Determinants of Daytime Sleepiness Among Middle-Aged Adults.

Daytime sleepiness is highly prevalent in middle-aged adults and has a detrimental impact on their quality of life. Our study examined the psychological and behavioral determinants of daytime sleepiness among adults aged 35 to 64 years. The main variables of interest were psychological factors (perceived stress and anxiety), physical activity factors (moderate-to-vigorous physical activity and sedentary behaviors), and dietary factors (fat, sugar, fruit, and vegetable intake). Partial correlation and multiple linear regression were conducted to determine their associations with daytime sleepiness, with adjustment for covariates. Our sample included 87 adults with a mean age of 47 ± 9 years. About 21% met the criterion for excessive daytime sleepiness. Greater anxiety, longer time spent in sedentary behaviors, and higher consumption of foods rich in trans fat, sugar, and calories were independently associated with higher daytime sleepiness levels. Targeted interventions or treatments are warranted to address the identified risk factors for middle-aged adults.

Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study.

BACKGROUND: Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes. METHODS: Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared. RESULTS: Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria. CONCLUSION: Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.

An Innovative Model of Behavior Management to Address Behavioral Emergencies in the Acute Medical Inpatient Setting: Pilot Data.

Workplace violence in healthcare is a significant and costly problem. The majority of violent events that occur in the medical inpatient setting are perpetrated by patients against staff and occur during a behavioral emergency. The primary purpose of this study was to evaluate the impact of an innovative model of behavior management on occurrence of behavioral emergencies and staff comfort and competence in managing difficult patient behaviors. This model consists of primary, secondary, and tertiary interventions provided by a clinical psychologist which include proactive training for hospital staff and consultation-liaison services for behavior management. Forty-six staff at the University of Virginia Medical Center completed a 1-h training on preventing and managing difficult patient behavior. Self-report data on comfort and competence in managing challenging patient behaviors was collected at baseline, immediately following the intervention, and one and three months post-intervention. Behavioral emergencies were tracked for the intervention unit and a comparison unit. The occurrence of behavioral emergencies decreased by 50% in the three months following the intervention compared to a 142% increase on the comparison unit. Staff reported the greatest increase in confidence from baseline to three months post-intervention on caring for patients with psychiatric illnesses, managing verbal abuse, being supported by medical center leadership, having clear roles and responsibilities, and effectiveness of the skills and strategies used to manage difficult patient behavior. The results of this study provide preliminary support for the use of a comprehensive model for managing the behavioral needs of medical inpatients.

Nutrient removal by rice-wheat cropping system as influenced by crop establishment techniques and fertilization options in conjunction with microbial inoculation.

Nutrient uptake by the rice-wheat cropping system (RWCS) is an important indicator of soil fertility and plant nutrient status. The hypothesis of this investigation was that the rate and sources of nutrient application can differentially influence nutrient removal and soil nutrient status in different crop establishment techniques (CETs). Cropping system yield was on par in all the CETs evaluated, however, there were significant changes in soil nutrient availability and microbiological aspects. The system nitrogen (N), phosphorus (P), potassium (K) and zinc (Zn) uptake in aerobic rice system followed by zero tillage wheat (ARS-ZTW) was 15.7-17.6 kg ha-1, 0.7-0.9 kg ha-1, 7-9.8 kg ha-1 and 13.5-23.1 g ha-1 and higher than other CETs. The formulations of Anabaena sp. (CR1) + Providencia sp. (PR3) consortium (MC1) and Anabaena-Pseudomonas biofilm (MC2) recorded significantly higher values of soil chlorophyll and microbial biomass carbon and positively affected cropping system nutrient uptake and soil nutrient balance, illustrating the beneficial effect of microbial inoculation through increased supply of biologically fixed N and solubilised P. Zinc fertilization (5 kg Zn ha-1 through ZnSO4·7H2O as soil application) increased soil DTPA-extractable Zn by 4.025-4.836 g ha-1, with enhancement to the tune of 20-24% after two cropping cycles of RWCS. Our investigation recommends the need for change in the present CETs to ARS-ZTW, along with the use of microbial inoculation as a means of significantly enhancing cropping system nutrient uptake and soil nutrient status improvement.

Increased Retention in Care After a Palliative Care Referral Among People Living With HIV.

BACKGROUND: Early palliative care addresses biopsychosocial needs for people living with HIV in an outpatient setting. We sought to describe patients referred to a palliative care program and compare the medical outcomes of emergency department (ED) visits, hospitalizations, primary care visits, and viral load suppression among patients enrolled in the program, to patients who did not enroll (no-show group). SETTING: We completed a retrospective cohort study at an urban, academically affiliated HIV primary care clinic. METHODS: Data were collected from electronic medical records. Descriptive statistics characterized patient demographics at baseline, comorbidities, and reasons for referral to palliative care. Viral load suppression, rates of ED visits, hospitalizations, primary care visits, and retention in care were compared between the palliative and no-show groups. RESULTS: The most common reasons for referral were chronic pain management and medication/appointment adherence. Median percent of viral load measurements suppressed increased over time, but did not differ statistically between groups (pre: 28.6% and 15.5%, post: 70.8% and 50.0%, palliative and no-show groups, respectively). Median rates of ED visits and hospitalizations were low and were not impacted by palliative care. Rates of primary care visit attendance remained stable in the palliative group (4.6/year) but declined in the no-show group (3.5/year), P < 0.05. Retention in care improved significantly after the palliative intervention (palliative: 85.4%-96.1%, no-show: 94.4%-82.5%), and at high and low palliative engagement, suggesting a threshold effect of the intervention. CONCLUSION: Outpatient early palliative care is a promising intervention that might impact retention in HIV care.

Mental Health Conditions Among Struggling GME Learners: Results From a Single Center Remediation Program.

BACKGROUND: Graduate medical education (GME) learners may struggle with clinical performance during training. A subset of these trainees has mental health conditions (MHCs). OBJECTIVE: To characterize the MHCs that underlie poor trainee performance and their relationship to specific clinical performance deficit (CPD). METHODS: At the University of Virginia (UVA), GME learners not meeting appropriate milestones, or who request help, have the option to self-refer or be referred to COACH (Committee on Achieving Competence Through Help). A physician remediation expert assesses the learner and identifies a primary CPD. If there is concern for an MHC, referral is made to a psychologist with expertise in working with trainees. All learners are offered remediation for the CPD. Using descriptive statistics, we tracked the prevalence of MHC and their correlation with specific CPDs. RESULTS: Between 2016 and 2019, COACH assessed 7% (61 of 820) of GME learners at UVA. Thirty-eight percent (23 of 61) had an MHC associated with the CPD. Anxiety was the most common MHC (48%), followed by depression (17%), cognitive dysfunction (17%), adjustment disorder (13%), and other (4%). Professionalism was the most identified CPD among learners with MHCs (52%). Of remediated learners, 47% have successfully finished remediation, 21% were terminated or voluntarily left their program, and 32% are still being remediated (83% of whom are in good standing). CONCLUSIONS: MHCs were identified in nearly 40% of struggling learners referred to a centralized remediation program. Professionalism is the most identified CPD among learners with MHCs.

Improving Water and Nutrient Use Efficiency in Rice by Changing Crop Establishment Methods, Application of Microbial Inoculations, and Zn Fertilization.

A field experiment was conducted during the wet seasons of 2013 and 2014 to evaluate the effect of three rice establishment methods: viz. puddled transplanted rice (PTR), system of rice intensification (SRI) and aerobic rice system (ARS), two cyanobacteria based inoculants, viz. Anabaena sp (CR1) + Providencia sp (PR3) consortium and Anabaena-Pseudomonas (An-Ps) biofilm formulation, and zinc (Zn) fertilization on the rice yield, water productivity, and nutrient use efficiency. The yields of rough, brown and milled rice were highest in SRI, which was on par with PTR and both methods proved significantly superior to ARS in both years. The total water productivity of rough and brown rice in the first year was significantly higher in SRI. The SRI method saved 21.9% and 27.4% irrigation water over PTR, and savings in ARS were 37.4% and 50.8% in first and second year respectively, over PTR. The use of An-Ps biofilm formulation along with 75% RDN improved the agronomic use efficiency of both nitrogenous and phosphatic fertilizers applied. On the basis of the present study, it can be concluded that SRI improved rice yields and water productivity; while involvement of An-Ps biofilm formulation can be recommended for improved nutrient use efficiency.

Introduction to the Special Issue: Invited Papers from the 2015 APAHC Conference.

The 7th biennial National Conference of APAHC, the Association of Psychologists in Academic Health Centers, was held in Atlanta, Georgia, February 5-7, 2015. Speakers were invited to contribute manuscripts based on their conference presentations, and many submitted manuscripts for this special edition of the Journal of Clinical Psychology in Medical Settings. Some papers will appear in the December 2015 issue of JCPMS; others will appear in the March 2016 issue. All papers have undergone a rigorous peer review process. The Conference Co-Chairs, Drs. Laura Shaffer and Amit Shahane, are Guest Editors for the special issue. In this article, they provide an overview of the conference's major themes, and also discuss some aspects of conference planning.

Integrating early palliative care for patients with HIV: provider and patient perceptions of symptoms and need for services.

Increasingly clinicians are using palliative care to address the symptomatic and psychosocial effects of disease often missed by routine clinical care, termed "early" palliative care. Within an inner-city medical center, we began a program to integrate early palliative care into HIV inpatient care. Patient symptom burden and desired services were assessed and compared to provider perceptions of patient's needs. From 2010-2012, 10 patients, with a median CD4+ T-cell count of 32.5 cells/µL, and 34 providers completed the survey. Providers ranked their patients' fatigue, sadness, anxiety, sexual dysfunction, and body image significantly higher than patients it for themselves. Patients ranked medical care, pharmacy, social work, physical therapy, and housing as significantly more important to them than providers estimated them to be. These differences may reflect the fact that physicians often overlook patients' unmet basic needs. Early palliative care may narrow this gap between providers' and patients' perceptions of needs through good communication and targeting barriers, such as housing instability, which are vital to overcome for consistent long-term follow up.

Personal meaning, social support, and perceived stigma in individuals receiving HIV mental health services.

Human immunodeficiency virus (HIV) stigma represents a significant source of stress among individuals living with HIV disease, prompting interest in research to identify factors that may help to ameliorate the stress burden associated with HIV stigma. Consistent with this research line, the current study was conducted as a cross-sectional investigation examining associations between positive global personal meaning, social support, and perceived HIV stigma. Global personal meaning refers to beliefs and aspirations through which one ascribes value and purpose in living. The study sample was comprised of individuals living with HIV disease who presented for an initial visit in a specialty HIV mental health services program. In bivariate analyses, social support was negatively correlated with multidimensional aspects of HIV stigma that included distancing, blaming, and discrimination stigma, whereas personal meaning was negatively associated only with blaming stigma. In further analyses using structural equation modeling, social support significantly mediated the association between personal meaning and both distancing and blaming stigma. Interactions between positive personal meaning and social support may be useful to consider in future research on psychological resource factors and HIV stigma. Understanding these interactions may also inform clinical efforts to address HIV stigma concerns.

Perceived stigma reductions following participation in mental health services integrated within community-based HIV primary care.

HIV stigma remains a significant challenge for individuals living with HIV disease that can adversely affect overall well-being and patterns of HIV health service engagement. Finding ways to effectively address stigma concerns is, therefore, an important consideration in the clinical management of HIV disease. This study examined changes in perceived stigma in a sample of 48 adults living with HIV disease as an outcome of their participation in a mental health services program integrated with community-based HIV primary care. Participants completed a self-report instrument that provided a multidimensional measure of perceived HIV stigma, including distancing, blaming, and discrimination dimensions. This scale was administered at the baseline mental health service visit and then re-administered at the three-month follow-up point. Study results showed reductions in self-reported perceived HIV stigma over time for the distancing (t = 4.01, p = 0.000, d = 0.43), blaming (t = 2.79, p = 0.008, d = 0.35), and discrimination (t = 2.90, p = 0.006, d = 0.42) dimensions of stigma. These findings suggest that participation in HIV mental health services may have a favorable impact on perceived HIV stigma. Implications of these findings are discussed, including possible mechanisms that might explain the observed results as well as suggested directions for future research in this area. Randomized controlled trials would represent an important next step to investigate the extent to which HIV mental health services can reduce levels of perceived HIV stigma.

Mediators of the childhood emotional abuse-hopelessness association in African American women.

Although there is an association between experiencing childhood emotional abuse and feeling hopeless as an adult, it is critical to understand the factors that may be protective in this relationship. The goal of this study was to determine if two protective factors, namely spiritual well-being, including both religious and existential well-being, and positive self-esteem, served to mediate the association between childhood emotional abuse and adult hopelessness. The sample for this investigation was low-income African American women suicide attempters who were abused by a partner in the prior year (N=121). A path analysis revealed that in this sample, the childhood emotional abuse-hopelessness link was mediated by existential well-being and positive self-esteem, as well as by the two-mediator path of emotional abuse on existential well-being on self-esteem on hopelessness. Results suggested that existential well-being may be a more salient protective factor for hopelessness than religious well-being among abused, suicidal African American women who experienced childhood emotional abuse. Findings highlight the value of culturally relevant strategies for enhancing existential well-being and self-esteem in this at-risk population to reduce their vulnerability to feelings of hopelessness.