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Paul J Hershberger,1 Stacy R Flowers,1 Sharlo L Bayless,2 Katharine Conway,1 Timothy N Crawford1,3 1Department of Family Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, USA; 2Wright State University Boonshoft School of Medicine, Dayton, OH, USA; 3Department of Population and Public Health Sciences, Wright State University Boonshoft School of Medicine, Dayton, OH, USACorrespondence: Paul J Hershberger, Department of Family Medicine, Wright State University Boonshoft School of Medicine, 725 University Blvd, Dayton, OH, 45435, USA, Tel +1 937-245-7223, Fax +1 937-245-7931, Email paul.hershberger@wright.eduBackground: The contemporary challenges of improving patient engagement in chronic disease management and addressing the growing problem of physician burnout are commonly viewed as separate issues. However, there is extensive evidence that person-centered approaches to patient engagement, such as motivational interviewing (MI), are associated both with better outcomes for patients and improved well-being for clinicians.Methods: We conducted an exploratory survey study to ascertain whether resident physicians who perceive that they embrace and utilize the MI approach also report less burnout. A total of 318 residents in several specialties were invited via email to complete a 10-question survey about patient engagement and the experience of burnout. Frequencies and percentages were calculated for all categorical/ordinal variables to describe survey participants and question responses. Correlation coefficients were obtained to assess relationships between all burnout and engagement questions.Results: A total of 79 residents completed the survey (response rate of 24.8%). There was broad agreement about the importance of patient engagement and the use of the MI approach, and approximately 60% of residents indicated that burnout was a problem. Two items related to residents’ perceived use of MI were correlated with feeling a sense of personal accomplishment, one of the protective factors against burnout.Conclusion: Consistent with other studies indicating that person-centered approaches are associated both with better patient outcomes and provider wellbeing, our data suggest that residents’ self-reported use of the MI approach in patient care may be related to less burnout. It appears that training in the MI approach in graduate medical education may be simultaneously good for patient outcomes and good for resident well-being.Plain Language Summary: Teaching resident physicians how to take care of their own health, and how to help patients take more responsibility for their health, are typically viewed as two separate challenges. However, studies have shown that patient-centered approaches have benefits both for patient health and clinician health. In our survey of resident physicians, we found that those who say they use motivational interviewing, a patient-centered approach, also report less burnout. This means that teaching resident physicians an effective way to interact with patients is also good for the trainees’ health.Keywords: patient engagement, physician burnout, motivational interviewing, graduate medical education

Objectives: Resource insecurity is a social determinant of health that can impact people with HIV (PWH), in particular older African Americans (AA) or blacks with HIV. The purpose of this study was to identify resource insecurities among older Blacks or AA PWH specifically related to food and housing. Secondary focus was to find associations between resource insecurity and substance use history, stigma, and various forms of discrimination., Methods: Eligible participants (N = 52) of this cross-sectional study were 50 years old or older, identified as Black or AA, diagnosed with HIV, and living in Ohio. Food insecurity was assessed using the Household Food Insecurity Access Scale and housing insecurity was defined as not having stable housing. Resource insecurity was categorized into food and housing secure, food or housing insecure, and food and housing insecure., Results: Almost half (48.1%) of participants reported housing insecurity, with approximately 58.0% experiencing food insecurity, and 38.5% facing both. Current substance use, particularly opiates, showed significant association with resource insecurity (OR = 5.54; 95% CI = 1.91-17.30). Moreover, experiences of everyday (OR = 1.19; 95% CI = 1.10-1.30) or major forms (OR = 1.75; 95% CI = 1.33-2.39) of discrimination, as well as HIV stigma (OR = 1.24; 95% CI = 1.01-1.55), were also linked to increased odds of resource insecurity among participants., Conclusions: Findings highlight how social factors contribute to resource insecurity among older AA PWH. Understanding the factors offers insight for targeted intervention in the fight against HIV transmission., (© 2024. The Author(s).)

Objective: To examine the effects of internalized HIV stigma on viral non-suppression via depressive symptoms, alcohol use, illicit drug use, and medication adherence and investigate whether social support moderates these effects., Design: Longitudinal observational clinical cohort of patients in HIV care in the US.Methods: Data from the CFAR Network for Integrated Clinical Systems (2016-2019) were used to conduct structural equation models (SEM) to test the indirect effects of internalized HIV stigma on viral non-suppression through depressive symptoms, illicit drug use, alcohol use, and medication adherence. Moderated mediation with an interaction between social support and internalized HIV stigma was examined., Results: Among 9,574 individuals included in the study sample, 81.1% were male and 41.4% were Black, non-Hispanic. The model demonstrated good fit (root mean square error of approximation = 0.028; standardized root means square residual = 0.067). The overall indirect effect was significant (b = 0.058; se  = 0.020; β = 0.048; 95%CI = .019-.098), indicating that internalized HIV stigma's impact on viral non-suppression was mediated by depressive symptoms, illicit drug use, and medication adherence. An interaction was observed between internalized HIV stigma and social support on alcohol use, however, there was no moderated mediation for any of the mediators., Conclusions: Internalized HIV stigma indirectly impacts viral non-suppression through its effects on depressive symptoms, illicit drug use, and medication adherence. Social support may buffer the impact, but more research is needed. Understanding the pathways through which internalized stigma impacts viral suppression is key to improving health of people with HIV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Few studies have examined which subgroups of people with HIV (PWH) carry the greatest burden of internalized HIV stigma (IHS), which may be important to care provision and interventions., Methods: PWH in the CFAR Network of Integrated Clinical Systems (CNICS) longitudinal, US-based, multisite, clinical care cohort completed tablet-based assessments during clinic visits including a four-item, Likert scale (low 1-5 high), IHS instrument. Associations between sociodemographic characteristics and IHS scores were assessed in adjusted linear regression models., Results: Twelve thousand six hundred and fifty-six PWH completed the IHS assessment at least once from February 2016 to November 2022, providing 28 559 IHS assessments. At baseline IHS assessment, the mean age was 49 years, 41% reported White, 38% Black/African American, and 16% Latine race/ethnicity, and 80% were cisgender men. The mean IHS score was 2.04, with all subgroups represented among those endorsing IHS. In regression analyses, younger PWH and those in care fewer years had higher IHS scores. In addition, cisgender women vs. cisgender men, PWH residing in the West vs. the Southeast, and those with sexual identities other than gay/lesbian had higher IHS scores. Compared with White-identifying PWH, those who identified with Black/African American or Latine race/ethnicity had lower IHS scores. Age stratification revealed patterns related to age category, including specific age-related differences by gender, geographic region and race/ethnicity., Discussion: IHS is prevalent among PWH, with differential burden by subgroups of PWH. These findings highlight the benefits of routine screening for IHS and suggest the need for targeting/tailoring interventions to reduce IHS among PWH., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Purpose: Because there are conflicting perspectives on the factor structure of the World Health Organization Quality of Life-BREF (WHOQOL-BREF) Questionnaire among college students, we evaluated the psychometric properties of the instrument in a sample of U.S. college students. Methods: We conducted secondary analysis of data collected from 1,138 undergraduate students from a large metropolitan university in the southeastern United States. Results: Confirmatory factor analysis did not support the original 4-factor structure. Based on exploratory factor analysis, three factors were retained and rotated using Varimax rotation, which accounted for 96% of the item variance. Coefficient alphas for the factors were: social/psychological health, 0.84; physical health, 0.81; and environment, 0.77. Sexual minorities had significantly lower scores on all factors than those who identified as heterosexuals. Conclusions: In this sample of college students, the WHOQOL-BREF was three-dimensional, and a significant amount of the item variance was explained. Lower quality of life scores of nonWhites and sexual minority college students point to a critical need that should be addressed., (© Copyright 2024 Springer Publishing Company, LLC.)

There is strong evidence that the implicit biases of health care professionals affect the treatment of patients, and that minority and other marginalized patients are disproportionately harmed. Assumptions made about patient knowledge or lack thereof function as judgments that are prone to bias, which then affect the education and advice imposed upon patients. We review how the motivational interviewing (MI) approach to patient engagement includes components of evidence-based bias-mitigating strategies, such as understanding circumstances from the patient's point of view, and therefore we propose that the MI approach can reduce the impact of bias in patient care., (© Paul J. Hershberger et al., 2024; Published by Mary Ann Liebert, Inc.)

Background: Finding time in the medical curriculum to focus on motivational interviewing (MI) training is a challenge in many medical schools. We developed a software-based training tool, "Real-time Assessment of Dialogue in Motivational Interviewing" (ReadMI), that aims to advance the skill acquisition of medical students as they learn the MI approach. This human-artificial intelligence teaming may help reduce the cognitive load on a training facilitator., Methods: During their Family Medicine clerkship, 125 third-year medical students were scheduled in pairs to participate in a 90-minute MI training session, with each student doing two role-plays as the physician. Intervention group students received both facilitator feedback and ReadMI metrics after their first role-play, while control group students received only facilitator feedback., Results: While students in both conditions improved their MI approach from the first to the second role-play, those in the intervention condition used significantly more open-ended questions, fewer closed-ended questions, and had a higher ratio of open to closed questions., Conclusion: MI skills practice can be gained with a relatively small investment of student time, and artificial intelligence can be utilized both for the measurement of MI skill acquisition and as an instructional aid., (© 2024. The Author(s).)

Foodborne illness affects approximately 48 million Americans annually. Food irradiation is a safe and effective way to kill bacteria and extend a product's shelf-life. However, challenges to wider implementation of this technology include consumer hesitancy stemming from misconceptions about safety and lack of knowledge of irradiation's benefits. Research has shown that consumers are more willing to accept irradiation if informed about its safety. Due to increases in multistate foodborne outbreaks and consumers' growing concern and expectation of food safety, it is an opportune time to reconsider irradiation as a food safety tool. Consumer attitudes toward food safety differ by demographic characteristics; however, research on the association of demographic factors with attitudes on food irradiation are limited. Data collected from a survey (N=1,009) conducted in August 2022 were analyzed to describe the relationship between age and food irradiation knowledge as influential factors to purchase irradiated foods. More than half (56%) of respondents reported that learning more about irradiation would likely influence purchasing decisions; older adults were more knowledgeable about food irradiation. These findings suggest that age could be an important factor to consider when tailoring messaging as a prevention strategy around the benefits of food irradiation.

Abstract: Twenty-four percent of all U.S. opioid overdose deaths involve a prescription opioid. Changing prescribing practices is considered a key step in reducing opioid overdoses. Primary care providers (PCPs) commonly lack the patient engagement skills needed to address patient resistance to taper or end opioid prescriptions. We developed and evaluated a protocol aimed at improving PCP opioid-prescribing patterns and modeled on the evidence-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach. We conducted a time series trial comparing provider opioid prescribing 8 months before and 8 months after training with the PRomoting Engagement for Safe Tapering of Opioids (PRESTO) protocol. The 148 Ohio PCPs who completed PRESTO training gained confidence in their ability to engage their patients on the topics of opioid overdose risk and potential opioid tapering. Promoting Engagement for Safe Tapering of Opioids participants had decreased opioid-prescribing over time, but this was not significantly different from Ohio PCPs who had not received PRESTO training. Participants completing PRESTO training had small, but significant increased buprenorphine prescribing over time compared with Ohio PCPs who had not received PRESTO training. The PRESTO approach and opioid risk pyramid warrant further study and validation., (Copyright © 2023 International Association for the Study of Pain.)

Background: Teach Back (TB) is recommended to assess and ensure patient understanding, thereby promoting safety, quality, and equity. There are many TB trainings, typically lacking assessment tools with validity evidence. We used a pediatric resident competency-based communication curriculum to develop initial validity evidence and refinement recommendations for a Teach-back Observation Tool (T-BOT)., Objective: This study aimed to develop initial validity evidence for a refined T-BOT and provide guidance for further enhancements to improve essential TB skills training among pediatric residents., Methods: After an interactive health literacy (HL) training, residents participated in recorded standardized patient (SP) encounters. Raters developed T-BOT scoring criteria, then scored a gold standard TB video and resident SP encounters. For agreement, Fleiss' Kappa was computed for >2 raters, and Cohen's Kappa for two raters. Percent agreement and intraclass correlation (ICC) were calculated. Statistics were calculated for gold standard (GS) and TB items overall for all six raters, and for five faculty raters. Agreement was based on Kappa: no agreement (≤0), none to slight (0.01-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), almost perfect (0.81-1.00)., Key Results: For six raters, Kappa for the GS was 0.554 (moderate agreement) with 71.4% agreement; I CC = .597; for SP encounters, it was 0.637 (substantial) with 65.4% agreement; I CC = .647. Individual item agreement for SP encounters average was 0.605 (moderate), ranging from 0.142 (slight) to 1 (perfect). For five faculty raters, Kappa for the GS was 0.779 (substantial) with 85.7% agreement; I CC = .824; for resident SP encounters, it was 0.751 (substantial), with 76.9% agreement; I CC = .759. Individual item agreement on SP encounters average was 0.718 (substantial), ranging from 0.156 (slight) to 1 (perfect)., Conclusion: We provide initial validity evidence for a modified T-BOT and recommendations for improvement. With further refinements to increase validity evidence, accompanied by shared understanding of TB and rating criteria, the T-BOT may be useful in strengthening approaches to teaching and improving essential TB skills among health care team members, thereby increasing organizational HL and improving outcomes. [ HLRP: Health Literacy Research and Practice . 2023;7(4):e187-e196. ].

The implantable arterial doppler (IAD) is frequently used to postoperatively monitor free flaps with high accuracy, but there are no guidelines for its use. Bedside exam is used adjunctively to determine necessary intervention. This systematic review seeks to discover why the doppler is used adjunctively despite its established record of accuracy. Criteria for inclusion and exclusion were established. In total, 280 articles were found on PubMed and Web of Science, then screened accordingly. Data from 22 articles were analyzed using a bivariate hierarchical random effects model. Twenty-two studies yielded 2996 total patients undergoing 3127 free flap procedures. The meta-analysis found a high sensitivity of 0.809 (95% CI = 0.709, 0.880) and specificity of 0.966 (95% CI = 0.947, 0.979). False-positive rate was found to be 0.034 (95% CI = 0.021, 0.053). Positive and negative predictive values were 0.711 (95% CI = 0.581, 0.817) and 0.979 (95% CI = 0.966, 0.988). Positive and negative likelihood ratios were 24.7 (95% CI = 14.5, 39.5) and 0.20 (95% CI = 0.12, 0.30). The established efficacy of the IAD is supported by this study. Clinical exams may remain as the final adjunct due to the risks of inaccurate IAD signals. Further studies are warranted to optimize its use for future practice guidelines., (© 2023 The Authors. Head & Neck published by Wiley Periodicals LLC.)

Objectives: The purpose of this pilot study was to explore the effect of HIV-related stigma and everyday major experiences of discrimination on medication and clinic visit adherence among older African Americans living with HIV in Ohio., Methods: We collected data from 53 individuals who were living with HIV in Ohio, ≥ 50 years of age, and who identified as Black or African American. We conducted logistic regression models to examine the impact of HIV-related stigma and experiences of discrimination on medication and visit adherence. Each model controlled for age, time since diagnosis, and sexual orientation., Results: The average age was 53.6 ± 2.1 years and 94.3% were men. Almost half (49.1%) of the participants reported poor medication adherence and almost a third (31.4%) reported poor visit adherence. HIV-related stigma (adjusted odds ratio (aOR) = 1.39; 95% confidence interval (CI) = 1.02-1.89) and major experiences of discrimination (aOR = 1.70; 95% CI = 1.11-2.60) were associated with a greater odds of poor medication adherence. Additionally, major experiences of discrimination were associated with a threefold increase in the odds of poor visit adherence (aOR = 3.24; 95% CI = 1.38-7.64)., Conclusions: HIV-related stigma and major experiences of discrimination impede optimal medication and HIV clinic visit adherence for older African Americans living with HIV. To reduce the impact of stigma and discrimination on HIV care engagement, our first step must be in understanding how intersecting forms of stigma and discrimination impact engagement among older African Americans living with HIV., (© 2022. W. Montague Cobb-NMA Health Institute.)

Introduction: Data on how surgeons perceive their habits of prescribing narcotics compared to their actual practice are scarce. This study examines the perception and actual narcotic prescribing habits of surgeons and advanced practitioners., Methods: Surgical residents, attendings, and advanced practice providers (APPs) were surveyed to assess their perceived prescribing habits at discharge for laparoscopic appendectomy and laparoscopic cholecystectomy. Data on narcotics prescription for patients receiving either of the procedures from January 2017 to August 2020 were extracted from electronic health records. Prescribed narcotics were converted to morphine equivalent doses (MEQs) for comparison., Results: Of the 52 participants, the majority were residents (57.7%). Approximately 90% of residents, 72% of attendings, and 18% of APPs reported regularly prescribing narcotics at discharge. Approximately 67% (889/1332) of patients were discharged with narcotics. Of those, the majority of patients' narcotics were prescribed by surgery residents (71.2%). However, 72% of residents, 80% of attendings, and 72% of APPs were confident on prescribing the correct regimen of narcotics. There were no differences in average daily MEQs among the groups. However, the number of narcotics prescribed was higher among APPs compared to that in the other groups (P < 0.0001)., Conclusions: Most participants self-reported routinely prescribing narcotics at discharge. Although not the current recommendation, participants felt confident they were prescribing the correct regimen, but were observed to prescribe more than the recommended number of total narcotics which indicates a discrepancy between perception and actual habits of prescribing narcotics. Our findings suggest a need for education in the general surgery residency and continuing medical education setting., (Copyright © 2022 Elsevier Inc. All rights reserved.)

In 2019, a new variant of coronavirus, SARS-CoV-2 (COVID-19) created a global pandemic that has highlighted and exacerbated health disparities. Educating the general public about COVID-19 is one of the primary mitigation strategies amongst health professionals. English is not the preferred language for an estimated 22% of the United States population making effective mass communication efforts difficult to achieve. This study seeks to understand and compare several topics surrounding COVID-19 health communication and healthcare disparities between individuals with English language preference (ELP) and non-English language preference (NELP) within the United States. A survey available in seven languages asking about knowledge and opinions on COVID-19, vaccines, preferred sources of health information, and other questions, was administered February-April 2021 to patients at an urban federally qualified health center that also serves global refugees and immigrants. Descriptive statistics and comparative analysis were performed to identify differences between ELP and NELP individuals. Analysis of 144 surveys, 33 of which were NELP, showed 90.97% of all patients agreed that COVID-19 was a serious disease and 66.67% would receive the COVID-19 vaccine. There were numerous differences between ELP and NELP individuals, including trust in government, symptom identification, preferred source of health information, and feelings that cultural needs had been met. This study has identified several significant differences in patient perceptions relating to the COVID-19 pandemic when comparing NELP to ELP and highlighted areas where improvement can occur. Applying this information, easily utilized targeted resources can be created to quickly intervene and address health disparities among patients seeking care at an urban community health center.

Background: Over 50% of new AIDS/HIV diagnoses are older adults and disproportionately African American people. Longstanding health inequities, driven by the enduring nature of systemic racism, pose challenges to obtaining optimal HIV services. Patient experiences and identities shape the health care experience, yet patient voices are often minimized, including their assessment of quality HIV care. Understanding these markers of care, including facilitators of and barriers to care and engagement, may help enhance the patient voice, potentially improving service delivery and eradicating HIV healthcare disparities., Method: Using a convergent mixed method design, our study identifies patient-identified markers of quality care among older African Americans (N = 35). Measurements of global stress, HIV stigma, and engagement in care were collected, and in-depth qualitative interviews explored the symbols of quality care as well as facilitators of and barriers to care., Results: We identified widespread participant awareness and recognition of quality care, the detection of facilitators and barriers across individual, clinic, and community levels. Facilitators of care include diet, health, relationships, community support, and compassionate HIV care. Barriers to care include health comorbidities, economic, food, and housing insecurity, lack of transportation, and structural racism., Conclusion: Our findings illuminate how the prominence of barriers to care often uproot facilitators of care, creating impediments to HIV service delivery as patients transition through the HIV care continuum. We offer implications for practice and policy, as well as recommendations for reducing structural barriers to care by enhancing the patient voice and for aligning services toward compassionate and inclusive care., (© 2022. W. Montague Cobb-NMA Health Institute.)

Frozen stuffed breaded raw chicken products have repeatedly been implicated in Salmonella outbreaks (1). These products are partially cooked to set the breading, often making them appear cooked (2). Despite their appearance, these products need to be cooked to an internal temperature of 165°F (74°C) to ensure that they are safe to eat. Producers began implementing labeling changes in 2006 to more clearly identify these products as raw; many warn against using microwave ovens (microwaves) to prepare them and provide validated cooking instructions solely for conventional ovens (ovens) (3,4). However, outbreaks continued to occur after implementation of these labeling changes (4). To describe the demographic characteristics of persons who prepare frozen stuffed chicken products and which appliances they use to prepare them, data from a May-July 2022 representative panel survey were analyzed. Although most (82.7%) respondents used an oven as one of their cooking methods, more than one half (54.0%) of respondents also used another appliance, including 29.0% who used a microwave. Oven use was lower among respondents with household income <$25,000 (68.9%), and who lived in mobile homes or other portable types of homes (66.5%). Among respondents who reported using microwaves to cook these products, 8% reported using a microwave with ≤750 W of power, which might be insufficient to thoroughly cook such products (1,5,6). Economic and other factors might influence some groups' access to recommended cooking appliances. Companies could consider implementing additional interventions that rely less on labeling and consumer preparation practices and focus on controlling or reducing levels of Salmonella in these products, such as selling them fully cooked, or monitoring and testing Salmonella levels, to ensure safety. These findings highlight challenges consumers might face in preparing frozen stuffed chicken products safely and can guide strategies for regulatory authorities and industry to prevent outbreaks and illnesses associated with them., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Abstract: This grounded theory study examined the use of alcohol and other drugs (AOD) on the management of HIV disease among 27 older African Americans (≥50 years). Interview transcripts were analyzed using constructivist grounded theory analytic techniques. Participants reported facing (a) environmental impacts of AOD use and (b) discrimination from the health care system. The analysis revealed six phases of AOD use, occurring at various stages of the HIV care continuum: (a) linking AOD use as the cause of HIV diagnosis, (b) having AOD use facilitate denial of HIV, (c) experiencing problematic use as a barrier to care engagement, (d) "testing the waters," (e) relying on AIDS service organizations and medical providers, and (f) changing or maintaining patterns of AOD use to maintain engagement with care. Recommendations include assessing a patient's AOD use in relationship to the care continuum to evaluate patients' experiences and barriers within systems of care., (Copyright © 2021 Association of Nurses in AIDS Care.)

Purpose: Biased perceptions of individuals who are not part of one's in-groups tend to be negative and habitual. Because health care professionals are no less susceptible to biases than are others, the adverse impact of biases on marginalized populations in health care warrants continued attention and amelioration., Method: Two characters, a Syrian refugee with limited English proficiency and a black pregnant woman with a history of opioid use disorder, were developed for an online training simulation that includes an interactive life course experience focused on social determinants of health, and a clinical encounter in a community health center utilizing virtual reality immersion. Pre- and post-survey data were obtained from 158 health professionals who completed the simulation., Results: Post-simulation data indicated increased feelings of compassion toward the patient and decreased expectations about how difficult future encounters with the patient would be. With respect to attribution, after the simulation participants were less inclined to view the patient as primarily responsible for their situation, suggesting less impact of the fundamental attribution error., Conclusion: This training simulation aimed to utilize components of evidence-based prejudice habit breaking interventions, such as learning more about an individual's life experience to help minimize filling in gaps with stereotyped assumptions. Although training simulations cannot fully replicate or replace the advantages that come with real-world experience, they can heighten awareness in the increase of increasing the cultural sensitivity of clinicians in health care professions for improving health equity., Competing Interests: No competing financial interests exist., (© Paul J. Hershberger et al., 2022; Published by Mary Ann Liebert, Inc.)

Objectives: To (1) compare the probability of cigarette smoking cessation for pregnant women with and without past-year mental illness by the trimester of pregnancy; and (2) examine the association between the receipt of past-year mental health treatment and prenatal cigarette smoking cessation among pregnant lifetime-smokers with mental illness., Methods: We conducted secondary analysis of data from the National Survey on Drug Use and Health (NSDUH) 2008-2014. The NSDUH included 2019 pregnant lifetime smokers aged 18-44 years, 528 of whom had a mental illness. We used multiple logistic regression to model the probability of prenatal cigarette smoking cessation., Results: Pregnant lifetime-smokers with mental illness had a lower rate of cigarette smoking cessation than women without mental illness (47.9% vs. 61.7%, p = 0.001). Compared to pregnant women without mental illness, pregnant women with mental illness had a significantly lower odds of smoking cessation in the first trimester (Adjusted Odds Ratio [AOR]: 0.34, 95% Confidence Interval [CI]: 0.18-0.66), but not in the second (AOR: 0.87, 95% CI: 0.46-1.63) and third trimesters (AOR: 0.94, 95% CI: 0.51-1.72). The likelihood of quitting smoking did not differ significantly for pregnant lifetime-smokers with mental illness who received and did not receive mental health treatment (AOR: 1.69, 95% CI: 0.87-3.28)., Conclusion: Pregnant lifetime-smokers with mental illness are less likely to quit smoking than those without mental illness; overall, pregnant women tended to quit smoking as they progressed in their pregnancy. The receipt of mental health treatment was not associated with quitting smoking. Mental health care providers need to screen for cigarette use among pregnant women and strengthen smoking cessation efforts., Clinical Relevance: Pregnancy presents a unique opportunity for mental health care providers to screen for cigarette use in women with mental illness and support their smoking cessation efforts., (© 2021 Sigma Theta Tau International.)

Background: Perception of a surgeon based on physical attributes in the operating room (OR) environment has not been assessed, which was our primary goal., Methods: A common OR scenario was simulated using 8 different actors as a lead surgeon with combinations of age (<40 vs. >55), race (white vs. black), and gender (male vs. female). One video scenario with a survey was electronically distributed to surgeons, residents, and OR nurses/staff. The overall rating, assessment, and perception of the lead surgeon were assessed., Results: Of 974 respondents, 64.5% were females. There were significant differences in the rating and assessment based upon surgeon's age (p = .01) favoring older surgeons. There were significant differences in the assessments of surgeons by the study group (p = .03). The positive assessments as well as perceptions trended highest towards male, older, and white surgeons, especially in the stressful situation., Conclusion: While perception of gender bias may be widespread, age and race biases may also play a role in the OR. Inter-professional education training for OR teams could be developed to help alleviate such biases., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Differential diagnosis (DDx) is a core clinical reasoning skill that all medical students and physicians must acquire and develop. Metamemory techniques (MMTs), including mnemonic devices and other heuristics, are frequently taught to students as a means of enhancing DDx generation. The Heart is A House (HIAH) , an MMT that works by prompting students to think about cardiac disease in terms of four structural subsystems, can be used to facilitate the generation of cardiac differentials, but its efficacy has not been studied., Methods: In a 3-hour DDx workshop, second-year medical students were given a brief case vignette of a patient with chest pain and dyspnea and asked to generate initial differential diagnoses before and after learning HIAH. Descriptive statistics and paired T-tests were used to compare the sizes of cardiac-only and total differentials pre-/post-HIAH. Cardiac diagnoses were classified according to the structural categories described by HIAH, and Simpson's Diversity Index (SDI) was used to evaluate the effect of HIAH on the variety of cardiac diagnoses produced., Results: All students in the course ( N  = 111) submitted pre-post differential lists. The mean number of diagnoses included in their differentials did not change significantly after exposure to HIAH (7.98 vs. 8.71, P  = .09). However, the number of potentially correct cardiac diagnoses increased from 1.79 to 4.75 ( P  < .0001), and the variety of structure/function cardiac categories considered by students increased more than twofold (from an SDI of 0.16 to 0.4, P  < .0001). These increases were accompanied by a small increase in incorrect diagnoses ( + 2.47%, P  = .0003) and a larger decrease in potentially correct noncardiac diagnoses (-41.88%, P  < .0001)., Conclusion: The use of HIAH was associated with an increase in the size and variety of cardiac differentials. This increase may have come at the cost of a reduced noncardiac differential. Educators may find HIAH useful for guiding students as they reason through cases involving potential cardiac etiologies. As with all heuristics, care must be exercised to avoid introducing unwanted bias., Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: Motivational interviewing (MI) is an evidence-based, brief interventional approach that has been demonstrated to be highly effective in triggering change in high-risk lifestyle behaviors. MI tends to be underutilized in clinical settings, in part because of limited and ineffective training. To implement MI more widely, there is a critical need to improve the MI training process in a manner that can provide prompt and efficient feedback. Our team has developed and tested a training tool, Real-time Assessment of Dialogue in Motivational Interviewing (ReadMI), that uses natural language processing (NLP) to provide immediate MI metrics and thereby address the need for more effective MI training., Methods: Metrics produced by the ReadMI tool from transcripts of 48 interviews conducted by medical residents with a simulated patient were examined to identify relationships between physician-speaking time and other MI metrics, including the number of open- and closed-ended questions. In addition, interrater reliability statistics were conducted to determine the accuracy of the ReadMI's analysis of physician responses., Results: The more time the physician spent talking, the less likely the physician was engaging in MI-consistent interview behaviors ( r = -0.403, p = 0.007), including open-ended questions, reflective statements, or use of a change ruler., Conclusion: ReadMI produces specific metrics that a trainer can share with a student, resident, or clinician for immediate feedback. Given the time constraints on targeted skill development in health professions training, ReadMI decreases the need to rely on subjective feedback and/or more time-consuming video review to illustrate important teaching points., Competing Interests: None of the authors have any conflicts of interest to report., (© 2021 Hershberger et al.)

Objective: The aim of the study was to assess the relationship of culture of safety dimensions and the rate of unanticipated care outcomes in long-term care facilities (LTCFs) using the Agency for Healthcare Research and Quality framework of resident safety culture., Methods: Cross-sectional survey data were collected on 13 dimensions of culture of safety in five LTCFs from registered nurses, licensed practical nurses (LPNs), nursing assistants, administrators/managers, administrative support, and rehabilitation staff. Secondary data on falls in the five LTCFs from quarters 1 to 3 of 2014 were obtained from the Centers for Medicare and Medicaid Services in February 2015. Spearman's ρ and the Generalized Estimating Equations using a log link (Poisson distribution) were used., Results: Communication and feedback about incidences reported the highest mean scores (M = 4.35, SD =0.71). Higher rate of falls was associated with a lower level of team work, lower degree of handoffs, and lower levels of organizational learning. The risk for falls increased as the number of residents per facility increased (rate ratio [RR] = 1.02; 95% confidence interval [CI] = 1.01-1.02) and as the number of LPN hours per resident increased (RR = 37.7, 95% CI = 18.5-76.50). Risk for long stay urinary tract infections increased as number of residents increased (RR =1.01, 95% CI =1.01-1.01). Increase in culture of safety score was associated with decrease in risk of falls, long stay urinary tract infections, and short stay ulcers., Conclusions: With the shortage of registered nurses in LTCFs and new reimbursement regulations, many LTCFs are hiring LPNs to have full staffing and save money. Licensed practical nurses may lack essential knowledge to decrease the rate of falls., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

This cross-sectional, correlational study's purpose was to evaluate the effects of resilience and moral distress on workplace engagement in emergency department nurses providing direct patient care. Data were collected from 175 emergency department nurses using a Web-based survey. The higher the nurses' resilience and the lower their moral distress, the greater their workplace engagement. Resilience and moral distress were not correlated; furthermore, moral distress did not mediate a relationship between resilience and workplace engagement. Resilience was higher with greater job satisfaction, increased age, and longer tenure as a nurse. Workplace engagement increased with higher job satisfaction and less time seeking other employment. Moral distress scores were higher in nurses reporting lower job satisfaction. Multiple regression analysis revealed that resilience, job satisfaction, and moral distress were independent predictors of workplace engagement. Interventions that improve resilience and job satisfaction and/or lower moral distress may improve workplace engagement of emergency department nurses.

Background: Old age, leucocytosis, hypoalbuminemia, and elevated creatinine have been identified as risk factors for fulminant Clostridioides difficile infection (CDI). High ATLAS scores have also been linked to fatal disease. The affiliated studies, however, involved patients prescribed metronidazole - a regimen no longer standard of care. The variables were thus reassessed in patients prescribed optimal therapy., Methods: Adults hospitalized with CDI at University of Kentucky Medical Center were retrospectively reviewed. Enrolled subjects were separated according to disease classification i.e. non-severe/severe versus fulminant CDI. Fulminant patients were further subdivided into hypotensive persons responsive to fluid resuscitation, and those with sequent shock, ileus, or megacolon. Following partition, the cohorts underwent correlation analysis., Findings: Forty-five subjects had non-severe/severe disease. Thirteen fulminant CDI patients responded to fluid resuscitation. Seventeen fulminant CDI patients developed shock, ileus, or megacolon. Median WBC counts, albumin values, and ATLAS scores varied among the cohorts. Although WBC counts were similar among the fulminant subsets, declining albumin values and increasing ATLAS scores mirrored disease worsening. Logistic regression revealed albumin values < 20 g/L (odds ratio [OR] 3.91) and ATLAS scores ≥ 6 (OR 5.03) to predict critical illness in hypotensive persons., Conclusion: Median WBC counts, albumin values, and ATLAS scores differed in patients separated by CDI severity. A notable variance in albumin values and ATLAS scores between fluid responsive fulminant disease and critical illness was moreover seen. The finding suggests hypoalbuminemia and high ATLAS scores in hypotensive CDI patients may herald shock, ileus, or megacolon., (© 2021 The Authors.)

Introduction: Interacting with patients in a manner that furthers self-responsibility for health is an important skill for primary care clinicians. Motivational interviewing (MI) is such an approach to patient engagement, but it remains to be more widely implemented. In a program training health professionals and health professions students in MI, we examined posttraining attitudes and intentions regarding the utilization of MI. Of particular interest was how posttraining intentions were associated with self-reported action 1 month later., Methods: We obtained immediate posttraining and 30-day follow-up data from 209 participants regarding intent to utilize the MI approach (self-reported implementation at the follow-up interval), impact on confidence with patient interaction, and perceived importance of the training. We analyzied frequencies and percentages for all categorical/ordinal variables to describe the participants and the survey question responses., Results: While 91.5% of participants intended to incorporate MI into their approach with patients (to a moderate or great extent) at posttraining, only 48.7% reported that they had actually implemented the MI approach (to a moderate or great extent) 30 days later. However, another 32.1% indicated that they had occasionally utilized MI. Attitudes toward the importance of MI training and the impact of training on confidence remained strong over the 30 days., Conclusion: Achieving more widespread implementation of the MI approach in the primary care setting is likely to be less dependent on convincing clinicians about its importance for patient engagement, but rather on the translation of intent to actual practice and implementation., (© 2021 by the Society of Teachers of Family Medicine.)

Opioid use disorder has long been associated with psychiatric symptoms, including dissociative experiences. Medications used to treat opioid use disorder can potentially impact dissociative symptoms, but the existing literature has not explored this. We examined the relationship between dissociative symptoms and opioid use disorder using the Dissociative Experiences Scale (DES). We studied subjects who were taking prescribed methadone, buprenorphine, or naltrexone for opioid use disorder. We gave the DES, the Patient Health Questionairre-9 (PHQ-9), and the PTSD Checklist for DSM-5 (PCL-5) with Criterion A to subjects in three substance use treatment facilities in Ohio. We conducted Analysis of Variance (ANOVA) and Spearman's Rank Correlations to examine associations between the variables and outcomes. We developed three separate multiple linear regression models. We included 116 participants in our exploratory and naturalistic study. The majority of participants were female (51.7%), white (89.5%), ≤ 40 years of age (64.7%), and taking buprenorphine (55%). The average DES score was 16.1 (standard deviation = 14.9) and we considered 80.9% to have low dissociation (score < 30). Approximately 55% (n = 64) of participants were taking prescribed buprenorphine. Approximately 27% (n = 32) were taking prescribed methadone and approximately 18% (n = 21) were taking prescribed naltrexone (oral or extended release). There was a significant association between opioid medication type and log dissociative symptoms (p = .01). Participants taking prescribed buprenorphine had higher mean log dissociation symptom scores (2.7) compared to those taking prescribed methadone (2.2) and prescribed naltrexone (2.1). Log dissociation symptom scores were significantly associated with last use of any opiates (rs = -0.21; p = .02) and time on medication (rs = -0.228; p = .01). Compared to those taking buprenorphine, those taking both methadone (β = -0.26; p = .01) and naltrexone (β = -0.27; p = .006) had significantly lower dissociation scores, controlling for the other variables in the model. Dissociation scores were positively correlated with depression scores (r = 0.45; p < .0001) and with PCL-5 scores (r = 0.51; p < .0001). Our study highlights the importance of diagnosing and monitoring dissociative symptoms in individuals who are taking prescribed medications for opioid use disorder, especially since dissociative symptoms can interfere with substance use treatment., (Copyright © 2020 Elsevier Inc. All rights reserved.)

In light of the disproportionate risk of hospitalization and death attributable to coronavirus disease 2019 (COVID-19) among racial and ethnic minority groups, parental attitudes and concerns regarding school reopening were assessed by race and ethnicity using data from three online CARAVAN omnibus surveys conducted during July 8-12, 2020, by ENGINE Insights.* Survey participants included 858 parents who had children and adolescents in kindergarten through grade 12 (school-aged children) living in their household. Overall, 56.5% of parents strongly or somewhat agreed that school should reopen this fall, with some differences by race/ethnicity: compared with 62.3% of non-Hispanic White (White) parents, 46.0% of non-Hispanic Black or African American (Black) parents (p = 0.007) and 50.2% of Hispanic parents (p = 0.014) agreed that school should reopen this fall. Fewer White parents (62.5%) than Hispanic (79.5%, p = 0.026) and non-Hispanic parents of other racial/ethnic groups (66.9%, p = 0.041) were supportive of a mask mandate for students and staff members. Understanding parental attitudes and concerns is critical to informing communication and messaging around COVID-19 mitigation. Families' concerns also highlight the need for flexible education plans and equitable resource provision so that youth education is not compromised., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Purpose: To compare trends in mental health and substance use disorders and treatment receipt of pregnant and nonpregnant women from 2008 to 2014., Methods: Using data from the 2008-2014 National Survey on Drug Use and Health, logistic regression was used to compare trends in mental health and substance use disorders and treatment receipt for mental health and substance use disorders among propensity score-matched groups of pregnant ( n  = 5520) and nonpregnant women ( n  = 11,040). Among women in the matched sample who met criteria for at least one mental illness, trends in mental health treatment receipt of pregnant ( n  = 1003) and nonpregnant women ( n  = 2634) were compared., Results: There were no differences in the trends by pregnancy status from 2008 to 2014. Past-year anxiety disorder, past-month psychological distress and illicit drug use disorder increased in the total sample from 2008 to 2014, yet trends in mental health treatment and unmet need for substance use treatment did not change over time. Pregnant women had lower odds of mental illness, but those who had mental illness were less likely to receive mental health treatment than their nonpregnant counterparts., Conclusions: There is a need for preventive strategies addressing anxiety disorder, psychological distress and illicit drug use among women of childbearing age as well as initiatives to increase access to mental health treatment among pregnant women.

Background : Differential diagnosis (DDx) is one of the key cognitive skills that medical learners must develop. However, little is known regarding the best methods for teaching DDx skills. As metacognition plays a fundamental role in the diagnostic process, we hypothesized that the teaching of specific heuristics and mnemonics collectively termed metamemory techniques (MMTs) would enhance the capacity of medical students to generate differential diagnoses. Methods : In a 90-min DDx workshop, third-year medical students (N = 114) were asked to generate differentials before and after learning each of four MMTs. Differential sizes were compared using a linear mixed-effect model. Students also completed a post-session questionnaire which included a subjective ranking of the MMTs, as well as Likert-scale and free-text sections for course feedback. Results : One MMT (the Mental CT Scan , an anatomic visualization technique) significantly increased the size of student differentials (+13.3%, p =.0005). However, a marked cumulative increase across all four MMTs was noted (+36.5%, p <.0001). A majority of students ranked the Mental CT Scan the most useful MMT (51.5%). They found the workshop both worthwhile (4.51/5, CI 4.33-4.69) and enjoyable (4.33/5, CI 4.12-4.55), and considered the MMTs they learned useful and practical (4.49/5, CI 4.32-4.67). Conclusion : The MMT-based DDx workshop was effective in enhancing the skill of DDx generation, and was rated very favorably by students.

Introduction: A gradual reduction of cigarette nicotine content to nonaddictive levels has been proposed as an endgame strategy to accelerate declines in combustible tobacco smoking. We assessed manufacturer-reported nicotine yield in cigarettes sold in the United States from 2013 to 2016., Methods: We merged machine-measured nicotine yield in cigarette smoke and pack characteristics obtained from reports filed by tobacco manufacturers with the Federal Trade Commission for 2013-2016 with monthly Nielsen data on US cigarette sales. Manufacturer-reported, sales-weighted, average annual nicotine yield was assessed, as were nicotine yield sales trends by quartile: markedly low (0.10-0.60 mg/stick), low (0.61-0.80 mg/stick), moderate (0.81-0.90 mg/stick), and high (0.91-3.00 mg/stick). Trends in overall, menthol, and nonmenthol pack sales, by nicotine yield quartiles over the study period and by year, were determined by using Joinpoint regression., Results: During 2013-2016, average annual sales-weighted nicotine yield for all cigarettes increased from 0.903 mg/stick (95% CI, 0.882-0.925) in 2013 to 0.938 mg/stick (95% CI, 0.915-0.962) in 2016 (P < .05). For menthol cigarettes, yield increased from 0.943 mg/stick in 2013 (95% CI, 0.909-0.977) to 1.037 mg/stick in 2016 (95% CI, 0.993-1.081), increasing 0.2% each month (P < .05). Most pack sales occurred among high (41.5%) and low (30.7%) nicotine yield quartiles. Cigarette sales for the markedly low quartile decreased by an average of 0.4% each month during 2013-2016 (P < .05)., Conclusion: During 2013-2016, manufacturer-reported, sales-weighted nicotine yield in cigarettes increased, most notably for menthol cigarettes. Continued monitoring of nicotine yield and content in cigarettes can inform tobacco control strategies.

Introduction: Although fibromyalgia is one of the most common and clinically important rheumatologic entities, physicians frequently report that their training fails to prepare them to manage this disease. Many medical schools devote insufficient time and attention to the subject of fibromyalgia, resulting in training gaps that can manifest as failures of both knowledge and empathy. There is a need for evidence-based, time-efficient methods for teaching this important subject. We have developed a narrative-driven video presentation for clerkship students and sought to evaluate its impact on fibromyalgia-related knowledge and attitudes., Methods: Fibromyalgia: A Patient's Perspective (FPP), a 13-minute video, was presented to third-year medical students (N = 54). Surveys of knowledge and attitudes were collected before and after the video. Composite scores, as well as Knowledge and Attitudes subscales, were computed, and paired t tests were used to compare pre/post means for these scales, as well as for individual questions. Mann-Whitney U and Kruskal-Wallis tests were used to identify correlations between survey scores and student sex and specialty of interest., Results: Between pre-experience and post-experience surveys, there were statistically significant differences for 11 of 15 questions (73%). The composite score increased from 3.8 (SD = 0.44) to 4.2 (SD = 0.47) ( P  < .0001). Knowledge and Attitude subscale scores also increased, from 4.0 (SD = 0.5) to 4.38 (SD = 0.5) ( P  < .0001) and 3.6 (SD = 0.5) to 3.93 (SD = 0.5) ( P  < .0001), respectively. Students reported favorable impressions of the video, with 87% agreeing that the video was helpful to learners and 79% disagreeing that a lecture would be preferable to the video. No differences in scores by sex or intended specialty were observed., Conclusion: The FPP video demonstrates promise as a tool for enhancing both knowledge of and positive, empathic attitudes toward fibromyalgia in medical learners. It may serve as a useful resource for educators looking to further develop their clinical pain management curricula., Competing Interests: Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Social support promotes behavior change and self-management that leads to improved health outcomes. The purpose of this study was to evaluate the role of self-management in mediating the relationship between social support dimensions and health outcomes of African Americans with type 2 diabetes (T2D). Cross-sectional data were collected from 102 African Americans with T2D at an outpatient clinic. The majority of the participants were female, single, unemployed, and having low income. Functional support, the quality of the primary intimate relationship, and the number of support persons were negatively correlated with depression. Functional support and satisfaction with support explained a significant small amount of the variance in self-management. However, self-management did not mediate the relationships between social support dimensions and the health outcomes. The results of this study shed the light on the unique relationships of social support dimensions with health outcomes of African Americans with T2D.

Introduction: The Affordable Care Act (ACA) enacted on March 23, 2010 significantly impacted access to healthcare for people living with HIV (PLWH). Expansion of care was accomplished in three areas: eliminating exclusions for pre-existing conditions, elimination of lifetime caps on healthcare expenditures, and expansion of Medicaid eligibility., Purpose: This study evaluated the impact of state implementation of the ACA Medicaid expansion on referral to HIV care at a Ryan White federally funded clinic in Kentucky (University of Kentucky Bluegrass Care Clinic [UK BCC])., Methods: Retrospective chart review of all newly enrolled patients at the UK BCC between March 2010 and June 2017. Data included patient demographics and referral source, and were divided into two groups to compare enrollments before and after Kentucky implemented the ACA Medicaid expansion. Data were collected from 2018-2019 and analyzed in 2020., Results: Following Medicaid expansion there were statistically significant changes in the patterns of referral to federally funded HIV care. These included a significant decrease in the proportion of referrals from state and local health departments, and an increase in both proportion of referrals from outpatient clinics and transfers from different HIV care providers., Implications: These results have implications for engaging more PLWH into HIV care, particularly in states where patients have increased access to screening and assessment of risk at primary care encounters through implementation of the ACA Medicaid expansion., (Copyright © 2020 Cameron A. Wade, Timothy N. Crawford, Nicole Leedy, and Alice C. Thornton.)

Background: Emerging research indicates that Head Start employees often struggle with health issues and may not be able to model the healthy behaviors that they hope to instill in young children. The purpose of this study was to examine the relationships between perceived physical health and chronic disease, stress, financial-resource strain, and job type. Method : This study was conducted in a large, multi-site Head Start agency located across five counties in the American Midwest. Employees ( N = 550) were invited to complete a 58-item questionnaire that assessed overall health and health behaviors, demographics, workplace environment, and interest in well-being programs. Bivariate analysis and multinomial logistic regressions were used to analyze the relationships between variables of interest and physical health. Findings : More than half ( n = 295; 53.64%) responded, and one quarter of the employees (25.42%) reported poor or fair health. Poor and fair physical health was associated with the number of chronic conditions, difficulty paying for basic necessities, and perceived stress, but not job type. A high percentage of responding employees (83.34%) reported interest in well-being programs, yet interests varied significantly by health status. Employees with poor and fair health expressed interest in stress and emotional-coping programs, in contrast to the fitness interests of employees who reported good, very good, or excellent health. Conclusion/Application to Practice : To meet the needs of employees with poor or fair physical health, employers should offer health behavior modification programs that address the sources of employee stress, including financial-resource strain and mental health challenges.

Introduction: Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia confers considerable morbidity and mortality. Although vancomycin or daptomycin monotherapy is usually curative, prolonged bacteremia necessitating supplemental ceftaroline has occurred. The practice has led to the question of whether to continue with ceftaroline following bacteremia resolution., Methods: Adult patients hospitalized with MRSA bacteremia at the University of Kentucky Medical Center between January 2015 and December 2017 were retrospectively reviewed. Study subjects required supplemental ceftaroline due to 4 or more days of bacteremia despite vancomycin or daptomycin. They additionally had accompanying native valve infective endocarditis, osteomyelitis, or brain abscess. Patients were divided into two cohorts. One group continued with ceftaroline plus vancomycin or daptomycin following bacteremia resolution (combination therapy group). The other group received vancomycin or daptomycin alone (monotherapy group). All involved received 6-8 weeks of therapy. Patients' Pitt bacteremia score (PBS) and Charlson comorbidity index (CCI) values were calculated. Treatment outcomes of inpatient mortality, recurrence of bacteremia, 30-day readmission, acute kidney injury, and leukopenia were recorded and compared., Results: A total of 30 patients comprised the study population. 15 patients were assigned to each cohort. The median PBS value of the combination therapy group was 2, compared with 1 among the monotherapy group. The median CCI score of both groups was 0. No statistically significant difference in the aforementioned treatment outcomes was seen between the two groups., Conclusion: In subjects with complicated and prolonged MRSA bacteremia requiring supplemental ceftaroline, clinical outcomes did not differ among patients prescribed vancomycin or daptomycin alone following bacteremia resolution versus patients who continued combination therapy.

Background: Under Ohio Medical Marijuana Control Program rules, Ohio physicians that recommend medical marijuana (MMJ) to patients must possess a Certificate to Recommend (CTR) from the State Medical Board. Although a pre-program state survey indicated that more than a quarter of Ohio physicians were likely to recommend MMJ, only 473 physicians obtained CTRs in the first year of the program, amounting to just 1.39% of the physician workforce. The purpose of this study is to evaluate demographic factors that influence a physician's decision to obtain the CTR., Method: Using physician demographic data extracted from Ohio's databases of medical licensees and CTR holders, as well as the American Medical Association Physician Masterfile, prevalence ratios for CTR holders were calculated for specialty, medical degree (Doctor of Medicine, MD, vs. Doctor of Osteopathy, DO), age and gender. A multivariate model was implemented to generate adjusted prevalence ratios (aPRs) reflecting the independent effects of specialty, degree, and age. To assess temporal variations in CTR acquisition, per-specialty CTR counts were also plotted as a function of program month., Results: The best-represented specialties among CTR holders were Family Medicine (29.11%), Internal Medicine and its subspecialties (22.57%), and Anesthesiology (9.07%). Expressed as an adjusted per-specialty prevalence ratio in reference to Family Medicine, the dominant specialty was Physical Medicine and Rehabilitation (aPR 2.08, 95% CI 1.34-3.24), with the lowest measurable prevalence ratios found in Pediatrics (aPR 0.17, 95% CI 0.10-0.30) and Surgery (aPR 0.33, 95% CI 0.22-0.50). DOs were more likely to obtain CTRs than MDs (aPR 1.72, 95% CI 1.39-2.15). The mean age of CTR holders was 54.03 +/- 11.43, vs. 51.13 +/- 13.38 for non-CTR holders (p < .0001). Although gender could not be included in the multivariate model, males were more likely than females to obtain a CTR (PR 1.54, 95%CI 1.26-1.89). A plot of per-month CTR acquisition by specialty demonstrated a fairly consistent specialty distribution of CTRs in the first year, as well as variations in overall CTR acquisition that may correspond to program-operational events., Conclusion: Specialty, type of medical degree, and age all correlate independently with the likelihood of registering to recommend medical marijuana in Ohio. Specialty distribution of CTRs remained fairly consistent in the program's first year, although overall CTR acquisition may be sensitive to program-operational events such as delays in dispensary opening or product availability.

Limited information is available about factors that affect care engagement among African American older people living with HIV (OPLWH), despite the fact that this is the racial/ethnic group most disproportionally living with HIV/AIDS in the United States. The present mixed methods study examined the experiences of stress, HIV-related stigma, and engagement in care in a sample of 35 African American OPLWH. Quantitative methods measured global stress, HIV-stigma, and engagement in care, while in-depth qualitative interviews captured the lived experiences of HIV care engagement. Engagement in care was moderately correlated with overall stigma (r = -0.33, p = .05) and perceived stress (r = -0.42, p = .01). Qualitative interviews revealed that stigma was not the most significant stressor in the elders' lives, but instead a present and underlying force that was overshadowed by everyday life stressors that affected care engagement. Recommendations include that a retention specialist work alongside health care providers to increase engagement.

Objective: Describe the characteristics and pharmacological management of hypertensive patients in a Nicaraguan ambulatory care clinic., Methods: The study analyzed a random sample of 349 charts of patients aged older than 18 years from an ambulatory care clinic in Nicaragua and analyzed those who were diagnosed or had a known history of hypertension., Results: Out of 349 patients, 19.77% (n=69) had a history of hypertension. Hypertensive patients were 66.2% female (n=45) with mean age of 56.1 years (SD=13.7). The most common comorbid condition was type 2 diabetes mellitus, which was present in 18.8% (n=13) of hypertensive patients. Other comorbid conditions included 10% (n=7) with chronic kidney disease and 75.8% (n=50) who were either overweight or obese. The most commonly prescribed antihypertensive medications were losartan, captopril, and enalapril., Conclusions: Hypertension is common in this clinic population and most commonly treated with angiotension-receptor blockers or angiotensin converting enzyme inhibitors.

Background : U.S. is experiencing a surging trend of methamphetamine use among individuals who use opioids. More research is needed to characterize this emerging "twin epidemic." Objectives: The study aims to identify social and behavioral characteristics associated with methamphetamine use among individuals with opioid use disorder (OUD) in the Dayton, Ohio, area, an epicenter of the opioid crisis and an emerging frontier of methamphetamine epidemic. Methods: 357 adult individuals with current OUD were recruited using targeted and respondent-driven sampling. Structured interviews collected information on social and drug use characteristics. Multivariable Logistic Regression was used to identify characteristics associated with the past 6-month use of methamphetamine. Results: 49.7% were female, and 88.8% were non-Hispanic whites. 55.6% used methamphetamine in the past 6-months, and 84.9% reported first use of methamphetamine after initiation of illicit opioids. Methamphetamine use was associated with homelessness (aOR = 2.46, p  = .0001), lifetime history of diverted pharmaceutical stimulant use (aOR = 2.97, p  < .001), injection route of heroin/fentanyl use (aOR = 1.89, p  = .03), preference for fentanyl over heroin (aOR = 1.82, p  = .048), lifetime history of extended-release injectable naltrexone (Vivitrol)-based treatment (aOR = 2.89, p  = .003), and more frequent marijuana use (aOR = 1.26, p  = .04). Discussion: The findings point to the complexity of motivational and behavioral pathways associated with methamphetamine and opioid co-use, ranging from self-treatment and substitution behaviors, attempts to endure homelessness, and greater risk taking to experience euphoria. More research is needed to understand the causal relationships and the association between methamphetamine and Vivitrol use. Public health responses to the opioid crisis need to be urgently expanded to address the growing epidemic of methamphetamine use.

The purpose of this study was to identify characteristics of investigations of sexual abuse concerning vulnerable adults residing in facility settings that were associated with case substantiation. Data on 410 reports of sexual abuse were collected prospectively from Adult Protective Services (APS) and state licensure agency staff in New Hampshire, Oregon, Tennessee, Texas, and Wisconsin over a six-month period. Specifically, we examined differences between reports that were substantiated and those that were not by comparing characteristics of alleged victims, alleged perpetrators, and aspects of investigation using logistic regression. We found that a relatively low proportion of cases (18%) were substantiated overall. Compared to cases that were not substantiated, cases that were substantiated were more likely to feature nursing home residents, older victims, female victims, and allegations of physical contact between the alleged perpetrator and victim. Despite the high proportion of alleged perpetrators who were facility staff (51%) compared to resident perpetrators (25%), cases with resident-to-resident allegations of abuse were much more likely to be substantiated, accounting for 63% of substantiated cases. In light of these findings, we believe it is important that investigators are trained to handle sexual abuse cases appropriately and that they are able to investigate the case thoroughly, promptly, and with as much information as possible. It is also critical that investigators make substantiation decisions using the appropriate standard for confirmation (e.g., preponderance of the evidence, beyond a reasonable doubt, clear and convincing evidence) as state law dictates.

This study sought to examine if age moderated the effect of alcohol on viral suppression among women living with HIV. A secondary data analysis, using data from the 550 Clinic Women's HIV Cohort Study was completed. Individuals were included if they were HIV positive, sought care in an urban clinic in Kentucky between 2009 and 2012, and had ≥1 year of follow-up. The primary independent variable was current alcohol use; the moderating variable was age (<50 years versus ≥50 years); and the outcome was suppression. Logistic regression models examined the interaction between age and alcohol. Among 360 women (average age 45.8 ± 10.1 years, 38 percent were ≥50 years), approximately 32.0 percent had consumed alcohol, and 40 percent achieved suppression. Women aged ≥ 50 years were more likely to achieve suppression than younger women. Age interacted significantly with alcohol ( p = .038). Stratified by age, alcohol was associated with poor viral suppression among older women; for older women, alcohol users had lower odds of suppression compared to nonusers (odds ratio = 0.37; 95 percent confidence interval = 0.14-0.99). Alcohol may impede the opportunity for older women to achieve suppression. Further study is needed to examine alcohol use among older women, specifically addressing quantity and frequency and their impact on suppression.

Objective: To examine racial/ethnic differences in the receipt of mental health treatment among pregnant women with mental health (i.e., depression and serious psychological distress) and/or substance use disorders., Method: Secondary analysis of data from the National Survey on Drug Use and Health was conducted. The sample consisted of 1232 pregnant women with mental health/substance use disorders., Results: Black/African American (Adjusted Odds Ratio [AOR]: 0.36, 95% Confidence Interval [CI]: 0.17-0.75), other non-Hispanic (AOR: 0.24, 95% CI: 0.11-0.52), and Hispanic (AOR: 0.42, 95% CI: 0.22-0.81) pregnant women had significantly lower odds of mental health treatment receipt compared to Whites, even when controlling for age, education, marital status, number of children, employment status, income, health insurance, county urbanicity, self-rated health status, type of mental health condition, and time. There were no racial/ethnic differences by mental health and/or substance use disorders. Among pregnant women who perceived unmet mental health treatment need (N = 299), a greater proportion of White compared to Non-White pregnant women perceived cost as an obstacle to access treatment (62.1% vs. 35.6%, p = .001); however, the two groups did not differ in other perceived barriers to mental health treatment (i.e., opposition to treatment, stigma, time/transportation limitation, and not knowing where to go)., Conclusions: Strategies are needed to increase access to mental health treatment among racial/ethnic minority women who are pregnant and have mental health/substance use disorders. Further studies are required to understand racial/ethnic differences in the perceived barriers to mental health treatment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Alcohol is prevalent among people living with HIV and can lead to multiple comorbid conditions (multimorbidity). The purpose of this study was to examine the relationship between alcohol use history and multimorbidity among people living with HIV. A retrospective cohort study design was conducted at an urban, academic infectious disease clinic in Kentucky. Individuals seeking care between 2010 and 2014 were included. Modified Poisson regression was used to examine the relationship between alcohol use history (never, current, and former use) and multimorbidity (≥ 2 conditions). A total of 949 individuals were included in the study, with 5.1 and 17.6% reporting former and current alcohol use, respectively. Sixty-five percent had ≥ 1 condition and 82.6% of those had ≥ 2 conditions diagnosed. The risk of multimorbidity was 1.70 (95% CI 1.35-2.14) times higher for a current user compared to a never user. Reductions in alcohol use may lead to lower rates of multimorbidity.

Purpose: The purpose of this study was to explore an association between e-cigarette use and Quality of Life (QOL) among college students., Methods: During February 2016, 1,132 students completed an online survey that included measures of tobacco use and the WHOQOL-BREF instrument. Differences were tested using Chi-square, Fisher's exact test, and ANOVA, and regression was used to assess possible relationships., Results: E-cigarettes were used by 6.97% of the participants, either solo or along with traditional cigarettes. Bivariate analyses suggest that male college students are more likely than females to use e-cigarettes, either solo or in combination with traditional cigarettes (χ 2 =19.4, P < .01). Lesbian, gay, and bisexual students are more likely than heterosexual students to use traditional cigarettes, either solo or in combination with e-cigarettes (χ 2 = 32.9, P < .01). Multivariate models suggest that for every 10-unit increase in overall QOL, psychological well-being, social relations or environmental health the adjusted odds of being a sole cigarette user were significantly lower (all, P < .01), respectively. For every 10-unit increase in psychological well-being the adjusted odds of being a dual user was significantly lower (OR = .83, P = .026)., Conclusions: Findings indicate that lower quality of life appears to be connected to tobacco use., Competing Interests: Conflict of Interest: All authors declare that they have no conflicts of interest.

The purpose of our study was to determine the extent to which individual characteristic variables predict trust of healthcare provider (HCP), lifestyle behaviors, and use of health services among adolescents attending public high school in rural Indiana. The sample included 224 individuals surveyed in 9th grade or 12th grade required courses. Trust of HCP and lifestyle behaviors were predicted using hierarchical multiple regression; number of HCP visits and emergency department (ED) visits in the past 12 months were predicted using negative binomial regression. This sample of adolescents living in a rural area reported riskier lifestyle behaviors than another sample of adolescents, lower trust of HCP than adults in general, and fewer HCP and ED visits than adolescents in general. Our study supports the need for school-based health services in rural areas and the opportunity for school nurses to act as care coordinators for marginalized youth.

Background: Limited studies are done regarding ability to produce gastric acid in preterm infants and most studies used in vivo method of assessing gastric pH. Objectives: To assess the feasibility of using an in vitro method of measuring gastric pH in babies ≤ 28 weeks gestational age (GA) and determine whether changes in gastric pH differ with gestational age, mode of delivery, and use of antenatal steroids. Design/Methods: Prospective study that enrolled extremely low birth weight (ELBW) babies. Gastric aspirate collected before feeding. In vitro testing of gastric aspirates for pH were done on days of life 1, 3, 5, 7, 14, and 28 by using pH electrode. The pH was measured on each sample in triplicate, mean calculated and used for data analysis. Stastical methods included descriptive statistics, t -tests and repeated measures ANOVA. Results: 29 subjects ≤ 28 weeks or birth weight ≤ 1,000 g were enrolled. No significant change was noted in pH measurements over time. Antenatal steroids and mode of delivery did not affect gastric acid pH. Conclusion: The in vitro method for gastric pH measurements is non-invasive and affords more frequent testing. It would be useful in studying various conditions that may affect gastric pH.

Background: In response to the growing body of evidence supporting the need for expanded interprofessional education among health professions, an interprofessional education program, based on the Interprofessional Education Collaborative Core Competencies, was piloted with nurse practitioner and dental students., Objectives: The purpose of this pilot study was to evaluate a technology enhanced interprofessional education program focused on the oral-systemic health connection for nurse practitioner and dental students., Design: A two-group comparative study using cross-sectional data and a quasi-experimental one-group pre-test/post-test design were used to evaluate students' knowledge of IPE core competencies, attitudes toward interprofessional education and interdisciplinary teamwork, and self-efficacy in functioning as a member of an interdisciplinary team., Setting and Participants: This program was implemented with master of science in nursing students pursuing a primary care nurse practitioner (NP) degree and dental students at a large urban academic health sciences center. Cohort 1 (N = 75) consisted of NP (n = 34) and dental students (n = 41) at the end of their degree program who participated in a one-time survey. Cohort 2 (N = 116) was comprised of second-year NP students (n = 22) and first-year dental students (n = 94) who participated in the IPE program., Methods: Students participated in a multi-faceted educational program consisting of technology- enhanced delivery as well as interactive exercises in the joint health assessment course. Data were collected prior to the initiation and at the conclusion of the program., Results: Nurse practitioner and dental students who participated in the program had better self-efficacy in functioning as a member of an interdisciplinary team than graduating students who did not participate. Students from both nursing and dentistry who participated in the program had significantly improved self-efficacy in functioning in interprofessional teams from pre- to post-test., Conclusion: An interprofessional education program can be a valuable addition to the health professions curriculum of nurse practitioner and dental students. Care must be taken to address logistical issues when working with students in different academic programs., (Copyright © 2018. Published by Elsevier Ltd.)