Video telehealth emotional awareness and expression therapy for older U.S. military veterans with chronic pain: A pilot study.

OBJECTIVES: Emotional Awareness and Expression Therapy (EAET) targets trauma and emotional conflict to reduce or eliminate chronic pain, but video telehealth administration is untested. This uncontrolled pilot assessed acceptability, feasibility, and preliminary efficacy of group-based video telehealth EAET (vEAET) for older veterans with chronic musculoskeletal pain. METHODS: Twenty veterans were screened, and 16 initiated vEAET, delivered as one 60-minute individual session and eight 90-minute group sessions. Veterans completed posttreatment satisfaction ratings and pain severity (primary outcome), pain interference, anxiety, depression, functioning, social connectedness, shame, and anger questionnaires at baseline, posttreatment, and 2-month follow-up. RESULTS: Satisfaction was high, and veterans attended 7.4 (SD = 0.6) of 8 group sessions; none discontinued treatment. Veterans attained significant, large reductions in pain severity from baseline to posttreatment (p < .001, Hedges' g = -1.54) and follow-up (p < .001, g = -1.20); 14 of 16 achieved clinically significant (≥ 30%) pain reduction, and 3 achieved 90-100% pain reduction. Secondary outcomes demonstrated significant, medium-to-large improvements. CONCLUSIONS: In this small sample, vEAET produced better attendance, similar benefits, and fewer dropouts than in-person EAET in prior studies. Larger, controlled trials are needed. CLINICAL IMPLICATIONS: Group vEAET appears feasible and highly effective for older veterans with chronic pain.

Virtual Human-Delivered Interviews for Patients With Chronic Pain: Feasibility, Acceptability, and a Pilot Randomized Trial of Standard Medical, Psychosocial, and Educational Interviews.

OBJECTIVE: Seminal advances in virtual human (VH) technology have introduced highly interactive, computer-animated VH interviewers. Their utility for aiding in chronic pain care is unknown. We developed three interactive telehealth VH interviews-a standard pain-focused, a psychosocial risk factor, and a pain psychology and neuroscience educational interview. We then conducted a preliminary investigation of their feasibility, acceptability, and efficacy. We also experimentally compared a human and a computer-generated VH voice. METHODS: Patients ( N = 94, age = 22-78 years) with chronic musculoskeletal pain were randomly assigned to the standard ( n = 31), psychosocial ( n = 34), or educational ( n = 29) VH interview and one of the two VH voices. Acceptability ratings included patient satisfaction and expectations/evaluations of the VH interview. Outcomes assessed at baseline and about 1-month postinterview were pain intensity, interference, emotional distress, pain catastrophizing, and readiness for pain self-management. Linear mixed-effects models were used to test between- and within-condition effects. RESULTS: Acceptability ratings showed that satisfaction with the VH and telehealth format was generally high, with no condition differences. Study attrition was low ( n = 5). Intent-to-treat-analyses showed that, compared with the standard interview, the psychosocial interview yielded a significantly greater reduction in pain interference ( p = .049, d = 0.43) and a marginally greater reduction in pain intensity ( p = .054, d = 0.36), whereas the educational interview led to a marginally greater yet nonsignificant increase in readiness for change ( p = .095, d = 0.24), as well as several significant improvements within-condition. Results did not differ by VH voice. CONCLUSIONS: Interactive VH interviewers hold promise for improving chronic pain care, including probing for psychosocial risk factors and providing pain-related education.

Feasibility and Efficacy of a Brief Mindfulness-Based Smoking Intervention Delivered via the Internet: A Randomized Controlled Trial.

Background: A growing body of literature suggests that mindfulness-based interventions are effective in reducing smoking. However, existing mindfulness interventions are often lengthy and require extensive interaction with a therapist, making them inaccessible to a large percentage of the population. The current study addressed this issue by testing the feasibility and efficacy of a single session, web-based, mindfulness intervention for smoking cessation. Methods: Participants (N = 80) took part in a fully online cue exposure exercise interspersed with brief instructions on how to cope with cravings for cigarettes. All participants were randomly assigned to receive either mindfulness-based or coping as usual instructions. Outcomes included participant satisfaction with the intervention, self-reported craving following the cue exposure exercise, and cigarette use 30 days post-intervention. Results: Participants in both groups found the instructions moderately helpful and easy to understand. Participants in the mindfulness group reported a significantly smaller increase in craving than those in the control group following the cue exposure exercise. Averaging across conditions, participants reported smoking fewer cigarettes in the 30 days following the intervention than in the 30 days prior, however there were no between group differences in cigarette use. Conclusion: Mindfulness-based interventions for smoking reduction can be effectively implemented in a brief, single-session online format. These interventions are easy to disseminate and can reach a large number of smokers with minimal participant burden. Results from the current study suggest that mindfulness-based interventions can help participants control craving in the face of smoking-related cues, although perhaps not change smoking quantity. Future research is needed to explore factors which may increase the efficacy of online, mindfulness-based interventions for smoking cessation, while still maintaining their accessibility and reach.

Emotional Awareness and Expression Interview: Examining Interview Content and Patient Experiences in Two Medical Samples.

A single session of Emotional Awareness and Expression Therapy (EAET)-the EAET Interview-was previously shown to lead to clinical benefits for patients with centralized somatic conditions in primary care (Ziadni et al. in Health Psychol 37(3):282-290, 2018) and tertiary care (Carty et al. in Pain Med 20(7):1321-1329, 2019) settings. There has yet to be an examination of patients' experiences of and reactions to the EAET Interview, which is crucial in evaluating possible clinical implementation of the interview. We conducted secondary analyses on 88 patients (M age = 41.32, 90.9% women) from the two prior trials (primary care N = 51; tertiary care N = 37). Analyses examined interview processes (stress disclosure themes, working alliance, and emotional processing) and patients' reactions to the interview (interview credibility and perceived value of the interview), comparing the two samples and examining correlations among these variables. All patients disclosed at least one stressful life experience, commonly interpersonal problems (89.2%) and childhood adversity (51.5%). Patients had moderately high levels of working alliance and emotional processing during the interview and reported high interview credibility and perceived value of the interview. More extensive emotional processing of stressors was associated with more positive patient reactions to the interview, including higher interview credibility (r = .23) and perceived value (r = .32). We conclude that the single-session EAET Interview was valued by most patients, and patients' emotional processing is particularly beneficial. Addressing the trauma and emotional conflicts of patients with centralized somatic conditions is both feasible and valuable in front-line medical settings.

Current and Cumulative Stress Experiences: A Model for Arab American Young Adults.

BACKGROUND: The effect of multiple stressors on immigrant young adults' endocrine functioning and health outcomes has not been comprehensively investigated. AIMS: This study tested a theoretical model of cumulative and current stressor effects on the hypothalamic-pituitary-adrenocortical (HPA) axis functioning and health-related quality of life (HRQL) among Arab American young adults. METHODS: Using a cross-sectional design, we recruited 160 participants, ages 18 to 24 years, from an urban university in the Midwest. Cumulative stress was assessed by self-report measures of childhood adversity, bullying victimization, and perceived ethnic discrimination. Current perceived stress was measured using the Perceived Stress Scale (PSS) while cortisol levels were measured in participants' hair. Structural equation modeling tested the effects of cumulative and current stress on cortisol and HRQL. RESULTS: Cumulative stress was negatively associated with HRQL (standardized path coefficient = -.51, p < .05). Interestingly, however, cumulative stress was inversely associated with hair cortisol level (standardized path coefficient = -.51, p < .05). Current stress was positively associated with cortisol level (standardized path coefficient = .43, p < .05) and negatively associated with the mental HRQL (standardized path coefficient < -.37, p < .05). CONCLUSION: Cumulative stress exhibited a different effect on HPA functioning from current perceived stress. Mental health was significantly impaired by both cumulative and current perceived stress. Implications for mental health nursing practice and research among Arab Americans are discussed.

Effects of a Sexual Health Interview among Arab American Women: An Experimental Disclosure Study.

Although sexuality is an important aspect of peoples' health and well-being, many people-professionals and patients alike-find sexuality uncomfortable to discuss. In Arab culture, certain sexual thoughts and behaviors are taboo, particularly for women, and it is not known whether an interview in which Arab American women disclose their sexuality to a health professional would be well-received and beneficial or upsetting and harmful. This experimental study tested whether engaging in a disclosure-oriented sexual health interview affects Arab American women's sexual and psychological health. A sample of 134 Arab American women, ages 18-35 years (M = 20.6), completed self-report measures of sexual health and attitudes and psychological symptoms, and then were randomized to an interview or control (waitlist) condition. The 60-min disclosure interview inquired about sexual attitudes, experiences, and conflicts. Five weeks later, all participants completed follow-up measures. Post-interview reports suggest that participants responded favorably to the interview and generally benefited from participation. Analyses of covariance (controlling for baseline levels of the outcome measure) indicated that the interview led to significantly greater sexual satisfaction and less discomfort with sexual self-disclosure at 5-week follow-up, compared to controls; the two conditions did not differ on follow-up sexual self-schema, sexual self-esteem, or psychological symptoms. Moderation analyses revealed that participation in the interview differentially improved the sexual self-schema of women with no past sexual experience, compared to women with sexual experience. These experimental findings suggest the value, rather than the risk, of clinicians encouraging Arab American women to openly disclose and discuss their sexual experiences and attitudes in a confidential, empathic setting.

The Development of Posttraumatic Stress Disorder and Depression Symptoms in Iraqi Refugees: Associations with Acculturation and C-reactive Protein.

ABSTRACT: Refugees experience distress from premigration trauma, often exacerbated by postmigration difficulties. To develop effective interventions, risk factors for mental health symptoms need to be determined. Male Iraqi refugees (N = 53) to the United States provided background information and reported predisplacement trauma and psychological health within 1 month of their arrival. An inflammatory biomarker-C-reactive protein (CRP) was assessed approximately 1.5 years after arrival, and a contextual factor-acculturation-and psychological health were assessed 2 years after arrival. We tested whether acculturation and CRP were associated with posttraumatic stress disorder (PTSD) and depression symptoms at the 2-year follow-up, controlling for baseline symptoms, age, body mass index, and predisplacement trauma. Acculturation was inversely related to depression, and CRP was positively related to both PTSD and depression at the 2-year follow-up. Interventions targeting acculturation could help reduce the development of depression symptoms in refugees. The role of CRP in the development of PTSD and depression symptoms warrants further research.

Clinical psychology PhD students' admission experiences: Implications for recruiting racial/ethnic minority and LGBTQ students.

AIM: The purpose of this study was to explore differences in the clinical psychology PhD program admissions experience (i.e., interviewing and decision-making) by race/ethnicity and lesbian, gay, bisexual, transgender, and queer (LGBTQ) identity. METHODS: Participants were 803 students (24% racial/ethnic minority; 19% LGBTQ) enrolled in US clinical psychology PhD programs. Two-group comparisons tested for differences in admission experiences by race/ethnicity and LGBTQ identity. RESULTS: Racial/ethnic minority and LGBTQ students considered a programmatic commitment to diversity as more important in application decisions compared to non-Hispanic White and cisgender heterosexual students, respectively. LGBTQ students were more likely to be advised to not discuss personal information (e.g., sexual orientation) than cisgender heterosexual students. Racial/ethnic minority and LGBTQ students identified financial considerations and program outcomes as more important in their decision-making compared with non-Hispanic White and cisgender heterosexual students, respectively. CONCLUSION: Increasing funding and fostering authentic training environments should be prioritized in institutional conversations around recruiting racial/ethnic minority and LGBTQ trainees.

Development of a Multicomponent Intervention to Initiate Health Behavior Change in Primary Care: The Kickstart Health Program.

There is a growing movement to integrate behavioral health specialists into primary care settings in order to better manage patients' health behaviors. Group interventions in healthcare settings can provide services to multiple individuals simultaneously; however, the participants' experiences taking part in these activities and the logistics of integrating them into clinical settings are largely under-studied. This article describes the development and implementation of a novel group intervention for health behavior change, The Kickstart Health Program, which integrates components of cognitive, behavioral, acceptance, and experiential therapies. Participant feasibility, acceptability, experiences, and treatment course were assessed. Acceptability among a small sample of attendees was high, and initial data on behavior change suggest there were benefits to patients who attended the program. Increases in mindfulness practice and decreases in exercise barriers from baseline to 10-week follow-up were detected as were improvements in overall perceived health and well-being. Participants expressed that the program was acceptable and successful at helping them reach their individual health goals; however, enrollment barriers negatively impacted the feasibility of the program in regard to attendance. Modification to the enrollment process such as embedding referrals into the electronic medical record, encouraging spouse or family co-enrollment, and peer coaching may address these barriers. The Kickstart Health Program has the potential to improve health behaviors and paves the way for unique studies of dissemination and implementation of efficacious behavioral health interventions into real-world healthcare settings.

Short-Term Psychodynamic Psychotherapy for Functional Somatic Disorders: A Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Functionalsomatic disorders (FSD) are common and costly, thereby driving the need for the development of effective brief treatment options. Short-term psychodynamic psychotherapy (STPP) is one candidate treatment method. OBJECTIVE: To review and meta-analyze, where possible, randomized controlled trials (RCTs) of STPP for FSD. METHODS: Following a systematic search of the literature, we performed a meta-analysis of available RCT groups to determine the effects of STPP on a range of outcomes after treatment, and medium- and long-term follow-ups. RESULTS: In meta-analyses of 17 RCTs, STPP significantly outperformed minimal treatment, treatment as usual, or waiting list controls on somatic symptom measures at all time frames, with small to large magnitude effect sizes. Descriptive reviews of 5 RCTs suggest that STPP performed at least as well as other bona fide psychological therapies. Limitations of this meta-analysis include small samples of studies and possible publication bias. CONCLUSIONS: STPP is a valid treatment option for diverse FSD conditions resulting in somatic symptom reductions that persist over time. STPP should be included in FSD treatment guidelines.

Emotional Awareness and Expression Therapy Achieves Greater Pain Reduction than Cognitive Behavioral Therapy in Older Adults with Chronic Musculoskeletal Pain: A Preliminary Randomized Comparison Trial.

OBJECTIVE: Emotional awareness and expression therapy (EAET) emphasizes the importance of the central nervous system and emotional processing in the etiology and treatment of chronic pain. Prior trials suggest EAET can substantially reduce pain; however, only one has compared EAET with an established alternative, demonstrating some small advantages over cognitive behavioral therapy (CBT) for fibromyalgia. The current trial compared EAET with CBT in older, predominately male, ethnically diverse veterans with chronic musculoskeletal pain. DESIGN: Randomized comparison trial. SETTING: Outpatient clinics at the West Los Angeles VA Medical Center. SUBJECTS: Fifty-three veterans (mean age = 73.5 years, 92.4% male) with chronic musculoskeletal pain. METHODS: Patients were randomized to EAET or CBT, each delivered as one 90-minute individual session and eight 90-minute group sessions. Pain severity (primary outcome), pain interference, anxiety, and other secondary outcomes were assessed at baseline, post-treatment, and three-month follow-up. RESULTS: EAET produced significantly lower pain severity than CBT at post-treatment and follow-up; differences were large (partial η2 = 0.129 and 0.157, respectively). At post-treatment, 41.7% of EAET patients had >30% pain reduction, one-third had >50%, and 12.5% had >70%. Only one CBT patient achieved at least 30% pain reduction. Secondary outcomes demonstrated small to medium effect size advantages of EAET over CBT, although only post-treatment anxiety reached statistical significance. CONCLUSIONS: This trial, although preliminary, supports prior research suggesting that EAET may be a treatment of choice for many patients with chronic musculoskeletal pain. Psychotherapy may achieve substantial pain reduction if pain neuroscience principles are emphasized and avoided emotions are processed.

Psychological Therapy for Centralized Pain: An Integrative Assessment and Treatment Model.

OBJECTIVE: Chronic pain is a significant health problem that is increasing in prevalence, and advances in treatment are needed. METHODS: We briefly review the leading evidence-based psychological therapies for chronic pain-cognitive-behavioral and acceptance/mindfulness-based therapies-and examine several limitations and missing perspectives of these approaches. We review six lesser-known interventions that address these limitations, and we describe our integrative model for psychological assessment and treatment of centralized pain. We present a typical patient and describe how we apply this approach, along with challenges to its implementation and possible solutions to these challenges. RESULTS: Greater pain treatment efficacy may be possible if clinicians: (a) distinguish patients with primarily centralized (i.e., somatoform or nociplastic) pain from those with primarily peripheral (nociceptive, inflammatory, or neuropathic) pain; (b) acknowledge the capacity of the brain not only to modulate pain but also generate as well as attenuate or eliminate centralized pain; (c) consider the powerful role that adverse life experiences and psychological conflicts play in centralized pain; and (d) integrate emotional processing and interpersonal changes into treatment. Our integrative treatment involves delivering a progression of interventions, as needed, to achieve pain reduction: tailored pain neuroscience education, cognitive and mindfulness skills to decrease the pain danger alarm mechanism, behavioral engagement in avoided painful and other feared activities, emotional awareness and expression to reverse emotional avoidance and overcome trauma or psychological conflict, and adaptive communication to decrease interpersonal stress. CONCLUSIONS: This integrative assessment and treatment model has the potential to substantially reduce and sometimes eliminate centralized pain by changing the cognitive, behavioral, emotional, and interpersonal processes that trigger and maintain centralized pain.

Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review.

PURPOSE OF REVIEW: Patients with chronic pain, especially primary or centralized pain, have elevated rates of psychosocial trauma and intrapersonal or intrapsychic conflict. To address these risk factors and potentially reduce pain, the authors developed emotional awareness and expression therapy (EAET). This article presents the rationale for EAET, describes its principles and techniques, reviews its development and early testing as well as recent clinical trials, and critically analyzes the evidence base. RECENT FINDINGS: Four initial trials (between 2006 and 2011) demonstrated the efficacy of earlier versions of EAET. Four recent randomized, controlled trials of different EAET durations (1 to 8 sessions) and formats (individual or group) in patients with fibromyalgia, irritable bowel syndrome, pelvic pain, or medically unexplained symptoms support the earlier findings. EAET reliably reduces pain and interference, although improvements in anxiety and depression are less reliably achieved and may be delayed. The largest and best conducted trial found superiority of EAET over cognitive-behavioral therapy for fibromyalgia. Patient retention in EAET is high, and adverse events are rare. EAET merits inclusion as a treatment option for primary pain conditions, and it may be the preferred treatment for some patients. Research is needed on EAET with other pain conditions and samples, using better controls and comparison conditions, and on additional ways to motivate and help patients engage in successful emotional processing.

The Effects of a Life Stress Emotional Awareness and Expression Interview for Women with Chronic Urogenital Pain: A Randomized Controlled Trial.

OBJECTIVE: Women with chronic urogenital pain (CUP) conditions have elevated rates of lifetime trauma, relational stress, and emotional conflicts, but directly assessing and treating psychological stress is rarely done in women's health care settings. We developed and tested the effects on patients' somatic and psychological symptoms of a life stress interview that encourages disclosure about stressors and uses experiential techniques to increase awareness of links between stress, emotions, and symptoms. METHODS: In this randomized trial, women with CUP recruited at a multidisciplinary women's urology center received either a single 90-minute life stress interview (N = 37) or no interview (treatment-as-usual control; N = 25). Self-report measures of pain severity (primary outcome), pain interference, pelvic floor symptoms, and psychological symptoms (anxiety and depression) were completed at baseline and six-week follow-up. RESULTS: Differences between the life stress interview and control conditions at follow-up were tested with analyses of covariance, controlling for baseline level of the outcome and baseline depression. Compared with the control condition, the interview resulted in significantly lower pain severity and pelvic floor symptoms, but the interview had no effect on pain interference or psychological symptoms. CONCLUSIONS: An intensive life stress emotional awareness expression interview improved physical but not psychological symptoms among women with CUP seen in a tertiary care clinic. This study suggests that targeting stress and avoided emotions and linking them to symptoms may be beneficial for this complex group of patients.

Problematic Prescription Opioid Use in a Chronic Pain Treatment Facility: The Role of Emotional Processes.

BACKGROUND: Factors associated with prescription opioid misuse in a chronic pain treatment population are limited, and increasing our understanding of associated factors could lead to improved targeting of prevention and intervention efforts. OBJECTIVE: The aim of this study was to evaluate factors associated with problematic prescription opioid use in patients with chronic pain, and whether assessing emotional processes - alexithymia, ambivalence over emotional expression (AEQ), and emotional approach coping - improves understanding of problematic prescription opioid use beyond traditional risk factors. METHODS: Participants were 100 patients with chronic pain (mean age = 47.57 years, SD = 11.57; 53% female; 81% African American) who were receiving a self-administered opioid medication through a local pain clinic. We assessed traditional risk factors (substance use history, pain, psychiatric distress, and pain catastrophizing), the three emotional processes, and problematic prescription opioid-related outcomes. RESULTS: Zero-order correlations revealed that alexithymia was significantly, positively related to problematic prescription opioid use behaviors (PDUQ), and AEQ was significantly positively related to both prescription opioid misuse behaviors and opioid use disorder symptoms. Multiple regressions that included traditional risk factors and the three emotional processes indicated that AEQ was a unique correlate of problematic opioid use behaviors (ß=.27, p=.04) and prescription opioid-related symptoms of abuse and dependence (ß=.37, p=.01); history of substance use disorders was also associated. CONCLUSIONS: In addition to personal history of substance use problems, AEQ is a modifiable risk factor - and thus potential treatment target - for prescription opioid misuse and opioid use disorders.

A Systematic Review of the Effectiveness of Psychological Treatments for IBS in Gastroenterology Settings: Promising but in Need of Further Study.

BACKGROUND: Psychological treatments are efficacious for irritable bowel syndrome (IBS) in clinical trials; however, their effectiveness when conducted in gastroenterology practice settings is unclear. AIM: To perform a systematic review of the types and effects of psychological treatments for IBS conducted in gastroenterology clinics. METHODS: We searched PubMed, EMBASE, and Cochrane central register. Studies conducted in gastroenterology clinic settings with IBS patients who were clinically referred from gastroenterology were included. RESULTS: We identified 3078 citations, of which only eight studies were eligible. Seven studies compared psychological treatments (average n = 25.7; range 12-43) to controls (average n = 25.4 patients; range 12-47), whereas one study compared two active "bonafide" interventions. Psychological treatments varied (cognitive-behavioral therapy, guided affective imagery, mindfulness, hypnosis, biofeedback, emotional awareness training). However, across approaches, short-term benefits were seen. IBS symptoms improved significantly among patients in cognitive and behavioral therapies, mindfulness-based stress reduction, guided affective imagery, and emotional awareness training compared with controls; there was a similar trend for gut-directed hypnotherapy. Similarly, IBS symptoms improved in a study of two active biofeedback and hypnosis treatments. CONCLUSIONS: Evidence for the effectiveness of psychological treatment in gastroenterology practice is promising but limited. Study designs that involve a blending of efficacy and effectiveness components are needed.

Justice for all? Beliefs about justice for self and others and telomere length in African Americans.

OBJECTIVE: Believing in justice can protect health. Among marginalized racial minorities however, both endorsing and rejecting beliefs about justice might be critical. The current research examined links between African Americans' beliefs about justice for self and for others and telomere length (TL)-an indicator of biological aging that is increasingly implicated in racial health disparities, with shorter telomeres indicating poorer health. METHOD: Healthy African Americans (N = 118; 30% male; M age = 31.63 years) completed individual differences measures of justice beliefs for self and others and then provided dried blood spot samples that were assayed for TL. RESULTS: We expected that a belief in justice for self would be positively associated with TL, whereas a belief in justice for others would be negatively associated. A significant 3-way interaction with chronological age confirmed this hypothesis-among older African Americans, TL was positively associated with believing in justice for self, but only when this belief was accompanied by a weak endorsement of the belief in justice for others. CONCLUSION: Findings underscore that for racial minorities, health might be best protected when justice beliefs are both endorsed and rebuffed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Perceived Discrimination, Racial Identity, and Multisystem Stress Response to Social Evaluative Threat Among African American Men and Women.

OBJECTIVE: Understanding individual differences in the psychobiology of the stress response is critical to grasping how psychosocial factors contribute to racial and ethnic health disparities. However, the ways in which environmentally sensitive biological systems coordinate in response to acute stress is not well understood. We used a social-evaluative stress task to investigate coordination among the autonomic nervous system, hypothalamic-pituitary-adrenal axis, and immune/inflammatory system in a community sample of 85 healthy African American men and women. METHODS: Six saliva samples, 2 at each of baseline, event, and recovery phases of the stressor task, were assayed for cortisol, dehydroepiandrosterone-sulfate, salivary alpha-amylase, and salivary C-reactive protein. Individual differences in perceived discrimination and racial identity were also measured. RESULTS: Factor analysis demonstrated that stress systems were largely dissociated before stressor exposure but became aligned during event and recovery phases into functional biological stress responses (factor loadings ≥ .58). Coordinated responses were related to interactions of perceived discrimination and racial identity: when racial identity was strong, highly perceived discrimination was associated with low hypothalamic-pituitary-adrenal axis activity at baseline (B's = .68-.72, p < .001), low stress mobilization during the task (B's = .46-.62, p < .049), and a robust inflammatory response (salivary C-reactive protein) during recovery (B's = .72-.94, p < .002). CONCLUSION: Culturally relevant social perceptions may be linked to a specific pattern of changing alignment in biological components of the stress response. Better understanding these links may significantly advance understanding of stress-related illnesses and disparities.

Indicators of Cognitive Impairment From a Medical Record Review: Correlations With Early (30-d) Readmissions Among Hospitalized Patients in a Nephrology Unit.

BACKGROUND: Patients with end-stage renal disease have the highest 30-day hospital readmission rates of any medical condition. Previous research suggests that cognitive impairment contributes to readmission. It is important to identify patients at risk for early readmission, and this might be accomplished efficiently using medical record data. METHOD: We reviewed the medical records of 100 patients with kidney disease (57 women, mean age = 61.2) who were hospitalized in the nephrology unit at an urban U.S. hospital. For each patient, we recorded easily available indicators of cognitive impairment along with other potential risk factors, and also recorded the number of 30-day readmissions over the past year. RESULTS: Half of the sample (n = 50) had at least 1 readmission (median = 0.5, range: 0-20). A lifetime history of delirium, which is a known marker of chronic cognitive impairment, was significantly related to readmissions, and several other impairment indicators (positive head imaging, history of seizures, and history of hypoxia) showed similar trends. A "cognitive impairment index" (positive for one or more variables possibly reflecting impaired central nervous system) was significantly related to the presence of a 30-day readmission, beyond the effects of a number of behavioral and medical covariates. CONCLUSIONS: Easily accessible cognitive impairment markers, especially a known history of delirium, may be useful to identify patients in nephrology units who are at increased risk for early hospital readmissions. Interventions can be targeted to these patients with the goal of reducing the likelihood of readmissions and improving health care outcomes.