institutes of Health (MD009652; Dr. Valerie Myers, Principal Investigator).

In addition to her research, Dr. King has served on a number of government task forces in the U.S. and abroad, including membership in the U.S. Department of Health and Human Services’ Scientific Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, and the Science Board of the U.S. President’s Council on Fitness, Sports, and Nutrition. She has also taken part in various types of community and international work, including Active For Life, Citizen Science to Promote Sustained Physical Activity in Low-Income Communities, Preventing Obesity Among Socioeconomically Disadvantaged Women and Children in Melbourne, Australia; and Computer-based Physical Activity Advice for Ethnic Minority Aging Adults in San Jose. Dr. King has received many distinguished awards and honors throughout her career.

New Study to Assess the Impact of California’s Mandatory Responsible Beverage Service Training Law

New Study to Assess the Impact of California’s Mandatory Responsible Beverage Service Training Law

Klein Buendel is collaborating with Dr. Robert Saltz and his team from the Pacific Institute for Research and Evaluation (PIRE) in California on a new research project to assess the impact of California’s new mandatory Responsible Beverage Service training law intended to prevent alcohol-involved motor vehicle crashes and other harms.  

Intoxicated driving continues to play a significant role in automobile accidents and fatalities. In response, California passed the Responsible Beverage Service Training Act of 2017. According to the California Department of Alcoholic Beverage Control, the law requires alcoholic beverage servers in California to attend responsible beverage service (RBS) training by July 1, 2022. Alcoholic beverage servers will be trained on the dangers of overserving alcohol to patrons in an effort to curb alcohol-related harm within local communities, particularly in regards to drunk driving and alcohol-related crimes. This change in law creates a new statewide mandate for licensees and a new training requirement for an estimated 1 million servers.

The new research study will examine whether there is a significant reduction in single nighttime motor vehicle injury crashes after implementation of the mandatory RBS training law, controlling for other factors in California that may influence this outcome, and the national trend in fatal alcohol-involved motor vehicle crashes. A second aim will address the question of whether the state mandate could have greater impact through wider use of high-quality evidence-based RBS training, or through RBS training supplemented by boosting management motivation to support the training objectives. The training program that will be implemented is the WayToServe® (WTS) online RBS training program developed and evaluated by PIRE, Klein Buendel, and the University of New Mexico. Currently, WTS is licensed to and sold by Wedge Communications LLC in multiple states.

A randomized controlled trial design will be used to examine the change in the refusal rate for alcohol service to pseudo-intoxicated patrons in a sample of 450 licensed on-premises bars and restaurants from 2020 (baseline) to 2024 (post-implementation of mandatory RBS training law). The evaluation will determine whether any change is more pronounced among bars that receive the original WTS RBS Training or the enhanced WTS Training Plus program. A significant feature of this design is that unlike previous evaluations of RBS training, this project will be able to document both short-term and long-term outcomes.  This is especially important for a statewide implementation where it cannot be known in advance how quickly or slowly servers will undertake the training, and how quickly, if at all, the training will have an effect on server behavior.

This research project will be funded by the National Institute on Drug Abuse (Dr. Robert Saltz, Principal Investigator). Collaborators include Dr. David Buller and Dr. W. Gill Woodall from Klein Buendel.

Collaborator Spotlight:
Dr. Aida Midgett and Dr. Diana Doumas

Collaborator Spotlight:
Dr. Aida Midgett and Dr. Diana Doumas

Dr. Aida Midgett and Dr. Diana Doumas, both from Boise State University, currently collaborate with KB Senior Scientist, Dr. Valerie Myers, on the STAC-T Project. STAC-T is a technology-delivered adaptation of a bullying intervention program for schools – STAC – that teaches students to act as “defenders” on behalf of targets of bullying. STAC stands for four bullying intervention strategies: “Stealing the Show,” “Turning it Over,” “Accompanying Others,” and “Coaching Compassion.”

Dr. Aida Midgett is a Professor and Chair of the Department of Counselor Education. She obtained her doctoral degree in Educational Psychology/Counseling Psychology and her masters degree in Community Counseling from Northern Arizona University. Her professional background includes behavioral health and school-based research, training counselor education students, and evaluating service-learning projects related to multicultural training. Dr. Midgett is a Licensed Professional Counselor. She has worked as a clinician in university, agency, and in-patient mental health hospital settings. Currently, her research focuses on evaluating the bystander bullying intervention program in K-12 settings.

Dr. Diana Doumas is a Distinguished Professor and Director for the Institute for the Study of Behavioral Health and Addiction. She is a Licensed Professional Counselor and Licensed Psychologist in Idaho. She is a member of the American Counseling Association, the Association of Counselor Education and Supervision, and Research Society on Alcoholism. Her experience includes both individual and couples counseling for clients with substance abuse, depression, anxiety, and interpersonal concerns. She specializes in empirically-based interventions and cognitive-behavioral therapy. Her research interests include substance abuse prevention and intervention, with a focus on harm reduction and online interventions for high-risk college and high school students.

The STAC-T project is funded by a small business (STTR) grant to Klein Buendel from the National Institute on Minority Health and Health Disparities at the National Institutes of Health (MD014943; Dr. Aida Midgett, Principal Investigator).

Association of Occupational Sun Safety Policy with Employee Practices

Association of Occupational Sun Safety Policy with Employee Practices

Occupational sun protection policies are fundamental for the increased implementation of employee sun safety practices. Investigators and staff from Klein Buendel, led by Dr. David Buller, Director of Research, recently published baseline results from a large-scale workplace sun safety policy project in the American Journal of Industrial Medicine.

In the publication, the authors report on the coding and evaluation of written safety policies from 21 state Departments of Transportation (DOTs) enrolled in a randomized trial testing methods for scaling-up an occupational sun safety intervention. A total of 1,113 managers who supervised people who work outdoors reported on workplace and employee sun safety practices in a baseline survey.

Analysis showed that 20 of the state DOTs had a policy with at least one sun protection component (e.g., sunscreen, eye protection, use of shade). Sun safety training was increased at workplaces with written sun safety policy and unwritten standard operating procedures on sun protection. Sun safety actions were highest where there was a written sun safety policy and unwritten standard operating procedures on workplace sun protection. The measures, methods, analyses, results, conclusions, and limitations of the baseline manager survey are detailed in the publication.

This research was funded by a grant from the National Cancer Institute at the National Institutes of Health (CA210259; Dr. David Buller, Principal Investigator). Coauthors include Dr. Barbara Walkosz, Savanna Olivas, Rachel Eye, Xia Liu, Alishia Kinsey, Mary Buller, and Andrew Grayson from Klein Buendel.

KLEIN BUENDEL’S 2020 RESEARCH HIGHLIGHTS

KLEIN BUENDEL’S 2020 RESEARCH HIGHLIGHTS

In the year of COVID-19, Klein Buendel scientists and staff continued to conduct rigorous behavioral science research with numerous collaborators from across the country – sometimes under modified conditions. Our investigators launched 5 new projects, published (or e-published ahead of print) 15 research manuscripts in peer-reviewed journals, and presented their research findings at 5 national and international conferences (many of them virtual this year).

In the spring, Dr. Valerie Myers, KB Senior Scientist, was appointed as the Education, Training, and Career Development Council Chair on the Society of Behavioral Medicine (SBM) Board of Directors. SBM is a non-profit organization that brings together multiple independent disciplines to provide new perspectives and progress on human behavior, health, and illness. 

In November, Dr. David Buller, KB’s Director of Research, gave a Grand Rounds presentation at the Rutgers Cancer Institute of New Jersey, entitled “Cancer Prevention Policy: Promoting Adoption and Implementation of Sun Safety Policy.” And in December, Dr. Buller presented during a webinar hosted by the National Cancer Institute Division of Cancer Control and Population Sciences. The webinar was part of a series designed to explore Policy Implementation Science highlighting the importance of adoption of evidence-based policy in governmental and non-governmental sectors. 

KB was recognized in 2020 as #50 on Colorado Biz Magazine’s Top 100 Woman-Owned Companies list, and as #115 on their Top 200 Private Companies list.

And WayToServe, KB’s evidence-based online responsible alcohol server training program, sold its 100,000th training.

Publications

(KB investigators and staff are indicated in bold type)

  • Kitt-Lewis E, Loeb SJ, Myers V, Jerrod T, Wion RK, Murphy JL. Barriers to and Strategies for Gaining Entry to Correctional Settings for Health Research. Nurs Leadersh (Tor Ont). 2020 Mar;33(1):71-80. doi: 10.12927/cjnl.2020.26190.
  • Reynolds KD, Buller DB, Berteletti J, Massie K, Ashley J, Buller MK, Meenan RT, Liu X. School-level factors associated with sun protection practices in California elementary schools. J Sch Health. 2020 May;90(5):386-394.
  • Buller DB, Pagoto S, Baker K, Walkosz B, Hillhouse JJ, Berteletti J, Bibeau JL, Henry K. Knowledge and support for indoor tanning laws among mothers and teen daughters in 34 states in a randomized trial. Ann Behav Med. 2020 May;54(Suppl 1): S59.
  • Myers VH, Loeb SJ, Kitt-Lewis E, Murphy JL, Wion R, Jerod T. An e-training package to enhance care of aged and dying prisoners. Ann Behav Med. 2020 May;54(Suppl 1): S178.
  • Arroyo KM, Goetz J, Waring ME, Berteletti J, Buller DB, Walkosz B, Baker K, Hillhouse JJ, Henry K, Stapleton J, Pagoto S. Frequency and type of health misinformation in participant comments in a Facebook-delivered cancer risk reduction intervention. Ann Behav Med. 2020 May;54(Suppl 1): S186.
  • Buller DB, Woodall G, Saltz RF, Grayson AM, Buller MK, Svendsen SN, Liu L, Cutter GR. Effects of an online responsible vendor training for recreational marijuana stores on sales to pseudo-underage customers. Ann Behav Med. 2020 May;54(Suppl 1): S492
  • Gonzalez CD, Walkosz BJ, Dellavalle RP. Aftercare instructions in the tattoo community: An opportunity to educate on sun protection and increase skin cancer awareness. J Clin Aesthet Dermatol. 2020 Jun;13(6):22-23.
  • Buller DB, Reynolds KD, Buller MK, Massie K, Berteletti J, Ashley J, Meenan R. Parent reports of sun safety communication and behaviour for students in a randomized trial on a school policy implementation intervention. Aus N Z J Public Health. 2020;44(3):208-214.
  • Kaphingst KA, Khan E, White KM, Sussman A, Guest D, Schofield E, Dailey YT, Robers E, Schwartz MR, Li Y, Buller D, Hunley K, Berwick M, Hay JL. Effects of health literacy skills, educational attainment, and level of melanoma risk on responses to personalized genomic testing. Patient Educ Couns. 2020 Aug 1:S0738-3991(20)30392-X. doi: 10.1016/j.pec.2020.07.019.
  • Reynolds KD, Buller DB, Buller MK, Massie K, Berteletti J, Ashley J, Meenan R. Randomized controlled trial evaluating an intervention supporting implementation of sun safety policies in California public elementary schools. Prev Med. 2020 Aug;137:106125. doi: 10.1016/j.ypmed.2020.106125.
  • Buller DB, Woodall WG, Saltz R, Grayson A, Svendsen S, Cutter GR. Sales to apparently alcohol-intoxicated customers and online responsible vendor training in recreational cannabis stores in a randomized trial. Int J Drug Policy. 2020 Sep;83:102860. doi:10.1016/j.drugpo.102860.
  • Manne S, Buller D, Devine K, Heckman C, Pagoto S, Frederick S, Mitarotondo A. Sun Safe Partners Online: pilot randomized controlled clinical trial. J Med Internet Res. 2020 Sep;22(9):e18037. doi: 10.2196/18037.
  • Buller DB, Buller MK, Meenan R, Cutter GR, Berteletti J, Eye R, Walkosz BJ, Pagoto S. Design and baseline data of a randomized trial comparing two methods for scaling-up an occupational sun protection intervention. Contemp Clin Trials. 2020 Sep 14:106147. doi: 10.1016/j.cct.2020.106147.
  • Walkosz BJ, Dellavalle RP. Scented lotions may cause scaring and premature fading of tattoos. Dermatol Online J. 2020 Oct;26(10): 13030/qt5d2676s2.
  • Meenan RT, Reynolds KD, Buller DB, Massie K, Berteletti J, Buller MK, Ashley J, Liu X. Economic evaluation of a sun protection program in California elementary schools. Am J Health Promot. 2020 Nov;34(8):848-856. doi: 10.1177/0890117120905217.

Conference Presentations

Research by KB scientists, staff, and collaborators was presented at the following conferences this year:

  • Society of Research on Adolescence Biennial Meeting (March 2020)
  • Eastern Nursing Research Society (March 2020)
  • International Papillomavirus Conference & Basic Science, Clinical and Public Health Workshops (July 2020)
  • American Public Health Association (October 2020)
  • Annual Conference on the Science of Dissemination and Implementation in Health (December 2020)
Written Policy Predicts Worksite Sun Safety Training and Actions in State Departments of Transportation

Written Policy Predicts Worksite Sun Safety Training and Actions in State Departments of Transportation

Dr. David Buller, Klein Buendel Director of Research, presented a poster on workplace sun safety policies at the virtual 13th Annual Conference on the Science of Dissemination and Implementation in Health December 15-17, 2020.  

The U.S. Surgeon General and Community Guide recommend implementation of interventions to protect outdoor workers from solar ultraviolet radiation (UV) exposure to prevent skin cancer. For the research presented in this poster, written policies at state Departments of Transportation (DOTs) were examined and analyses tested the hypothesis that presence and strength of sun safety policy would be associated with greater implementation of workplace sun safety actions. 

Written policies from 21 U.S. state DOTs were coded for 15 sun safety components including engineering controls (physical work environment), administrative controls (workplace procedures), and personal protection practices (workers’ sun safety). Managers supervising outdoor workers in 138 regional DOT districts reported on workplace sun safety training and actions (monitoring UV Index to adjust work schedules, employees wearing UV-protective clothing, hats, eyewear, and sunscreen, sun safety messages to employees, employer provides sun protection resources and temporary/permanent shade, employer requests contractor staff comply with policy, employer encourages employees to regularly check skin, and employer conducts a risk assessment). 

Twenty state DOTs had a policy with at least one sun protection component (e.g., sunscreen, clothing, hat, shade provision, adjusting schedules), but almost none included training of employees, managers or supervisors. Many policies were also not explicitly intended for sun safety, except for sunscreen. Though not written, some reported unwritten standard operating, administrative, or training procedures on sun protection. Sun safety training and actions were predicted by a written sun safety policy and unwritten procedure, managers’ behaviors, job responsibilities, and characteristics. 

Policies are essential for implementation and maintenance of employee sun safety. While many state DOTs have policies, they could be improved by explicitly referencing sun safety. Also, training should be added to policy to create collective commitment among managers to support policy implementation and improve employees’ sun safety skills on the job. 

This research is funded by a grant from the National Cancer Institute (CA134705; Dr. David Buller, Principal Investigator). Additional poster coauthors included Dr. Barbara Walkosz, Mary Buller, Rachel Eye, Andrew Grayson, Alishia Kinsey, Xia Liu, and Savanna Olivas from Klein Buendel. 

Listen to the poster presentation.

Scented Lotions and Adverse Tattoo Reactions

Scented Lotions and Adverse Tattoo Reactions

Klein Buendel Senior Scientist, Dr. Barbara Walkosz, is a co-author on a recent publication in the Dermatology Online Journal. In the manuscript, Dr. Walkosz and her co-authors discuss how scented lotions may cause scaring, premature aging, and fading of tattoos.

Tattoo aftercare instructions are often provided to clients after receiving a tattoo. However, aftercare instructions can vary by studio and are often not universal or supported by research. The authors examine a case study of a man with no pre-existing skin conditions, family history, allergies, or other factors, who developed a rash on his new tattoo. Upon questioning, it was discovered that the client had applied a scented lotion to the new tattoo, at which point he began to experience problems with scabbing and fading tattoo ink.

The authors provide a case discussion about how the use of a scented lotion may have caused a negative, adverse reaction to the new tattoo and discuss the importance of treating a new tattoo as flesh wound. The full discussion and conclusion can be found in the publication.

This research team was funded by a grant and supplement from the National Cancer Institute (CA206569; Dr. Barbara Walkosz and Dr. Robert Dellavalle, Multiple Principal Investigators). Authors also include, Dr. Adrian Pona from the Department of Dermatology at University of Colorado School of Medicine and the Department of Internal Medicine at the Vidant Medical Center of East Carolina University; Dr. Cristian Gonzalez from the Department of Dermatology at University of Colorado School of Medicine; and Dr. Robert Dellavalle from the University of Colorado School of Medicine and the U.S. Department of Veterans Affairs Rocky Mountain Regional VA Medical Center Dermatology Service.