Dietary Walnuts Preserve Aspects of Health Span and Alter the Hippocampal Lipidome in Aged High-Fat Diet-Fed Mice.

Evidence continues to accrue that aging and its diseases can be delayed by pharmacologic and dietary strategies that target the underlying hallmarks of the aging process. However, identifying simple, safe, and effective dietary strategies involving the incorporation of whole foods that may confer some protection against the aging process is also needed. Recent observational studies have suggested that nut consumption can reduce mortality risk in humans. Among these, walnuts are particularly intriguing, given their high content of n-3 fatty acids, fiber, and antioxidant and anti-inflammatory compounds. To this end, 12-month-old male CB6F1 mice were provided either a defined control low-fat diet (LFD), a control high-fat diet (HFD), or an isocaloric HFD containing 7.67% walnuts by weight (HFD + W), and measures of healthspan and related biochemical markers (n = 10-19 per group) as well as survival (n = 20 per group) were monitored. Mice provided the HFD or HFD + W demonstrated marked weight gain, but walnuts lowered baseline glucose (p < 0.05) and tended to temper the effects of HFD on liver weight gain (p < 0.05) and insulin tolerance (p = 0.1). Additional assays suggested a beneficial effect on some indicators of health with walnut supplementation, including preservation of exercise capacity and improved short-term working memory, as determined by Y maze (p = 0.02). However, no effect was observed via any diet on inflammatory markers, antioxidant capacity, or survival (p = 0.2). Ingenuity Pathway Analysis of the hippocampal transcriptome identified two processes predicted to be affected by walnuts and potentially linked to cognitive function, including estrogen signaling and lipid metabolism, with changes in the latter confirmed by lipidomic analysis. In summary, while walnuts did not significantly improve survival on a HFD, they tended to preserve features of healthspan in the context of a metabolic stressor with aging.

Implementation of a Statewide Program to Promote Safe Sleep, Breastfeeding and Tobacco Cessation to High Risk Pregnant Women.

Infant mortality remains a problem in the United States with sleep-related deaths accounting for a significant portion. Known risk reduction strategies include breastfeeding, avoiding tobacco use and following the American Academy of Pediatrics' safe sleep guidelines. The purpose of this project was to evaluate outcomes of Safe Sleep Instructor-led community baby showers, which included safe sleep promotion, breastfeeding promotion and tobacco cessation education. Certified Safe Sleep Instructors (n = 35) were trained on how to plan and host a Community Baby Shower to provide education to pregnant women of low socioeconomic status or with high risk of infant mortality. Eighteen Community Baby Showers were held across two urban and eight rural counties in Kansas. Surveys were administered pre- and post-event to assess participant knowledge, confidence and intentions to follow through with planned action related to safe sleep, breastfeeding and reducing tobacco risk. Matched data were summarized and evaluated for differences using McNemar's and Wilcoxon Signed Rank tests. Significant increases were observed in Baby Shower participants' (n = 845) reported plans to follow the AAP Safe Sleep guidelines (all p < 0.001), likelihood to breastfeed (p < 0.001), confidence in ability to breastfeed for more than 6 months (p < 0.001), knowledge of local breastfeeding support resources (p < 0.001), knowledge of ways to avoid second-hand smoke exposure (p < 0.001) and knowledge of local tobacco cessation services (p = 0.004). Based on the result of the pre- and post-event surveys, certified Safe Sleep Instructors were able to plan and host successful events to increase knowledge and confidence related to risk reduction strategies to reduce sleep-related infant deaths.

Toward an Emerging Role for Motivational Interviewing in Primary Care.

PURPOSE OF REVIEW: Implementing Motivational Interviewing (MI) in primary care settings has been problematic due in part to persistent gaps in knowledge. Examples include poor understanding of how to effectively train persons to conduct MI, or of which aspects of MI-related communication are associated with better outcomes for patients. This review describes how recent research findings addressing the knowledge gaps support a growing role for MI in primary care. RECENT FINDINGS: Two trials of MI training combined classroom time with ongoing coaching and feedback, resulting in enhanced MI ability relative to a control arm where PCPs received minimal or no MI training. A third MI training trial excluded coaching and feedback, failing to increase use of MI. Adding to a growing list of behavioral health-related problems for which MI training has shown some effectiveness, a trial of training PCPs to use MI with depressed patients was associated with significantly improved depressive symptoms. Moreover, aspects of the PCPs' MI-related language and patients' arguments for positive behavior changes, "change talk," appeared to explain the positive effects of MI training on depression outcome. MI-training approaches have improved such that PCPs and possibly other clinic staff may want to consider MI training as a way to more effectively support their patients as they address behavioral health-related problems (e.g., tobacco use). MI training should focus on eliciting "change talk" from patients. Researchers and funding agencies might collaborate to continue closing knowledge gaps in the MI literature.

Evidence for preserved insulin responsiveness in the aging rat brain.

Insulin appears to exert salutary effects in the central nervous system (CNS). Thus, brain insulin resistance has been proposed to play a role in brain aging and dementia but is conceptually complex and unlikely to fit classic definitions established in peripheral tissues. Thus, we sought to characterize brain insulin responsiveness in young (4-5 months) and old (24 months) FBN male rats using a diverse set of assays to determine the extent to which insulin effects in the CNS are impaired with age. When performing hyperinsulinemic-euglycemic clamps in rats, intracerebroventricular (ICV) infusion of insulin in old animals improved peripheral insulin sensitivity by nearly two-fold over old controls and comparable to young rats, suggesting preservation of this insulin-triggered response in aging per se (p < 0.05). We next used an imaging-based approach by comparing ICV vehicle versus insulin and performed resting state functional magnetic resonance imaging (rs-fMRI) to evaluate age- and insulin-related changes in network connectivity within the default mode network. In aging, lower connectivity between the mesial temporal (MT) region and other areas, as well as reduced MT signal complexity, was observed in old rats, which correlated with greater cognitive deficits in old. Despite these stark differences, ICV insulin failed to elicit any significant alteration to the BOLD signal in young rats, while a significant deviation of the BOLD signal was observed in older animals, characterized by augmentation in regions of the septal nucleus and hypothalamus, and reduction in thalamus and nucleus accumbens. In contrast, ex vivo stimulation of hippocampus with 10 nM insulin revealed increased Akt activation in young (p < 0.05), but not old rats. Despite similar circulating levels of insulin and IGF-1, cerebrospinal fluid concentrations of these ligands were reduced with age. Thus, these data highlight the complexity of capturing brain insulin action and demonstrate preserved or heightened brain responses to insulin with age, despite dampened canonical signaling, thereby suggesting impaired CNS input of these ligands may be a feature of reduced brain insulin action, providing further rationale for CNS replacement strategies.

Acoustically mounted microcrystals yield high-resolution X-ray structures.

We demonstrate a general strategy for determining structures from showers of microcrystals. It uses acoustic droplet ejection to transfer 2.5 nL droplets from the surface of microcrystal slurries, through the air, onto mounting micromesh pins. Individual microcrystals are located by raster-scanning a several-micrometer X-ray beam across the cryocooled micromeshes. X-ray diffraction data sets merged from several micrometer-sized crystals are used to determine 1.8 Ǻ resolution crystal structures.

On the possibility of using polycrystalline material in the development of structure-based generic assays.

The discovery of ligands that bind specifically to a targeted protein benefits from the development of generic assays for high-throughput screening of a library of chemicals. Protein powder diffraction (PPD) has been proposed as a potential method for use as a structure-based assay for high-throughput screening applications. Building on this effort, powder samples of bound/unbound states of soluble hen-egg white lysozyme precipitated with sodium chloride were compared. The correlation coefficients calculated between the raw diffraction profiles were consistent with the known binding properties of the ligands and suggested that the PPD approach can be used even prior to a full description using stereochemically restrained Rietveld refinement.

Safe Sleep Practices of Kansas Birthing Hospitals.

BACKGROUND: Sleep-related death is tied with congenital anomalies as the leading cause of infant mortality in Kansas, and external risk factors are present in 83% of these deaths. Hospitals can impact caregiver intentions to follow risk-reduction strategies. This project assessed the current practices and policies of Kansas hospitals with regard to safe sleep. METHODS: A cross-sectional survey of existing safe sleep practices and policies in Kansas hospitals was performed. Hospitals were categorized based on reported delivery volume and data were compared across hospital sizes. RESULTS: Thirty-one of 73 (42%) contacted hospitals responded. Individual survey respondents represented various hospital departments including newborn/well-baby (68%), neonatal intensive care unit (3%) and other non-nursery departments or administration (29%). Fifty-eight percent of respondents reported staff were trained on infant safe sleep; 44% of these held trainings annually. High volume hospitals tended to have more annual training than low or mid volume birth hospitals. Thirty-nine percent reported a safe sleep policy, though most of these (67%) reported never auditing compliance. The top barrier to safe sleep education, regardless of delivery volume, was conflicting patient and family member beliefs. CONCLUSIONS: Hospital promotion of infant safe sleep is being conducted in Kansas to varying degrees. High and mid volume birth hospitals may need to work more on formal auditing of safe sleep practices, while low volume hospitals may need more staff training. Low volume hospitals also may benefit from access to additional caregiver education materials. Finally, it is important to note hospitals should not be solely responsible for safe sleep education.

Micronutrient Gaps in Three Commercial Weight-Loss Diet Plans.

Weight-loss diets restrict intakes of energy and macronutrients but overlook micronutrient profiles. Commercial diet plans may provide insufficient micronutrients. We analyzed nutrient profiles of three plans and compared their micronutrient sufficiency to Dietary Reference Intakes (DRIs) for male U.S. adults. Hypocaloric vegan (Eat to Live-Vegan, Aggressive Weight Loss; ETL-VAWL), high-animal-protein low-carbohydrate (Fast Metabolism Diet; FMD) and weight maintenance (Eat, Drink and Be Healthy; EDH) diets were evaluated. Seven single-day menus were sampled per diet (n = 21 menus, 7 menus/diet) and analyzed for 20 micronutrients with the online nutrient tracker CRON-O-Meter. Without adjustment for energy intake, the ETL-VAWL diet failed to provide 90% of recommended amounts for B12, B3, D, E, calcium, selenium and zinc. The FMD diet was low (<90% DRI) in B1, D, E, calcium, magnesium and potassium. The EDH diet met >90% DRIs for all but vitamin D, calcium and potassium. Several micronutrients remained inadequate after adjustment to 2000 kcal/day: vitamin B12 in ETL-VAWL, calcium in FMD and EDH and vitamin D in all diets. Consistent with previous work, micronutrient deficits are prevalent in weight-loss diet plans. Special attention to micronutrient rich foods is required to reduce risk of micronutrient deficiency in design of commercial diets.

The role of fatty acid desaturase (FADS) genes in oleic acid metabolism: FADS1 Δ7 desaturates 11-20:1 to 7,11-20:2.

INTRODUCTION: In mammals, FADS2 catalyzes "front-end" Δ4-, Δ6-, and Δ8-desaturation of fatty acyl chains, whereas FADS1 has Δ5-desaturase activity. Eighteen and 20-carbon precursors to highly unsaturated n-3 and n-6 fatty acids are the usual substrates for FADS1 and FADS2. Our main objective was to characterize the metabolic fate of oleic acid (OA) due to action of FADS gene products. METHODS: MCF-7 cells were stably transformed with either FADS1 or FADS2 or empty vector. A series of dose-response experiments were conducted with albumin-bound fatty acid substrates (18:1n-9 and 20:1n-9) provided in concentrations up to 100µM. Cells were harvested after 24h, after which FAME were prepared and analyzed by GC-FID and covalent adduct chemical ionization tandem mass spectrometry (CACI-MS/MS). RESULTS: When stably transformed cells were incubated with 18:1n-9, FADS1 and control cells elongated 18:1n-9 → 20:1n-9 (11-20:1), while FADS2 cells Δ6 desaturated, elongated, and then Δ5 desaturated via FADS1 coded activity leading to Mead acid, 9-18:1 → 6,9-18:2 → 8,11-20:2 (20:2n-9) → 6,8,11-20:3 (20:3n-9). Surprisingly, FADS1 cells Δ7 desaturated 11-20:1 → 7,11-20:2, the latter detected at low levels in control and FADS2 cells. Our results imply three pathways operate on 18:1n-9: 1) 18:1n-9 → 18:2n-9 → 20:2n-9 → 20:3n-9; 2) 18:1n-9 → 20:1n-9 → 20:2n-9 → 20:3n-9 and 3) 18:1n-9 → 20:1n-9 → 7,11-20:2. CONCLUSION: Alternative pathways for oleic acid metabolism exist depending on FADS2 or FADS1 activities, we present the first evidence of Δ7 desaturation via the FADS1 gene product.

Safe Sleep Knowledge and Use of Provided Cribs in a Crib Delivery Program.

BACKGROUND: Risk of infant sleep-related death can be reduced through safe sleep practices. Barriers to infant safe sleep have been mitigated through education and crib distribution, however, previous studies have not explored whether distributed cribs are put to use. METHODS: In a rural Michigan county, the Great Start Sleep Initiative supplied cribs and education shortly after infant birth to families with high-risk of infant mortality, as assessed through comprehensive interviews with families by program staff. Participant knowledge was evaluated using structured pre- and post-assessments before and after education. Further, a home visit was conducted to evaluate the infant's sleeping environment. Data from the program, collected between January 2012 and December 2014, was evaluated. RESULTS: Cribs and concomitant education were delivered to 75 caregivers. Knowledge of safe sleep practices increased significantly at follow-up with 67 caregivers (89%) affirming back positioning, 68 (91%) endorsing removal of unsafe items or soft objects, such as blankets, from the sleeping area, and 42 (56%) renouncing bed-sharing. At the home visit, 74 caregivers (99%) were using a crib to put their infant down to sleep, 70 (93%) were using the provided crib, and 67 (89%) had no unsafe items in the child's sleeping area. CONCLUSIONS: Providing education to high-risk mothers resulted in improved safe sleep knowledge and provided cribs are used in these homes.

Developing a state-wide infrastructure for safe sleep promotion.

OBJECTIVES: Sleep-related deaths are the third leading cause of infant death in Kansas. This manuscript describes implementation of an infrastructure of regional trainers to educate on the American Academy of Pediatrics safe sleep recommendations. DESIGN: Prospective evaluation of training program on knowledge transfer. SETTING: Instructors were recruited from throughout the state of Kansas and trained to provide safe sleep education in their communities. PARTICIPANTS: Instructors were a mix of healthcare workers and community members. Their trainees encompassed both professionals and caregivers. INTERVENTION: Instructors attended a 2-day training, including completing 18-item pre and post-training knowledge tests, a training evaluation survey, and performing a portion of the structured safe sleep presentation and crib demonstration for feedback. MEASUREMENT: Instructors were evaluated before and after training. After conducting trainings in their region, instructors submitted trainees' pre and post-test results. Scores were compared using t-test. RESULTS: Twenty-three instructors were trained. Scores averaged 13.5 (SD=2.4) for the pre-test and 15.3 (SD=2.4) for the post-test. Those scoring <80% post-training (n=6) received additional instruction. In the subsequent year, 13 trainers provided safe sleep education at 21 events to a total of 378 trainees. Trainee scores averaged 11.4 (SD=2.7) on the pre-test and increased to 13.9 (SD=2.5) on the post-test (P<.001). Findings were consistent when adjusting for variation between individual trainers. CONCLUSIONS: Safe sleep instructors can be trained to disseminate safe sleep guidelines; however, only half provided at least 1 training within 1 year. Future recommendations include over-recruiting potential instructors, incorporating trainings into existing positions or otherwise incentivizing trainers.

The Relationship of Personality Style and Attention Deficit Hyperactivity Disorder in Children.

INTRODUCTION: This study was to identify personality correlates of children with a diagnosis of Attention Deficit Hyperactive Disorder (ADHD). The Jungian Personality Type dimensions primarily considered were Sensing/Intuiting and Perceiving/Judging. A Sensing child is likely to be very present-centered. A Perceiving child tends to be curious and resist order and structure. METHODS: Children attending a general pediatric clinic with a diagnosis of ADHD were eligible to participate. Enrolled children were administered the Murphy-Meisgeier Type Indicator for Children. Binomial tests were performed comparing Perceiving and Sensing personality components to accepted population rates. RESULTS: Participants (n = 117) were predominantly male (78%) with a median age of 10 years. The Sensing trait (72%) was more prevalent than expected, though prevalence for the Perceiving trait (44%) did not differ from population rates. CONCLUSION: Personality types occasioned with the diagnosis of ADHD could be useful in establishing/normalizing treatment regimens and approaches to assist these children and their families better.

Qualitative Assessment of Pregnant Women's Perceptions of Infant Sleep Boxes.

Although several states have implemented programs providing boxes for infant sleep, safe sleep experts express concern regarding the paucity of safety and efficacy research on boxes. The purpose of this study was to assess pregnant women's perceptions regarding use of baby sleep boxes. A convenience sample was recruited from a community prenatal education program. Twenty-eight women were administered a brief semistructured interview about their knowledge of baby sleep boxes, opinions about the boxes, and questions they would have. For most (n = 15, 54%), this was their first pregnancy. Participants self-identified as white (43%), black (36%), Hispanic (18%), and "other" (4%). Ten subthemes emerged related to previous knowledge of boxes (useful for families in need, historic precedent in other countries), positive attributes (portable, compact, affordable, decorative), and negative attributes (low to ground, structural integrity/design, stability, stigma). Research on safety and efficacy could reduce concerns, but issues of stigma may persist.

Metabolic fate of docosahexaenoic acid (DHA; 22:6n-3) in human cells: direct retroconversion of DHA to eicosapentaenoic acid (20:5n-3) dominates over elongation to tetracosahexaenoic acid (24:6n-3).

Docosahexaenoic acid (22:6n-3) supplementation in humans causes eicosapentaenoic acid (20:5n-3) levels to rise in plasma, but not in neural tissue where 22:6n-3 is the major omega-3 in phospholipids. We determined whether neuronal cells (Y79 and SK-N-SH) metabolize 22:6n-3 differently from non-neuronal cells (MCF7 and HepG2). We observed that (13) C-labeled 22:6n-3 was primarily esterified into cell lipids. We also observed that retroconversion of 22:6n-3 to 20:5n-3 was 5- to 6-fold greater in non-neural compared to neural cells and that retroconversion predominated over elongation to tetracosahexaenoic acid (24:6n-3) by 2-5-fold. The putative metabolic intermediates, (13) C-labeled 22:5n-3 and (13) C-labeled 24:5n-3, were not detected in our assays. Analysis of the expression of enzymes involved in fatty acid beta-oxidation revealed that MCF7 cells abundantly expressed the mitochondrial enzymes CPT1A, ECI1, and DECR1, whereas the peroxisomal enzyme ACOX1 was abundant in HepG2 cells, thus suggesting that the initial site of 22:6n-3 oxidation depends on the cell type. Our data reveal that non-neural cells more actively metabolize 22:6n-3 to 20:5n-3 via channeled retroconversion, while neural cells retain 22:6n-3.

Motivational interviewing improves depression outcome in primary care: A cluster randomized trial.

OBJECTIVE: To examine the effects of Motivational Interviewing (MI) conducted by primary care providers on rates of improvement over time for depressive symptoms and remission among low-income patients with newly diagnosed Major Depressive Disorder. METHOD: Ten care teams were randomized to MI with standard management of depression (MI-SMD; 4 teams, 10 providers, 88 patients) or SMD alone (6 teams, 16 providers, 80 patients). Patients were assessed at 6, 12 and 36 weeks with the Patient Health Questionnaire-9 (PHQ-9). Treatment receipt was ascertained through patient inquiry and electronic records. Audio-recorded index encounters were evaluated for mediators of improved depressive symptoms (providers' MI ability and patient language favoring participating in treatment or other depression related mood-improving behaviors). RESULTS: In Intention-To-Treat analyses, MI-SMD was associated with a more favorable trajectory of PHQ-9 depressive symptom scores than SMD alone (randomization group × time interaction estimate = 0.13, p = .018). At 36 weeks, MI-SMD was associated with improved depressive symptoms (Cohen's d = 0.41, 95% CI [0.11, 0.72]) and remission rate (Success Rate Difference = 14.53 [1.79, 27.26]) relative to SMD alone. MI-SMD was not associated with a significant group x time interaction for remission, or with increased receipt of antidepressant medication or specialty mental health counseling. The providers' ability to direct clinical discussions toward treating depression, and the patients' language favoring engagement in mood-improving behaviors, mediated the effects of MI-SMD on depressive symptoms (ps < .05). DISCUSSION: Training providers to frame discussions about depression using MI may improve upon standard management for depression. (PsycINFO Database Record

HRSA's PCRE grant recipients' plans for continuation after funding ends.

BACKGROUND AND OBJECTIVES: In 2010, the US Department of Health and Human Services, under the Affordable Care Act, appropriated over $167 million to the Health Resources and Services Administration (HRSA) for the Primary Care Residency Expansion (PCRE) program. In 2011, grants from the PCRE program were provided to residency programs in the specialties of family medicine, internal medicine, and pediatrics, allowing them to increase the number of residents in their programs. Seventy-seven programs received grant funding, and 504 primary care resident positions were created. The grants provide 5 years of funding for these positions. There is no provision for federal funding of these positions after 2016. The purpose of this study was to determine the number of residencies that had identified funding that would allow them to continue training these new positions after the PCRE grant period ends. METHODS: Programs receiving PCRE funding were identified through the HRSA data warehouse website.1 Program directors were surveyed by email between January and March of 2013. RESULTS: A total of 55 programs responded, for a 71.4% response rate. Of those programs, 17.5% had identified funding that would allow them to continue training the increased number of positions beyond 2016. CONCLUSIONS: This one-time funding exhibits challenges to sustainability. This information will help inform policy makers that sustainable expansion of primary care graduate medical education (GME) training will require strategies other than time-limited funding mechanisms.

Training to use motivational interviewing techniques for depression: a cluster randomized trial.

OBJECTIVE: The goal of this study was to assess the effects of training primary care providers (PCPs) to use Motivational Interviewing (MI) when treating depressed patients on providers' MI performance and patients' expressions of interest in depression treatment ("change talk") and short-term treatment adherence. METHODS: This was a cluster randomized trial in urban primary care clinics (3 intervention, 4 control). We recruited 21 PCPs (10 intervention, 11 control) and 171 English-speaking patients with newly diagnosed depression (85 intervention, 86 control). MI training included a baseline and up to 2 refresher classroom trainings, along with feedback on audiotaped patient encounters. We report summary measures of technical (rate of MI-consistent statements per 10 minutes during encounters) and relational (global rating of "MI Spirit") MI performance, the association between MI performance and number of MI trainings attended (0, 1, 2, or 3), and rates of patient change talk regarding depression treatments (physical activity, antidepressant medication). We report PCP use of physical activity recommendations and antidepressant prescriptions and patients' short-term physical activity level and prescription fill rates. RESULTS: Use of MI-consistent statements was 26% higher for MI-trained versus control PCPs (P = .005). PCPs attending all 3 MI trainings (n = 6) had 38% higher use of MI-consistent statements (P < .001) and were over 5 times more likely to show beginning proficiency in MI Spirit (P = .036) relative to control PCPs. Although PCPs' use of physical activity recommendations and antidepressant prescriptions was not significantly different by randomization arm, patients seen by MI-trained PCPs had more frequent change talk (P = .001). Patients of MI-trained PCPs also expressed change talk about physical activity 3 times more frequently (P = .01) and reported more physical activity (3.05 vs 1.84 days in the week after the visit; P = .007) than their counterparts visiting untrained PCPs. Change talk about antidepressant medication and fill rates were similar by randomization arm (P > .05 for both). CONCLUSIONS: MI training resulted in improved MI performance, more depression-related patient change talk, and better short-term adherence.

Aspects of patient and clinician language predict adherence to antidepressant medication.

OBJECTIVE: High-quality patient-clinician communication is associated with better medication adherence, but the specific language components associated with adherence are poorly understood. We examined how patient and clinician language may influence adherence. METHODS: We audio-recorded primary care encounters from 63 patients newly diagnosed with depression and prescribed an antidepressant medication. We rated clinicians' language (motivational interviewing-adherent statements [MIAs], reflections, and global ratings of empathy and "motivational interviewing spirit") along with patients' "change talk" (CT) demonstrating motivation to take medication. Filling a first prescription and an estimate of overall adherence, the proportion of >180 days covered (PDC) (primary outcome), were measured based on pharmacy records. RESULTS: Fifty-six patients (88.8%) filled an initial prescription, and mean (standard deviation) PDC across all subjects was 45.2% (33.6%). MIAs, complex reflections, and empathy were associated with more CT (for all: rs ≥0.27; P < .05). Two or more and 0 or 1 CT statements were associated with 63.0% and 36.6% PDC, respectively. Empathy, motivational interviewing spirit, and CT were associated with filling the first prescription (for all: rs ≥0.25; P < .05). In an adjusted analysis, empathy (t = 2.3; P = .027) and ≥2 CT statements (t = 2.3; P = .024) were associated with higher PDC. CONCLUSIONS: Clinician empathy, reflections, and MIAs may elicit patient CT, whereas empathy and CT seem to enhance filling an initial prescription and PDC.