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Abstract Background There are no empirically-grounded criteria or tools to define or benchmark the quality of outpatient clinical documentation. Outpatient clinical notes document care, communicate treatment plans and support patient safety, medical education, medico-legal investigations and reimbursement. Accurately describing and assessing quality of clinical documentation is a necessary improvement in an increasingly team-based healthcare delivery system. In this paper we describe the quality of outpatient clinical notes from the perspective of multiple stakeholders. Methods Using purposeful sampling for maximum diversity, we conducted focus groups and individual interviews with clinicians, nursing and ancillary staff, patients, and healthcare administrators at six federal health care facilities between 2009 and 2011. All sessions were audio-recorded, transcribed and qualitatively analyzed using open, axial and selective coding. Results The 163 participants included 61 clinicians, 52 nurse/ancillary staff, 31 patients and 19 administrative staff. Three organizing themes emerged: 1) characteristics of quality in clinical notes, 2) desired elements within the clinical notes and 3) system supports to improve the quality of clinical notes. We identified 11 codes to describe characteristics of clinical notes, 20 codes to describe desired elements in quality clinical notes and 11 codes to describe clinical system elements that support quality when writing clinical notes. While there was substantial overlap between the aspects of quality described by the four stakeholder groups, only clinicians and administrators identified ease of translation into billing codes as an important characteristic of a quality note. Only patients rated prioritization of their medical problems as an aspect of quality. Nurses included care and education delivered to the patient, information added by the patient, interdisciplinary information, and infection alerts as important content. Conclusions Perspectives of these four stakeholder groups provide a comprehensive description of quality in outpatient clinical documentation. The resulting description of characteristics and content necessary for quality notes provides a research-based foundation for assessing the quality of clinical documentation in outpatient health care settings.

Introduction: Mental health disorders affect 18% of the U.S., Population: Problems with access to mental health care for the African American community are multifactorial. Provider and staff perceptions and opinions regarding factors attributing to problems with mental health access are explored., Method: Providers and staff (N=10) completed a 26-item electronic questionnaire RESULTS: The primary barriers to screening, consultation, and follow-through were time constraints, location of services, and lack of parental support, respectively., Conclusions: Integrating behavioral health into primary care is a promising way to address many reported barriers, such as time restraints, social stigma, and lack of resources., (Published by Elsevier Inc.)

Amidst a pandemic and the events following George Floyd's murder in 2020, discussions of race have escalated in the psychoanalytic community. One theoretical formulation, Afropessimism, has served as a lightning rod across both psychoanalytic and academic circles. Another, Black Rage, offers a psychoanalytic theory of the psychic effect of racial oppression on traumatized subjects. Using both as catalysts, this essay explores the historicity of the questions raised by the racial unrest of the pandemic--the deep embedding of questions of race and Blackness in unconscious prehistories of modernity, the human, and our understanding of our social worlds.

Background: The current study examined independent and interactive effects of polymorphisms of the mu opioid receptor gene (OPRM1, A118G) and variable number tandem repeats of the dopamine transporter gene (DAT1, SLC6A3) on alcohol consumption and subjective responses to alcohol in 127 young, healthy, social drinkers., Methods: Participants completed an in-person assessment, which included self-reported alcohol drinking patterns and blood sampling for DNA, and in a second visit, a cumulative alcohol dosing procedure with subjective ratings across multiple time points and breath alcohol contents (0.03 to 0.1%). DNA was analyzed for OPRM1 AA versus AG/GG (*G) genotypes, DAT1 10-repeat allele (A10) versus 9 or lesser alleles (A9), and ancestral informative markers., Results: There were significant epistatic interactions between OPRM1 and DAT1 genotypes. Subjective High Assessment Scale scores after alcohol consumption were highest in *G and A9 carriers, and lowest in *G and A10 carriers. Negative subjective effects were also highest in *G and A9 carriers. Effects were similar in a sensitivity analysis limited to Caucasian subjects. There were independent and epistatic interactions on drinking. The OPRM1 *G allele was independently associated with fewer heavy drinking days. The A9 allele was associated with a greater number of drinking days, which was attenuated in carriers of the *G allele., Conclusions: These findings highlight the biological importance of interactions between these 2 genes and interactions between brain opioid and dopamine systems., (Copyright © 2017 by the Research Society on Alcoholism.)

Background: Stress and anxiety are widely considered to be causally related to alcohol craving and consumption, as well as development and maintenance of alcohol use disorder (AUD). However, numerous preclinical and human studies examining effects of stress or anxiety on alcohol use and alcohol-related problems have been equivocal. This study examined relationships between scores on self-report anxiety, anxiety sensitivity, and stress measures and frequency and intensity of recent drinking, alcohol craving during early withdrawal, as well as laboratory measures of alcohol craving and stress reactivity among heavy drinkers with AUD., Methods: Media-recruited, heavy drinkers with AUD (N = 87) were assessed for recent alcohol consumption. Anxiety and stress levels were characterized using paper-and-pencil measures, including the Beck Anxiety Inventory (BAI), the Anxiety Sensitivity Index-3 (ASI-3), and the Perceived Stress Scale (PSS). Eligible subjects (N = 30) underwent alcohol abstinence on the Clinical Research Unit; twice daily measures of alcohol craving were collected. On day 4, subjects participated in the Trier Social Stress Test; measures of cortisol and alcohol craving were collected., Results: In multivariate analyses, higher BAI scores were associated with lower drinking frequency and reduced drinks/drinking day; in contrast, higher ASI-3 scores were associated with higher drinking frequency. BAI anxiety symptom and ASI-3 scores also were positively related to Alcohol Use Disorders Identification Test total scores and AUD symptom and problem subscale measures. Higher BAI and ASI-3 scores but not PSS scores were related to greater self-reported alcohol craving during early alcohol abstinence. Finally, BAI scores were positively related to laboratory stress-induced cortisol and alcohol craving. In contrast, the PSS showed no relationship with most measures of alcohol craving or stress reactivity., Conclusions: Overall, clinically oriented measures of anxiety compared with perceived stress were more strongly associated with a variety of alcohol-related measures in current heavy drinkers with AUD., (Copyright © 2017 The Authors. Alcoholism: Clinical and Experimental Research published by Wiley Periodicals, Inc. on behalf of Research Society on Alcoholism.)

Objective: This study of adults with osteoarthritis and their spouses examined spouse responses to patients' pain as mediators of the associations between spouse confidence in patients' ability to manage arthritis and improvements in patients' physical function and activity levels over time., Method: Participants were 152 older adults with knee osteoarthritis and their spouses. In-person interviews were conducted with patients and spouses (separately) at 3 time points: baseline (Time[T] 1), 6 months after baseline (T2), and 18 months after baseline (T3). At each time point, patients reported their self-efficacy for arthritis management, functional limitations, and time spent in physical activity; spouses reported their confidence for patients' arthritis management and their empathic, solicitous, and punishing responses to patients' pain. Multiple mediation regression models were used to examine hypothesized associations across 2 distinct time frames: 6 months (T1-T2) and 12 months (T2-T3)., Results: Across 6 months, spouse confidence was indirectly related to improvements in patients' functional limitations and activity levels through increased empathic responses to patient pain. Across 12 months, spouse confidence was indirectly related to improvements in patients' functional limitations and activity levels through decreased solicitous responses to patient pain., Conclusions: This study adds to the literature on spousal influences on health by identifying 2 spouse behaviors that help to explain how spouse confidence for patients' illness management translates into improvements in patients' physical health over time. Findings can inform the development of couple-focused illness management interventions aiming to increase the positive influence of the spouse on patients' health behaviors and outcomes. (PsycINFO Database Record, ((c) 2016 APA, all rights reserved).)

Objectives: The resource model of self-control posits that self-control is a finite resource that can be depleted. Individuals with diabetes must continually restrict their diet, requiring self-control. As a result, dietary adherence is difficult, and lapses are common. People with diabetes who overexert self-control following a lapse may be especially likely to experience a subsequent relapse, as suggested by the resource model. This investigation used the resource model of self-control to test whether overexertion of dietary self-control following a lapse would be predictive of a subsequent relapse in dietary control., Design: We tested this prediction in a daily diary study of 128 individuals with diabetes (Mage  = 66.12)., Methods: Participants' reports of their daily dietary adherence were used to define lapses in adherence, post-lapse adherence, and relapses., Results: Individuals who overexerted self-control after a lapse were more likely to experience a subsequent relapse (OR = 3.276, p = .016) and to do so sooner (HR = 2.12, p = .023)., Conclusions: People with diabetes may seek to compensate for a lapse in adherence by overexerting self-control, but doing so may deplete their self-control and increase the risk of a future relapse. Statement of contribution What is already known on this subject? The resource model of self-control posits that self-control is a limited resource that can be temporarily depleted. Numerous experimental studies have demonstrated support for this model showing that when participants are instructed to engage in a self-control task, they produce less self-control on a subsequent task. The majority of the existing studies are not conducted in naturalistic settings and do not use patient populations. What does this study add? This study is an ecologically valid test of the resource model of self-control. This study applies the resource model of self-control to a patient population., (© 2016 The British Psychological Society.)

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis influences the risk for developing stress-related disorders. Sex-dependent differences in the HPA axis stress response are believed to contribute to the different prevalence rates of stress-related disorders found in men and women. However, studies examining the HPA axis stress response have shown mixed support for sex differences, and the role of endogenous sex hormones on HPA axis response has not been adequately examined in humans. This study utilized the largest sample size to date to analyze the effects of biological sex and sex hormones on HPA axis social stress responses. Healthy, 18- to 30- year-old community volunteers (N=282) completed the Trier Social Stress Test (TSST), a widely used and well-validated stress-induction laboratory procedure. All women (n=135) were tested during the follicular phase of their menstrual cycle (when progesterone levels are most similar to men). Adrenocorticotropic hormone (ACTH) and cortisol measures were collected at multiple points throughout pre- and post-TSST. Testosterone and progesterone (in men) and progesterone and estradiol (in women) were determined pre-TSST. Following the TSST, men had greater ACTH and cortisol levels than women. Men had steeper baseline-to-peak and peak-to-end ACTH and cortisol response slopes than women; there was a trend for more cortisol responders among men than women. Testosterone negatively correlated with salivary cortisol response in men, while progesterone negatively correlated with ACTH and cortisol responses in women. These data confirm that men show more robust activation of the HPA axis response to the TSST than do women in the follicular phase of the menstrual cycle. Testosterone results suggest an inhibitory effect on HPA axis reactivity in men. Progesterone results suggest an inhibitory effect on HPA axis reactivity in women. Future work is needed to explain why men mount a greater ACTH and cortisol response to the TSST than do women during the follicular phase of the menstrual cycle., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Benford's Law is a probability distribution for the first significant digits of numbers, for example, the first significant digits of the numbers 871 and 0.22 are 8 and 2 respectively. The law is particularly remarkable because many types of data are considered to be consistent with Benford's Law and scientists and investigators have applied it in diverse areas, for example, diagnostic tests for mathematical models in Biology, Genomics, Neuroscience, image analysis and fraud detection. In this article we present and compare statistically sound methods for assessing conformance of data with Benford's Law, including discrete versions of Cramér-von Mises (CvM) statistical tests and simultaneous confidence intervals. We demonstrate that the common use of many binomial confidence intervals leads to rejection of Benford too often for truly Benford data. Based on our investigation, we recommend that the CvM statistic Ud(2), Pearson's chi-square statistic and 100(1 - α)% Goodman's simultaneous confidence intervals be computed when assessing conformance with Benford's Law. Visual inspection of the data with simultaneous confidence intervals is useful for understanding departures from Benford and the influence of sample size.

The severity of a patient's illness may be detrimental for the psychological well-being of the spouse, especially for those in a particularly close relationship. Using 2 waves of data collected from a sample of 152 knee osteoarthritis (OA) patients and their spouses, we examined associations between change in patients' illness severity and change in 3 indicators of spouses' well-being (positive affect, depressive symptoms, and life satisfaction) over a 6-month period. We also tested the hypothesis that spouses' perceived relationship closeness with the patient would moderate these associations. Consistent with our prediction, a high level of relationship closeness exacerbated the negative impact of increases in patient illness severity on spouses' positive affect and depressive symptoms over 6 months. Spouses' life satisfaction declined when patients became more ill, regardless of level of relationship closeness. Our findings highlight the value of examining change in illness as a predictor of change in spouse well-being and the potential downside of relationship closeness for couples living with chronic illness., ((c) 2015 APA, all rights reserved).)

Background: In addition to patient self-efficacy, spouse confidence in patient efficacy may also independently predict patient health outcomes. However, the potential influence of spouse confidence has received little research attention., Purpose: The current study examined the influence of patient and spouse efficacy beliefs for arthritis management on patient health., Methods: Patient health (i.e., arthritis severity, perceived health, depressive symptoms, lower extremity function), patient self-efficacy, and spouse confidence in patients' efficacy were assessed in a sample of knee osteoarthritis patients (N = 152) and their spouses at three time points across an 18-month period. Data were analyzed using structural equation models., Results: Consistent with predictions, spouse confidence in patient efficacy for arthritis management predicted improvements in patient depressive symptoms, perceived health, and lower extremity function over 6 months and in arthritis severity over 1 year., Conclusions: Our findings add to a growing literature that highlights the important role of spouse perceptions in patients' long-term health.

Marriage can enhance health for individuals with a chronic disease, yet spouses may also undermine disease management. The current study investigated spousal undermining of dietary regimen in 129 patients with type 2 diabetes mellitus. A total of 40 patients reported that their spouses tempted them with forbidden foods, and 15 reported that their spouses conveyed disregard for their diabetic diet. Spousal tempting was associated with worse dietary adherence, and spousal disregard with worse nondietary adherence. Spousal undermining is relatively rare but is associated with patients' disease management and warrants further investigation to better understand how spouses influence partners' day-to-day management of chronic diseases.

Spouses frequently attempt to influence (control) or support their chronically ill partners' adherence behaviors. Studies have documented effects of spousal control and support on chronically ill individuals, but little is known about how these two forms of involvement in a partner's disease management may be associated with spouses' stress or the quality of their interactions with their ill partners. The current study sought to address this gap by examining spouses' day-to-day involvement in their marital partner's management of type 2 diabetes (n = 129). Multilevel analyses of daily diary data revealed that on days when spouses exerted control, they reported more stress and more tense marital interactions, although these associations were more pronounced when patients exhibited poor adherence, had been ill for a longer period of time, and had more comorbid health conditions. On days when spouses provided support, in contrast, they reported less stress and more enjoyable marital interactions. The findings from the current study suggest that spouses' day-to-day stress and quality of interactions with their partners are associated with spouses' involvement in their partners' disease management, with health-related social control and support exhibiting distinctive associations.

Objective: To investigate daily dietary adherence and diabetes-specific distress among older adults with type 2 diabetes mellitus (T2DM) as a function of spouses' diet-related support and diet-related control (persuasion and pressure) and whether these daily processes differ among couples who do and do not appraise responsibility for managing T2DM as shared., Methods: End-of-day diaries were completed by 126 couples in which one partner had T2DM (patient) and the other did not (spouse). Using electronic diary methods, each partner independently recorded data for 24 consecutive days (patients recorded their day's dietary adherence and diabetes-specific distress; spouses recorded their day's involvement in patients' dietary management). To assess dietary adherence, patients reported the extent to which they followed dietary recommendations that day with items from the Summary of Diabetes Self-Care Activities Measure. To assess diabetes-specific distress, patients reported the extent to which they worried about diabetes that day using items from the Problem Areas in Diabetes (PAID) scale., Results: Multilevel modeling revealed that, relative to the prior day, spouses' diet-related support was associated with increases in patients' adherence whereas diet-related persuasion and pressure were associated with decreases in adherence; spouses' pressure was associated with increases in patients' diabetes-specific distress. When partners appraised responsibility for managing T2DM as shared, support was associated with decreases in diabetes-specific distress; pressure was associated with decreases in adherence., Conclusions: Our findings offer insight into partners' day-to-day disease-related interactions and identify those that are likely to be beneficial versus detrimental for patients' physical and psychological health., ((PsycINFO Database Record (c) 2013 APA, all rights reserved).)

Although chronic pain has been linked to poorer psychosocial well-being in the spouse, the extent to which patient pain affects spouse sleep is unknown. The aim of the present study was to test the hypothesis that greater daily knee pain would be associated with poorer sleep for the spouse that evening. We also tested the hypothesis that this pain contagion is exacerbated in couples who have a close relationship. A total of 138 knee osteoarthritis (OA) patients and their spouses completed baseline interviews and a 22-day diary assessment. Multilevel lagged models indicated that greater knee OA pain at the end of the day was associated with spouses' poorer overall sleep quality that night and feeling less refreshed after sleep. In contrast, there was no evidence that spouse sleep was related to greater patient pain the next day. The effects of patient pain on spouse sleep were not due to disturbances in patient sleep and were also independent of spouse sex, depressive symptoms, and physical comorbidities; both partners' negative affect; and the quality of marital interactions throughout the day. As predicted, we also found that patient pain was more strongly related to less refreshing sleep for spouses who were in a close relationship. Findings illustrate that chronic pain may place the spouse's health at risk and suggest an important target for couple-oriented interventions., (Copyright © 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Objectives: Spouses may be involved in their partner's diabetes management by providing social support to affirm healthy behaviors and social control to modify health behaviors. Yet, investigations of the influence of spousal involvement on daily patient health behaviors are limited. In daily diaries, we investigated how spousal support and control independently and jointly influence patient physical activity and efficacy to engage in physical exercise on a daily basis., Methods: Older adults (age 55 and older) with Type 2 diabetes and their spouses (N = 70 couples) completed electronic diaries for seven consecutive days that assessed spouse-reported involvement and patient-reported minutes of physical exercise and efficacy to engage in future physical exercise. A subset of patients (N = 53) also wore an activity monitoring device on the wrist that provided a measure of energy expenditure., Results: Multilevel analyses indicated that on a daily basis, spousal support was positively associated with physical activity, whereas spousal control was either unrelated or linked to less physical activity. On days in which spouses provided high levels of both support and control, however, patients felt more efficacious that day about exercising tomorrow and exhibited an increase in energy expenditure on the next day., Conclusions: Findings suggest that spousal exercise support on its own or in conjunction with spousal exercise control may facilitate daily diabetes management through physical activity., (PsycINFO Database Record (c) 2013 APA, all rights reserved.)

Background: Physical activity is critical for the management of knee osteoarthritis, and the spouse may play a role in encouraging or discouraging physical activity., Purpose: The purpose of this study was to examine four types of spousal influence-spouses' daily activity, autonomy support, pressure, and persuasion-on the daily physical activity of adults living with knee osteoarthritis., Methods: A total of 141 couples reported their daily experiences for 22 days using a handheld computer and wore an accelerometer to measure moderate activity and steps., Results: Spouses' autonomy support for patient physical activity, as well as their own level of activity, was concurrently associated with patients' greater daily moderate activity and steps. In addition, on days when male patients perceived that spouses exerted more pressure to be active, they spent less time in moderate activity., Conclusions: Couple-oriented interventions for knee osteoarthritis should target physical activity in both partners and spousal strategies for helping patients stay active.

The common-sense model posits that behavioural coping with illness is shaped by a complex combination of individuals' abstract and concrete beliefs about their illness. We investigated this theoretical assumption in a study of 116 older adults diagnosed with type 2 diabetes who completed in-person interviews at baseline and six and 12 months later. Specifically, we examined (1) the interaction of patients' abstract and concrete beliefs about the timeline of their diabetes as a predictor of change in adherence to a healthy diet and (2) whether these interactive effects differ among male and female patients. Abstract timeline beliefs were conceptualised as those pertaining to disease duration; concrete timeline beliefs were conceptualised as those pertaining to variability of disease symptoms (i.e. symptoms are stable versus fluctuating). As predicted, duration beliefs were positively associated with improvement in adherence among patients who viewed disease symptoms as stable, but not among those who viewed symptoms as variable. When gender was considered, these interactive effects were observed among male (but not female) patients. Findings revealed that the behavioural effects of men's abstract knowledge about their diabetes were conditioned by their concrete representations of the disease, suggesting a bottom-up process of influence with implications for intervention.

Rationale: The serotonergic and opioidergic neurotransmitter systems are critical regulators of the hypothalamic-pituitary-adrenal (HPA) axis through their respective excitatory and inhibitory inputs. Serotonin transporter (5-HTT) genotype has been studied as a marker of HPA axis dysregulation and for predicting risk of psychopathology, with mixed findings., Objectives: We stimulated the HPA axis with naloxone, an opioid receptor antagonist, to examine cortisol reactivity based on 5-HTT-linked polymorphic region (5-HTTLPR) genotypes., Methods: Healthy community volunteers (N = 78) received intravenous (IV) placebo followed by sequential doses of IV naloxone (50, 100, 200, and 400 μg/kg) every 30 min. Plasma cortisol was measured every 15 min. Participants were genotyped for the long (L) and short (S) alleles of the 5-HTT gene and for rs25531 (A/G) in the 5-HTTLPR repetitive element and compared by the 5-HTTLPR/rs25531 genotype (triallele) and by the 5-HTTLPR genotype (biallele) classification., Results: In triallele analyses, individuals with one or more L(A) alleles showed higher cortisol response to naloxone compared with individuals with no L(A) alleles. In biallele analyses, less robust effects were found, although individuals with two L alleles showed a higher cortisol response compared with other genotypes., Conclusions: Naloxone blockade leads to a greater activation of the HPA axis among individuals with the L(A) allele. Including rs25531 in the analysis with the 5-HTTLPR genotype appears more sensitive in detecting genetic differences in naloxone-induced cortisol than when using only the 5-HTTLPR genotype. Future research should investigate the interactive effects between the serotonergic and opioidergic systems on HPA axis dysregulation and psychopathophysiology.

For married patients, chronic illness management often includes involvement of their spouses. We examined expectations regarding spouse involvement in the health of a partner with type 2 diabetes (N = 139 couples) from the perspectives of the patient and spouse. Partners' dyadic expectations and spouses' gender were posited to moderate spouses' diet-related control and patients' diet adherence. Among male patients, when both partners shared an expectation for spouse involvement greater diet-related spouse control was associated with better diet adherence of patients. In contrast, when expectations for spouse involvement were not shared, greater spouse control by wives was associated with poorer diet adherence. Dyadic expectations for spouse involvement did not moderate the association between spouse control and diet adherence among female patients. Findings suggest that shared expectations for spouse involvement can facilitate spouses' attempts to improve patients' dietary adherence, especially among male patients and their wives.

Objectives: We investigated patients' difficulties in managing their diet (i.e. diet setbacks) and associations with change in disease-specific and general emotional distress (diabetes distress and depressive symptoms) among patients with type 2 diabetes and their spouses., Method: Data for this study were collected in couples' homes (N=115 couples) using structured interviews and self-administered questionnaires at three time points: baseline (T1), six months after baseline (T2) and 12 months after baseline (T3)., Results: Patients' diet setbacks were associated with an increase in their diabetes distress in the shorter-term (over six months). Patients' diet setbacks were not associated with longer-term change in diabetes distress or with change in depressive symptoms at either time point (six months or one year). In contrast, spouses' perceptions of patients' diet setbacks were associated with increases in their own diabetes distress at both time points (over six months and one year), and also with an increase in their depressive symptoms in the longer-term (over one year)., Conclusion: Findings reveal detrimental consequences of patients' diet nonadherence for emotional well-being that extend to the well-being of their spouses.

Stress has long been suggested to be an important correlate of uncontrolled drinking and relapse. An important hormonal response system to stress-the hypothalamic-pituitary-adrenal (HPA) axis-may be involved in this process, particularly stress hormones known as glucocorticoids and primarily cortisol. The actions of this hormone system normally are tightly regulated to ensure that the body can respond quickly to stressful events and return to a normal state just as rapidly. The main determinants of HPA axis activity are genetic background, early-life environment, and current life stress. Alterations in HPA axis regulation are associated with problematic alcohol use and dependence; however, the nature of this dysregulation appears to vary with respect to stage of alcohol dependence. Much of this research has focused specifically on the role of cortisol in the risk for, development of, and relapse to chronic alcohol use. These studies found that cortisol can interact with the brain's reward system, which may contribute to alcohol's reinforcing effects. Cortisol also can influence a person's cognitive processes, promoting habit-based learning, which may contribute to habit formation and risk of relapse. Finally, cortisol levels during abstinence may be useful clinical indicators of relapse vulnerability in alcohol-dependent people.

Spouses often seek to influence the health behaviors of chronically ill partners, but little research has examined whether spouses find such involvement to be burdensome. The current study examined this question in a sample of 191 nondiabetic spouses whose partners had type 2 diabetes. Results revealed that spouses who attempted to exert more control over their partners' dietary behavior experienced greater burden, particularly when their partners exhibited poor dietary adherence and reacted negatively to spouses' involvement. The findings contribute to a sparse body of knowledge on how spouses are affected by efforts to influence their chronically ill partners' disease management.

Spouses often monitor and seek to alter each other's health behavior, but such social control attempts can provoke behavioral resistance and emotional distress. Expectations regarding spouses' roles in their partners' health may influence reactions to spousal social control, with resistance and hostility less likely to occur among people who believe spouses should be involved in their partners' health. Evidence consistent with this idea emerged in a study of 191 patients with type 2 diabetes. Patients with greater expectations for spousal involvement (particularly females) generally reacted less negatively to spousal control. The findings help to clarify when people with a chronic illness are likely to resist and resent, rather than appreciate, spousal control.

Objective: In this study, we examined whether the benefits of spousal assistance for patient well-being and physical functioning depend on the fit between amount of assistance provided and the personal importance of completing activities independently., Methods: Individuals with osteoarthritis of the hip or knee were assessed for independence centrality, depressive symptoms, self-efficacy for managing pain, and physical functioning (N = 159 to 230). Spouses reported the amount of support provided with daily tasks., Results: As predicted, moderation analyses indicated that spousal support was associated with greater self-efficacy for managing pain in patients with low independence centrality, but was not associated with self-efficacy in patients with high independence centrality. Also consistent with our hypotheses, spousal support was associated with greater depressive symptoms and slower walk time in patients with high independence centrality, but there were no effects of spouse support on these outcomes for patients with low independence centrality., Conclusions: Our findings demonstrate the implications of miscarried spousal support for patient well-being and physical functioning, and they suggest a means of tailoring couple-oriented interventions for chronic illness.

Development of multidrug resistance (MDR) is a major deterrent in the effective treatment of metastatic cancers by chemotherapy. Even though MDR and cancer invasiveness have been correlated, the molecular basis of this link remains obscure. We show here that treatment with chemotherapeutic drugs increases the expression of several ATP binding cassette transporters (ABC transporters) associated with MDR, as well as epithelial-mesenchymal transition (EMT) markers, selectively in invasive breast cancer cells, but not in immortalized or non-invasive cells. Interestingly, the mere induction of an EMT in immortalized and non-invasive cell lines increased their expression of ABC transporters, migration, invasion, and drug resistance. Conversely, reversal of EMT in invasive cells by downregulating EMT-inducing transcription factors reduced their expression of ABC transporters, invasion, and rendered them more chemosensitive. Mechanistically, we demonstrate that the promoters of ABC transporters carry several binding sites for EMT-inducing transcription factors, and overexpression of Twist, Snail, and FOXC2 increases the promoter activity of ABC transporters. Furthermore, chromatin immunoprecipitation studies revealed that Twist binds directly to the E-box elements of ABC transporters. Thus, our study identifies EMT inducers as novel regulators of ABC transporters, thereby providing molecular insights into the long-standing association between invasiveness and MDR. Targeting EMT transcription factors could hence serve as novel strategies to curb both metastasis and the associated drug resistance.

We investigated two types of negative and positive social control strategies, warning and encouragement, used by spouses to urge patients with type II diabetes to improve adherence to the diabetic diet. Warning refers to things a spouse may say or do to caution the patient about the consequences of eating a poor diet, and encouragement refers to things a spouse may say or do to promote healthier food choices by the patient. Our dyadic design (n=109 couples) assessed spouses' use of warning and encouragement (reported by spouses and by patients), as well as patients' reports of dietary adherence. Spouses being actively involved in patients' dietary choices was the largest category of open-ended descriptors of both warning and encouragement. Both spousal warning and encouragement were associated with patients' adherence to the recommended diabetic diet, with warning associated with poorer adherence and encouragement associated with better adherence. Moreover, it was the spouses' perceptions of their own influence attempts, and not patients' reports, that were consequential for patients' adherence. Patients' dietary behavior, and ultimately disease management, appears to be best served when the spouse uses more positively toned and less coercive influence attempts., (PsycINFO Database Record Copyright (c) 2010 APA, all rights reserved)

Although spousal support has been linked to positive outcomes in various health-related contexts, some research has found that the amount of social support provided to those who are chronically ill deteriorates over time. The current study refines the literature by considering multiple factors associated with spouses' provision of emotional support to partners with Type 2 diabetes. This diary study (N = 126 couples) examined the roles that stressor (disease severity and diabetes-specific anxiety), recipient (negative and positive affect), provider (negative and positive affect), and relationship (tension and enjoyment) factors play in spouses' provision of emotional support. Daily disease severity, patients' and spouses' daily negative affect, and spouses' daily relationship enjoyment were predictors of support provision. Wives, but not husbands, provided more support on days when patients experienced diabetes-specific anxiety. Results advance understanding of support provision in the context of a chronic stressor.

The animal research community comprises members from a wide variety of backgrounds, some of whom must learn basic surgical skills. Though demand for animal research personnel who have surgical skills is increasing, surgical training opportunities are becoming more scarce. Electronic learning or e-learning platforms can be used as an adjunct to hands-on surgical training. Course developers can adapt these e-learning courses to fit the needs of participants who have varying levels of expertise. The authors outline the steps involved in developing an effective e-learning surgical course. They also describe how to use various equipment and software products to help implement e-learning courses. Though the authors focus on developing surgical courses, course developers could apply the general steps outlined by the authors when developing any e-learning course.

Objective: The objective was to investigate self-efficacy to manage recovery from surgery and perceptions of the spouse's emotional responsiveness of adults recovering from knee surgery as mediators of the association between the quality of support from the spouse following surgery and recovery outcomes., Research Method: In-person interviews of married older adults (N = 134) with osteoarthritis of the knee who underwent total knee replacement surgery were conducted at 1 month before surgery, 1 month after surgery, and at 3 months after surgery., Main Outcome Measures: Outcomes were knee limitations and depressive symptoms., Results: Self-efficacy mediated the associations between emotional support and problematic support and improvement in knee limitations as well as between emotional support and improvement in depressive symptoms. Perceptions of the spouse's emotional responsiveness did not mediate associations between support and recovery outcomes., Conclusions: Findings suggest that emotional support from the spouse can improve recovery outcomes in part by strengthening efficacy beliefs to manage recovery, and problematic support can hinder optimal recovery in part by weakening efficacy beliefs.

Objective: The authors investigated health-related effects of social control (influence) that spouses exert in relation to osteoarthritis patients' medical adherence after total knee replacement surgery. Patients' behavioral and emotional responses to control were examined as mediators of associations between spouses' use of two control strategies (pressure, persuasion) and patients' physical and psychological recovery., Design: The authors used a three-wave panel design with assessments at one month before surgery, 1 month and 3 months after surgery. Data were collected during in-person interviews with 70 married, older adult patients., Main Outcome Measures: Recovery outcomes were assessed as improvement in knee limitations and depressive symptoms at the 3 month follow-up., Results: Spousal pressure and persuasion at one month postsurgery were indirectly associated with patients' recovery outcomes through patients' positive emotional responses to control., Conclusion: Although there are often immediate behavioral benefits in response to partners' use of both pressure and persuasion, the long-term health effects of these strategies seem to be accounted for by their opposing links to positive emotions. Findings further refine theory on health-related social control in marriage., ((c) 2009 APA, all rights reserved.)

Objective: The authors examine the impact of two caregiving stressors, care receivers' behavior problems (an objective stressor) and caregivers' feelings of overload (a subjective stressor), on three dimensions of caregiver health., Method: The participants were 234 primary caregivers of elderly relatives with dementia living in the community who completed a comprehensive interview about their current care situation, including stressors and health., Results: Higher levels of both objective and subjective stressors were associated with all three dimensions of caregiver health: poorer self-reported health, more negative health behaviors, and greater use of health care services. The association between objective stressors and health was mediated by caregivers' feelings of overload., Conclusions: These findings demonstrate caregivers' vulnerability to the effects of stressors across three dimensions of health and also underscore the importance of subjective appraisals of stress.

Purpose: This study explored whether adult day service (ADS) use was associated with reductions in behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia., Design and Methods: We used a quasi-experimental design to compare a group of 133 persons with dementia (PWDs) who initially enrolled in an ADS program to a control group not using these services (n = 68). Caregivers used a 24-hour log on multiple, consecutive days to report on five domains of BPSD., Results: We used growth-mixture modeling techniques to model change in the BPSD domains over a 2-month period as well as to handle the preponderance of zeros that were inherent in the data. Results showed a relationship between ADS use and caregivers' report of fewer nighttime sleep-related problems for their PWDs. We found trends for other domains, specifically depressive symptoms and agitated behavior, but no significant group differences emerged for these and the other domains., Implications: The findings of ADS use on PWDs' duration of nighttime sleep problems provide some evidence of the benefits of ADS; the findings also support its utility as part of the continuum of care for PWDs and their caregivers. For other behavior domains, enhanced or more targeted behavioral strategies coupled with ADS might offer caregivers and their PWDs the best possible combination for ameliorating BPSD.

Dementia is commonly associated with memory loss, but Behavioral and Psychological Symptoms of Dementia (BPSD) such as disruptive behaviors, agitation, and problems with mood, usually have a more significant impact on caregivers' stress. It is known that BPSD and caregivers' stress reactions vary in frequency over the long-term course of dementia, however little is known about the variability over the short-term. The current study included 85 people with dementia and their primary caregivers assessed over three months. Caregivers used a 24-hour log on multiple, consecutive days to report behavioral symptoms of dementia on seven domains of behavior, as well as their stress reactions for each domain. Using latent growth curve analysis, most BPSD and caregiver stress appraisals were found to be, on average, stable over the three-month time frame. For many BPSD and stress appraisal models, however, intra-individual differences in rate of change were significantly different from the mean trend, indicating behaviors and stress are not stable over three months when assessed at the level of the individual. Covariates were used to explain individual differences in rates of change; however few variables were significantly associated with intra-individual short-term change over time.

Type I and type II interferons (IFNs) bind to different cell surface receptors but activate overlapping signal transduction pathways. We examined the effects of a type I IFN (IFN-alphacon1) and a type II IFN (IFN-gamma1b) on gene expression in A549 cells and demonstrate that there is a common set of genes modulated by both IFNs as well as a set of genes specifically regulated by each, reflecting the activation of different signaling pathways. In particular, IFN-gamma induced many more genes of the signaling pathways, apoptosis, and cytokine interactions than did IFN-alpha. Even with genes induced by both IFNs there were distinctive quantitative differences in expression. IFN-gamma1b plays a major role in the induction and regulation of the complement pathway. Previous work has shown a synergistic antiviral and antiproliferative effect of type I and type II IFNs in cell culture and in the treatment of tumors in mice. We demonstrate that a majority of genes showed an additive effect of IFN-alphacon1 and IFN-gamma1b, but a subset of genes is synergistically induced; these include ISG20, MX2, OAS2, and other genes known to be involved in the antiviral response, TRAIL (TNFSF10) and caspases involved in apoptosis and chemokine genes RANTES, CXCL10, and CXCL11. Greater than additive transcription of some of these genes in the presence of both IFNs was confirmed by real-time kinetic RT-PCR. Elevated induction of many of these genes may be sufficient to explain the synergistic antiviral and antitumor effects of this combination of IFNs in vivo.

The authors examined spouses' provision of health-related support and control as predictors of health behavior and mental health among patients participating in cardiac rehabilitation (N = 94 couples). Cross-sectional analyses revealed that spouses' support was positively associated with patient health behavior. Prospective analyses of change over 6 months (N = 65 couples) revealed that spouses' support predicted increased patient mental health, whereas spouses' control predicted decreased patient health behavior and mental health. Findings suggest that spouses' efforts to facilitate patients' healthy lifestyle behaviors are associated with patients' health behavior and mental health, but not always as spouses might intend., (((c) 2006 APA, all rights reserved).)

The authors investigated associations between spousal control (influence) and support on the recovery outcomes for 70 men and women (mean age = 70) undergoing an increasingly common surgical treatment for osteoarthritis (OA) of the knee. Spouses' positive (motivating) and negative (pressuring) control and spouses' emotional (understanding) and problematic (dismissing) support were examined as predictors of patients' adherence and improvement in well-being. Positive control was associated with better adherence, but only among patients whose spouses provided little problematic support. In contrast, negative control strategies tended to elicit increases in negative affect. Overall, our findings revealed that the effectiveness of spousal control depended largely on the quality of support provided by the spouse., (((c) 2006 APA, all rights reserved).)

This study examined (1) predictors of treatment outcome for opioid-dependent participants in a single-site controlled trial comparing methadone, buprenorphine, and LAAM treatments and (2) the extent to which various subpopulations of patients may have more successful outcomes with each medication. The relationships between patient demographics, drug use history, and psychological status and outcome measures of treatment retention, opiate use, and cocaine use were assessed. We believe this study to be the first to demonstrate that predictors of treatment success appear to be largely similar in LAAM, buprenorphine, and methadone treatment for opioid dependence. We did not find any factors that would strongly guide selection of one medication over others., (Copyright 2005 APA, all rights reserved.)

Family caregivers of persons with dementia rely on a range of resources to provide care and cope with caregiving stressors. Informal (unpaid) and formal (paid) instrumental support contribute to diverse caregiver outcomes. Previous research of caregiver support has focused on subjective measures of help or has compared caregivers receiving formal services to those who do not. We focused instead on the effects of change in the amount of formal and informal instrumental assistance on caregivers' distress. We expected that greater gains in assistance would be associated with greater reduction of caregivers' distress. Increases informal but not informal levels of assistance were associated with improvement in each measure of distress. Additional measures may be needed to fully understand the effects of informal and formal assistance.

This study examined agreement between patients and two role partners (spouses and physicians) on patients' pain severity and the relationships between dyadic agreement and patients' well-being. We hypothesized that compared to disagreement between patients and role partners, dyadic agreement would be related to better psychological well-being (more disease-specific self-efficacy and positive affect, and less depression). Participants were 114 older women with osteoarthritis, their caregiving husbands, and their rheumatologists. Among patient-spouse dyads, agreement was associated with better well-being, especially when compared to spouses' underestimation of patients' pain. Contrary to predictions, patient-physician agreement was not related to better patient well-being. Agreement between patients and physicians was associated with less (rather than more) self-efficacy and positive affect when compared to physicians' underestimation of patients' pain.

The authors examined congruence in the negative emotions (depression, anger) of 101 female osteoarthritis patients (M age = 69 years) and their caregiving husbands (M age = 71 years) and the extent to which patients' pain behavior (e.g., limping, rubbing joints) exacerbated linkages between partners' negative emotions. Associations between patients' and husbands' emotions were examined within domains (e.g., depression-depression) and across domains (e.g., depression-anger) over a 6-month interval. Regression analyses revealed that patients' initial levels of depressive symptoms and anger were related to increases in their husbands' anger over time. The associations between patients' depressive symptoms and their husbands' depressive symptoms and anger were conditioned by pain behaviors. Patients who were more depressed and who engaged in high levels of pain behavior had husbands who became more depressed and angry.

The objective of this study was to determine whether adult day service use was related to decreases in primary caregiving hours (i.e., the time caregivers spent on activities of daily living/instrumental activities of daily living and behavior problems for care recipients) and care recipient function for these domains. Three-month longitudinal data from the Adult Day Care Collaborative Study (N = 400) were used. Adult day service users reported greater decreases in hours spent on behavior problems when compared to nonusers, even after controlling for baseline differences between the two groups. In addition, adult day service users reported decreased frequency of behavior problems in their relatives who attended adult day programs. The findings suggest that adult day services, if used over time, are effective in restructuring caregiving time and may offer potential benefits not only to family caregivers but to community-residing older adults who have dementia as well.

Background: The objective of this study was to determine whether adult day service use interacts with decreases in primary caregiving hours (i.e. the time caregivers spent on activities of daily living/instrumental activities of daily living, memory problems, and behavior problems for patients) to alleviate caregiver stress and negative mental health over time., Methods: Three-month longitudinal data from the Adult Day Care Collaborative Study (n=400) were used., Results: Decreases in memory problem hours among adult day service users were associated with reduced feelings of role overload; decreases in ADL hours among non-users were associated with decreases in worry and strain over a three-month period., Conclusion: The findings suggest that adult day services are potentially effective in restructuring caregiving time and providing respite to family members., (Copyright 2002 John Wiley & Sons, Ltd.)

The authors investigated psychosocial resources (positive support, active coping) and psychosocial constraints (negative support, avoidant coping) as predictors of improvement in the health of 63 older adults undergoing surgery for osteoarthritis of the knee. Following surgery, patients and social partners are motivated both to strive for the appetitive goal of recovery (approach), and to protect themselves from pain and impairment (avoidance). The authors assessed resources and constraints 6 weeks after surgery as predictors of outcomes (improvement in knee pain, knee functioning, and psychological well-being) 6 months after surgery. The constraints patients encountered early in recovery were strong predictors of poor recovery. Although resources were associated with some improvement, these effects were largely accounted for by constraints.

This study focused on the negative reactions of older women with osteoarthritis to the receipt of instrumental support (i.e., physical assistance) from their husbands and the effects of such negative reactions on the women's psychological well-being and self-care. Applying a person-environment fit model, the authors predicted that women's negative reactions to spousal support would be determined by the fit between this support and the personal centrality (importance) of being functionally independent. Consistent with this prediction, women who received high levels of support from the husband and for whom being functionally independent was not highly central reacted less negatively to this support. More negative reactions to spousal support were related to greater concurrent depressive symptomatology and fewer self-care behaviors. In addition, negative reactions were predictive of the women's increased depressive symptomatology and decreased life satisfaction. Findings illustrate a useful theoretical approach to the examination of support from family caregivers.

This paper compares employed and non-employed caregivers of cognitively impaired elderly family members. Using two competing positions derived from role theory, role conflict and role expansion, we explored whether holding the positions of both caregiver and worker led to greater role overload and psychological role conflict, or provided an outlet that helps caregivers better manage the demands placed on them. We found no differences between employed and non-employed caregivers on measures of role overload, worry and strain, and depression. For working caregivers, however, greater conflict on the job was associated with higher role overload and worry and strain while beneficial work experiences were only weakly associated with lower role overload and worry and strain. There was an interaction effect between positive work experiences and role overload when predicting depressive symptoms. These results provide some support for role conflict, but also suggest that caregivers may vary considerably in how they adapt to multiple roles.

Objectives: To examine (a) change versus stability over one year in four social roles occupied by 182 midlife women (parent care provider, mother, wife and employee), (b) increases in role stress and increases in role rewards as predictors of change in centrality, and (c) whether increases in stress or increases in rewards were stronger predictors when the 2 were considered simultaneously., Method: Interviews were conducted at 2 time points approximately 1 year apart. Participants were asked to rate the personal importance of each role on a scale of 1 to 10. Stress and rewards in each role were also assessed., Results: Analyses revealed considerable change in role centrality, especially in the parent-care and employee roles. Increases in wife and employee stress were associated with decreases in the centrality of these roles, whereas increases in rewards in each of the four roles were related to increases in the centrality of the respective roles. When considered simultaneously, role rewards were stronger predictors of change in centrality than role stress., Discussion: These findings suggest that the centrality of a social role can change over time in response to stressful and rewarding role experiences.