Outcomes of a 3-Year Quality Improvement Study to Improve Advance Care Planning in Patients With Decompensated Cirrhosis.

INTRODUCTION: To report outcomes of a 3-year quality improvement pilot study to improve advance directive (AD) completion. METHODS: The pilot consisted of champions, education, electronic health record templates, and workflow changes. We assessed changes, predictors, and effects of AD completion. RESULTS: The pilot led to greater (8.3%-36%) and earlier AD completion, particularly among those divorced, with alcohol-associated liver disease, and with higher Model of End-Stage Liver Disease-Sodium score. Decedents whose AD specified nonaggressive goals experienced lower hospital lengths of stay. DISCUSSION: Advance care planning initiatives are feasible and may reduce health care utilization among decedents requesting less aggressive care.

Online ejaculation training programs promote non-evidence-based treatment of male sexual dysfunction.

Purposefully reducing the frequency of ejaculation, coined "semen retention", and the similar practice of "NoFap", have been popularized on social media. They are frequently accompanied by unsubstantiated claims of health benefits. Their increasing popularity has led to the emergence of online courses claiming to teach these techniques. The goal was to characterize the landscape of courses offering ejaculatory training. A systematic Google search was performed using terms related to ejaculation training to identify training programs. Information regarding instructor credentialing, type and duration of courses, costs, and claims of medical benefits were extracted. Eleven ejaculation training courses were identified with 10 instructors (two courses named the same coach). Costs varied from $5 to $147 per week or a $20 to $199 one-time payment. None of the course instructors claimed standardized credentials in the fields of medicine or mental health. Seven instructors (70%) solely cited their own personal experience as their qualifying credentials. Courses claimed to improve erectile dysfunction, premature ejaculation, porn addiction, sexual performance anxiety, testosterone levels, and/or depression. Ejaculation training programs are costly, readily available online, and provided by instructors with no medical background. Despite no scientific evidence, these courses claim to improve various aspects of men's health and can be potentially damaging financially, physically, and mentally to participants.

Predictive Algorithm for Hepatic Steatosis Detection Using Elastography Data in the Veterans Affairs Electronic Health Records.

BACKGROUND AND AIMS: Nonalcoholic fatty liver disease (NAFLD) has reached pandemic proportions. Early detection can identify at-risk patients who can be linked to hepatology care. The vibration-controlled transient elastography (VCTE) controlled attenuation parameter (CAP) is biopsy validated to diagnose hepatic steatosis (HS). We aimed to develop a novel clinical predictive algorithm for HS using the CAP score at a Veterans' Affairs hospital. METHODS: We identified 403 patients in the Greater Los Angeles VA Healthcare System with valid VCTEs during 1/2018-6/2020. Patients with alcohol-associated liver disease, genotype 3 hepatitis C, any malignancies, or liver transplantation were excluded. Linear regression was used to identify predictors of NAFLD. To identify a CAP threshold for HS detection, receiver operating characteristic analysis was applied using liver biopsy, MRI, and ultrasound as the gold standards. RESULTS: The cohort was racially/ethnically diverse (26% Black/African American; 20% Hispanic). Significant positive predictors of elevated CAP score included diabetes, cholesterol, triglycerides, BMI, and self-identifying as Hispanic. Our predictions of CAP scores using this model strongly correlated (r = 0.61, p < 0.001) with actual CAP scores. The NAFLD model was validated in an independent Veteran cohort and yielded a sensitivity of 82% and specificity 83% (p < 0.001, 95% CI 0.46-0.81%). The estimated optimal CAP for our population cut-off was 273.5 dB/m, resulting in AUC = 75.5% (95% CI 70.7-80.3%). CONCLUSION: Our HS predictive algorithm can identify at-risk Veterans for NAFLD to further risk stratify them by non-invasive tests and link them to sub-specialty care. Given the biased referral pattern for VCTEs, future work will need to address its applicability in non-specialty clinics. Proposed clinical algorithm to identify patients at-risk for NAFLD prior to fibrosis staging in Veteran.

Intense positive affect without arousal is possible: Subjective and physiological reactivity during a partnered sexual meditative experience.

Though common models suggest that affect intensity can be thought of as orthogonal to arousal, examples of intensely pleasant low arousal stimuli remain rare. To support this orthogonal model, we examined whether a specific meditative sexual practice, Orgasmic Meditation (OM), induces such a state. Thus, this study measured changes in subjective affect as well as skin conductance responses (SCR), as a proxy for physiological arousal associated with sympathetic nervous system activity, during a single 15-minute partnered sexual meditative practice (Orgasmic Meditation; OM) in 93 participants. Almost all participants experienced sustained positive affect during the task. Whereas seconds after OM start approximately half the participants experienced sustained increased SCR, the other half experienced sustained decreased SCR. This observation suggests that the experience of sustained positive affect in intimate interactions may be associated with multiple mechanistic profiles including both decreased and increased arousal.

Sex film viewing, but not hypersexual concerns, are associated with more sexual arousal in anticipation of an intimate partner experience.

BACKGROUND: Hypersexual behaviours could reflect psychopathology, in part, because they impair interactions with intimate partners. METHODS: Hypersexual concerns were measured as: (1) concern about inability to control one's own sexual behaviours; and (2) sexual films viewed. The outcome, sexual arousal, was measured using two indicators: (1) self-reported sexual arousal (before/after); and (2) skin conductance response from the person stimulated (continuously). Two-hundred and fifty participants completed Orgasmic Meditation (OM), a coupled, structured, 15-min manual-genital stroking. RESULTS: Reported difficulty controlling their own sexual behaviours was not related to sexual arousal reports. Participants who viewed more sexual films reported more sexual arousal before starting OM than participants who viewed less sexual films. Strokers who viewed more sexual films were associated with a higher skin conductance response in the stroked partner. CONCLUSIONS: Despite statistical power and pre-registration, hypersexual concerns did not predict sexual responses with a partner. Sex film viewing may increase sexual responsiveness in individuals and their partners.

Development of an international sexual and reproductive health survey instrument: results from a pilot WHO/HRP consultative Delphi process.

Population health surveys are rarely comprehensive in addressing sexual health, and population-representative surveys often lack standardised measures for collecting comparable data across countries. We present a sexual health survey instrument and implementation considerations for population-level sexual health research. The brief, comprehensive sexual health survey and consensus statement was developed via a multi-step process (an open call, a hackathon, and a modified Delphi process). The survey items, domains, entire instruments, and implementation considerations to develop a sexual health survey were solicited via a global crowdsourcing open call. The open call received 175 contributions from 49 countries. Following review of submissions from the open call, 18 finalists and eight facilitators with expertise in sexual health research, especially in low- and middle-income countries (LMICs), were invited to a 3-day hackathon to harmonise a survey instrument. Consensus was achieved through an iterative, modified Delphi process that included three rounds of online surveys. The entire process resulted in a 19-item consensus statement and a brief sexual health survey instrument. This is the first global consensus on a sexual and reproductive health survey instrument that can be used to generate cross-national comparative data in both high-income and LMICs. The inclusive process identified priority domains for improvement and can inform the design of sexual and reproductive health programs and contextually relevant data for comparable research across countries.

Partner intimate touch is associated with increased interpersonal closeness, especially in non-romantic partners.

Relationship closeness promotes desirable health outcomes. Most interventions to increase relationship closeness are verbal, which may not suit all couples. We consider whether Orgasmic Meditation (OM), a structured, partnered, largely non-verbal practice that includes genital touch, also increases relationship closeness. We hypothesized that OM would increase feelings of closeness for both romantic and non-romantic partners. This is important, because intimate touch with non-romantic partners is commonly considered deleterious by clinicians, which may inadvertently increase feelings of shame. Dyads (n = 125) reported their feelings of closeness before and after OM. Approximately half of the participants were romantic partners, while the other half only engaged in OM together (non-romantic). Closeness after OM increased on average across participants. Non-romantic dyads increased self-other overlap more than romantic dyads. These data support that a partnered, largely non-verbal practice is associated with increased feelings of closeness in the moment, including for individuals who are not in a romantic relationship.

Low Cost MR Compatible Haptic Stimulation with Application to fMRI Neurofeedback.

The most common feedback displays in the fMRI environment are visual, e.g., in which participants try to increase or decrease the level of a thermometer. However, haptic feedback is increasingly valued in computer interaction tasks, particularly for real-time fMRI feedback. fMRI-neurofeedback is a clinical intervention that has not yet taken advantage of this trend. Here we describe a low-cost, user-friendly, MR-compatible system that can provide graded haptic vibrotactile stimulation in an initial application to fMRI neurofeedback. We also present a feasibility demonstration showing that we could successfully set up the system and obtain data in the context of a neurofeedback paradigm. We conclude that vibrotactile stimulation using this low-cost system is a viable method of feedback presentation, and encourage neurofeedback researchers to incorporate this type of feedback into their studies.

Sexual Responsivity and the Effects of Negative Mood on Sexual Arousal in Hypersexual Men Who Have Sex With Men (MSM).

BACKGROUND: A number of studies have found that hypersexuality is associated with a high propensity for sexual excitation. In comparison, less is known about the relationship between hypersexuality and sexual arousal at the state level. Also, previous research has revealed a relationship between hypersexuality and negative mood. However, the possibility that sexual response might not be as negatively impacted by negative mood in hypersexual individuals has, as yet, not been tested. AIM: The purpose of this study was to investigate sexual responsivity and the effects of negative mood on sexual arousal in hypersexual men who have sex with men (MSM). METHODS: A total of 211 MSM were assigned to a hypersexuality (N = 81) or a control (N = 130) group using an interview patterned with a semi-structured Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders format. Participants filled out questionnaires and were shown neutral, sexual, and anxiety- and sadness-inducing films. OUTCOMES: Changes in penile circumference and self-reported sexual arousal were the primary outcomes analyzed in this study. RESULTS: Controlling for age and HIV status, no differences were found in genital response between hypersexual and non-hypersexual men. Also, the 2 groups did not differ in subjective sexual arousal. Moreover, no effects of negative mood were found. Time series clustering analyses revealed 3 groups-low responders and slow and fast high responders. Sexual excitation, but not sexual compulsivity or pornography use, predicted cluster membership. CLINICAL TRANSLATION: Hypersexual MSM may benefit more from an exploration of motivational and behavioral, as compared to psychophysiological, mechanisms underlying possible links between (negative) mood and sexual behavior. STRENGTHS & LIMITATIONS: Strengths of the study include its sample size, making it one of the larger psychophysiological sex studies; the use of clinical interviews for group assignment; the inclusion of genital response measures; and the application of time series clustering to examine differences among participants. Limitations include possible sample heterogeneity and the reliance on researcher-selected stimuli. CONCLUSION: Given the lack of any effects of negative mood on sexual response in hypersexual MSM, future studies could explore in more depth possible motivational and behavioral effects, including, for example, the impact of negative mood on the tendency to seek out sex as a form of distraction or for validation or emotional support. Janssen E, Prause N, Romine RS, et al. Sexual Responsivity and the Effects of Negative Mood on Sexual Arousal in Hypersexual Men Who Have Sex With Men (MSM). J Sex Med 2020;17:1751-1760.

Surveying Pornography Use: A Shaky Science Resting on Poor Measurement Foundations.

A great deal of pornography research relies on dubious measurements. Measurement of pornography use has been highly variable across studies and existing measurement approaches have not been developed using standard psychometric practices nor have they addressed construct validation or reliability. This state of affairs is problematic for the accumulation of knowledge about the nature of pornography use, its antecedents, correlates, and consequences, as it can contribute to inconsistent results across studies and undermine the generalizability of research findings. This article provides a summary of contemporary measurement practices in pornography research accompanied by an explication of the problems therein. It also offers suggestions on how best to move forward by adopting a more limited set of standardized and validated instruments. We recommend that the creation of such instruments be guided by the careful and thorough conceptualization of pornography use and systematic adherence to measurement development principles.

A weak scientific basis for gaming disorder: Let us err on the side of caution.

We greatly appreciate the care and thought that is evident in the 10 commentaries that discuss our debate paper, the majority of which argued in favor of a formalized ICD-11 gaming disorder. We agree that there are some people whose play of video games is related to life problems. We believe that understanding this population and the nature and severity of the problems they experience should be a focus area for future research. However, moving from research construct to formal disorder requires a much stronger evidence base than we currently have. The burden of evidence and the clinical utility should be extremely high, because there is a genuine risk of abuse of diagnoses. We provide suggestions about the level of evidence that might be required: transparent and preregistered studies, a better demarcation of the subject area that includes a rationale for focusing on gaming particularly versus a more general behavioral addictions concept, the exploration of non-addiction approaches, and the unbiased exploration of clinical approaches that treat potentially underlying issues, such as depressive mood or social anxiety first. We acknowledge there could be benefits to formalizing gaming disorder, many of which were highlighted by colleagues in their commentaries, but we think they do not yet outweigh the wider societal and public health risks involved. Given the gravity of diagnostic classification and its wider societal impact, we urge our colleagues at the WHO to err on the side of caution for now and postpone the formalization.

Functional significance of subjective response to alcohol across levels of alcohol exposure.

Pre-clinical neurobiological models of addiction etiology including both the allostatic model and incentive sensitization theory suggest that alcohol consumption among alcohol-dependent (AD) individuals will be dissociated from hedonic reward as positive reinforcement mechanisms wane in later stage dependence. The aims of this study are to test this claim in humans by examining the relationship between dimensions of subjective responses to alcohol (SR) and alcohol craving across levels of alcohol exposure. Non-treatment-seeking drinkers (n = 205) completed an i.v. alcohol challenge (final target breath alcohol concentration = 0.06 g/dl) and reported on SR and craving. Participants were classified as light-to-moderate drinkers (LMD), heavy drinkers (HD) or AD. Analyses examined group differences in SR and craving response magnitude, as well as concurrent and predictive associations between SR domains and craving. At baseline, LMD and AD reported greater stimulation than HD, which carried over post-alcohol administration. However, stimulation was dose-dependently associated with alcohol craving in HD only. Furthermore, lagged models found that stimulation preceded craving among HD only, whereas this hypothesized pattern of results was not observed for craving preceding stimulation. Sedation was also positively associated with craving, yet no group differences were observed. In agreement with the prediction of diminished positive reinforcement in alcohol dependence, this study showed that stimulation/hedonic reward from alcohol did not precede craving in AD, whereas stimulation was dose-dependently associated with and preceded craving among non-dependent HD.

Scholars' open debate paper on the World Health Organization ICD-11 Gaming Disorder proposal.

Concerns about problematic gaming behaviors deserve our full attention. However, we claim that it is far from clear that these problems can or should be attributed to a new disorder. The empirical basis for a Gaming Disorder proposal, such as in the new ICD-11, suffers from fundamental issues. Our main concerns are the low quality of the research base, the fact that the current operationalization leans too heavily on substance use and gambling criteria, and the lack of consensus on symptomatology and assessment of problematic gaming. The act of formalizing this disorder, even as a proposal, has negative medical, scientific, public-health, societal, and human rights fallout that should be considered. Of particular concern are moral panics around the harm of video gaming. They might result in premature application of diagnosis in the medical community and the treatment of abundant false-positive cases, especially for children and adolescents. Second, research will be locked into a confirmatory approach, rather than an exploration of the boundaries of normal versus pathological. Third, the healthy majority of gamers will be affected negatively. We expect that the premature inclusion of Gaming Disorder as a diagnosis in ICD-11 will cause significant stigma to the millions of children who play video games as a part of a normal, healthy life. At this point, suggesting formal diagnoses and categories is premature: the ICD-11 proposal for Gaming Disorder should be removed to avoid a waste of public health resources as well as to avoid causing harm to healthy video gamers around the world.

EEG to Primary Rewards: Predictive Utility and Malleability by Brain Stimulation.

Theta burst stimulation (TBS) is thought to affect reward processing mechanisms, which may increase and decrease reward sensitivity. To test the ability of TBS to modulate response to strong primary rewards, participants hypersensitive to primary rewards were recruited. Twenty men and women with at least two opposite-sex, sexual partners in the last year received two forms of TBS. Stimulations were randomized to avoid order effects and separated by 2 hours to reduce carryover. The two TBS forms have been demonstrated to inhibit (continuous) or excite (intermittent) the left dorsolateral prefrontal cortex using different pulse patterns, which links to brain areas associated with reward conditioning. After each TBS, participants completed tasks assessing their reward responsiveness to monetary and sexual rewards. Electroencephalography (EEG) was recorded. They also reported their number of orgasms in the weekend following stimulation. This signal was malleable by TBS, where excitatory TBS resulted in lower EEG alpha relative to inhibitory TBS to primary rewards. EEG responses to sexual rewards in the lab (following both forms of TBS) predicted the number of orgasms experienced over the forthcoming weekend. TBS may be useful in modifying hypersensitivity or hyposensitivity to primary rewards that predict sexual behaviors. Since TBS altered the anticipation of a sexual reward, TBS may offer a novel treatment for sexual desire problems.

Clitorally Stimulated Orgasms Are Associated With Better Control of Sexual Desire, and Not Associated With Depression or Anxiety, Compared With Vaginally Stimulated Orgasms.

INTRODUCTION: Most women report that clitoral stimulation is an integral aspect of their orgasm experience. Thus, recent claims that vaginal stimulation and vaginally generated orgasms are superior to clitoral stimulation and clitorally generated orgasms pathologize most women and maintain a clitoral vs vaginal dichotomy that might not accurately reflect the complexity of women's sexual experience. AIM: To have women report on their experienced source of orgasm, including combinations of vaginal and clitoral stimulation, the solo or partnered context of the stimulation, and the intensity of the orgasms from different sources and to predict indicators of mental health and sexual health using the orgasm source. METHODS: Eighty-eight women 18 to 53 years old answered detailed questions about their usual and recent orgasm experiences, sexual history, depression, and anxiety. Then, they viewed a series of neutral and sexual films. They were instructed to increase or decrease their sexual arousal or respond "as usual" to the sexual films. They reported their sexual arousal after each film. MAIN OUTCOME MEASURES: Outcomes assessed included mental health (depression and anxiety) and sexual health (orgasm quality, ability to regulate sexual response to sex films). Reported sexual arousal was analyzed for the regulation task. RESULTS: Most women (64%) reported that clitoral and vaginal stimulation contributed to their usual method of reaching orgasm. Women who reported that clitoral stimulation was primarily responsible for their orgasm reported a higher desire to self-stimulate and demonstrated greater control over their self-reported sexual arousal. The primary stimulation site for orgasm was unrelated to measurements of depression or anxiety despite sufficient statistical power. CONCLUSION: Most women reported that clitoral and vaginal stimulation is important in orgasm. Women experience orgasms in many varied patterns, a complexity that is often ignored by current methods of assessing orgasm source. The reported source of orgasm was unrelated to orgasm intensity, overall sex-life satisfaction, sexual distress, depression, or anxiety. Women who reported primarily stimulating their clitoris to reach orgasm reported higher trait sexual drive and higher sexual arousal to visual sexual stimulation and were better able to increase their sexual arousal to visual sexual stimulation when instructed than women who reported orgasms primarily from vaginal sources.