Alcohol and drug use among deaf and hard-of-hearing individuals: A secondary analysis of NHANES 2013-2014.

BACKGROUND: Within the field of behavioral health research, one of the most understudied populations is the US deaf and hard-of-hearing (D/HH) population-a diverse group of individuals with hearing loss that have varied language and communication preferences, community affiliations, and sociocultural norms. Recent research identified concerning behavioral health disparities experienced by the D/HH population; yet, little research has been conducted to extend these findings to the topic of substance use disorder. METHODS: To begin to fill this gap, the authors conducted a secondary analysis of data from the 2013-2014 administration of the National Health and Nutrition Examination Survey, comparing alcohol and drug use between participants based on their reported hearing status, i.e., D/HH or hearing. RESULTS: Findings suggest that the overall lifetime prevalence of alcohol and drug use does not differ based on hearing status, and that D/HH and hearing adolescents begin using cannabis on a similar timeline. However, findings also revealed that D/HH respondents were more likely to have been regular cannabis users and heavy alcohol users than hearing respondents. In other words, when D/HH individuals use substances, they tend to be heavy users. CONCLUSIONS: These findings stress the importance of directing resources to the prevention and treatment of heavy alcohol use in the D/HH population, given that binge drinking is associated with a number of health problems and social consequences. Additionally, the continuation of this empirical work is rather urgent given recent legislative changes regarding cannabis use. D/HH individuals possess a number of risk factors for substance use disorder and, as such, may be more greatly impacted by these legislative changes than individuals from the general US population. It is imperative that this impact be captured by future research efforts in order to inform the development of prevention and intervention efforts for the traditionally underserved D/HH population.

Recovery Services and Outcomes in a State Psychiatric Hospital.

Recovery has emerged as a focus of mental health rehabilitation in the past decade. Many have suggested that various domains of recovery-orientated services are integrated to an efficacious mental health care system. In this study we examined the association of domains of recovery-oriented services with recovery outcomes among inpatients in a state psychiatric hospital. A convenience sample of 36 hospital patients participated in a survey that included two standardized scales, with one measuring 6 domains of recovery-orientation of hospital-based services and one measuring 5 aspects of patients' recovery outcomes. We used regression analysis to estimate the association between recovery-oriented services and recovery outcomes adjusting for gender, race, and education. Nearly 90% of patients had lengths of stay of more than 3 months. On average, patients reported receiving moderate levels of recovery-oriented services. Nevertheless those who reported receiving higher levels of recovery-oriented services also reported better recovery outcomes. Specifically three domains of recovery-oriented services, i.e., life goal vs. symptom management, individual tailored, and diversity of treatment options, are associated with better overall recovery and 3 specific aspects of recovery, namely willingness to ask for help, goal and success orientation, and reliance on others. The data from a small sample of patients at a state psychiatric hospital suggest that self-reported recovery-oriented services received are associated with better recovery outcomes. Future larger studies are warranted to confirm the study findings, and to examine whether a contemporary recovery-focused care model can facilitate even greater recovery outcomes.

Rheumatoid arthritis triple therapy compared with etanercept: difference in infectious and gastrointestinal adverse events.

Objective: The main aim of this study was to examine the differences between triple therapy (T: SSZ and HCQ added to MTX) and etanercept (E) added to MTX with regard to the infectious and gastrointestinal (GI) adverse events (AEs) reported in The Rheumatoid Arthritis Comparison of Active Therapies Trial. Methods: The patients were 353 RA MTX incomplete responders who were randomized to T (n = 178) or E (n = 175). Of these, 88 patients were switched to the alternative treatment from the initial treatment (E or T) at 24 weeks per protocol. Infectious and GI serious AEs (SAEs) and non-serious AEs (NAEs) were reported during 48 and 4 weeks after the intervention period. Generalized linear models were used to estimate the incidence rate ratios (IRRs) of AEs between the two therapies. Results: Patients on E therapy were more likely to have infectious NAEs (IRR = 1.56, 95% CI: 1.11, 2.19). There was a greater number of infectious SAEs that occurred when patients received E than T therapy [12 E (6.9%) vs 4 T (2.2%), P = 0.19]. Pneumonia was the most common infectious SAE for both treatments [6 E (3.4%) and 2 T (1.1%)]. Conversely, patients who were on E were less likely to have GI NAEs than those on T therapy (IRR = 0.62, 95% CI: 0.40, 0.94). The most common GI SAE reported was GI haemorrhage, which occurred among three patients on E (1.7%). Conclusion: This study provides evidence of different likelihoods of infectious and GI AEs associated with two common, equally effective treatments for RA patients who have had incomplete responses to MTX. Trial registration: ClinicalTrials.gov, http://clinicaltrials.gov , NCT00405275.

Meta-Analysis of Odds Ratios: Current Good Practices.

BACKGROUND: Many systematic reviews of randomized clinical trials lead to meta-analyses of odds ratios (ORs). The customary methods of estimating an overall OR involve weighted averages of the individual trials' estimates of the logarithm of the OR. That approach, however, has several shortcomings, arising from assumptions and approximations, that render the results unreliable. Although the problems have been documented in the literature for many years, the conventional methods persist in software and applications. A well-developed alternative approach avoids the approximations by working directly with the numbers of subjects and events in the arms of the individual trials. OBJECTIVE: We aim to raise awareness of methods that avoid the conventional approximations, can be applied with widely available software, and produce more-reliable results. METHODS: We summarize the fixed-effect and random-effects approaches to meta-analysis; describe conventional, approximate methods and alternative methods; apply the methods in a meta-analysis of 19 randomized trials of endoscopic sclerotherapy in patients with cirrhosis and esophagogastric varices; and compare the results. We demonstrate the use of SAS, Stata, and R software for the analysis. RESULTS: In the example, point estimates and confidence intervals for the overall log-odds-ratio differ between the conventional and alternative methods, in ways that can affect inferences. Programming is straightforward in the 3 software packages; an appendix, Suppemental Digital Content 1 (http://links.lww.com/MLR/B335) gives the details. CONCLUSIONS: The modest additional programming required should not be an obstacle to adoption of the alternative methods. Because their results are unreliable, use of the conventional methods for meta-analysis of ORs should be discontinued.

Spiritual distress of military veterans at the end of life.

OBJECTIVE: Although combat experiences can have a profound impact on individuals' spirituality, there is a dearth of research in this area. Our recent study indicates that one unique spiritual need of veterans who are at the end of life is to resolve distress caused by combat-related events that conflict with their personal beliefs. This study sought to gain an understanding of chaplains' perspectives on this type of spiritual need, as well as the spiritual care that chaplains provide to help veterans ease this distress. METHOD: We individually interviewed five chaplains who have provided spiritual care to veterans at the end of life in a Veterans Administration hospital. The interviews were recorded, transcribed, and analyzed based on "grounded theory." RESULTS: Chaplains reported that they frequently encounter veterans at the end of life who are still suffering from thoughts or images of events that occurred during their military career. Although some veterans are hesitant to discuss their experiences, chaplains reported that they have had some success with helping the veterans to open up. Additionally, chaplains reported using both religious (e.g., confessing sins) and nonreligious approaches (e.g., recording military experience) to help veterans to heal. SIGNIFICANCE OF RESULTS: Our pilot study provides some insight into the spiritual distress that many military veterans may be experiencing, as well as methods that a chaplain can employ to help these veterans. Further studies are needed to confirm our findings and to examine the value of integrating the chaplain service into mental health care for veterans.

Acupuncture and relaxation response for craving and anxiety reduction among military veterans in recovery from substance use disorder.

BACKGROUND AND OBJECTIVES: Substance use disorder (SUD) is a major health issue, especially among military veterans. We previously reported the effects of auricular acupuncture and the relaxation response (RR) on reducing craving and anxiety following 10-week interventions among veterans who were in recovery from SUDs. Our current analysis examines effects following each intervention session and RR daily practice. METHODS: We conducted a three-arm randomized controlled trial on residents of a homeless veteran rehabilitation program. Sixty-Seven enroled participants were randomly assigned to acupuncture (n=23), RR (n=23), or usual care (n=21). Participants in the two intervention groups rated their degree of craving for substance on a scale of 1-10 and anxiety levels on a scale of 1-4 (total score 20-80) before and after each intervention session. Mixed effects regression models were used for analysis. RESULTS: Craving and anxiety levels decreased significantly following one session of acupuncture (-1.04, p=.0001; -8.83, p<.0001) or RR intervention (-.43, p=.02; -4.64, p=.03). The level of craving continued to drop with additional intervention sessions (regression coefficient b=-.10, p=.01, and b=-.10, p=.02 for acupuncture and RR groups, respectively). Number of daily practice days of RR-eliciting techniques is also associated with reduction in craving ratings (b=-.02, p=.008). CONCLUSIONS: Findings demonstrate the value of attending regular acupuncture and RR-eliciting intervention sessions, as well as the daily practice of RR-eliciting techniques. SCIENTIFIC SIGNIFICANCE: Substance addiction is a complex disease and effective treatment remains a challenge. Our study findings add to the scientific evidence of these two non-pharmaceutical approaches for SUD.

End-of-life spiritual care at a VA medical center: chaplains' perspectives.

OBJECTIVE: Spiritual care is an essential component of quality palliative care. Recognizing the importance, the Department of Veterans Affairs (VA) mandates the inclusion of chaplains in a palliative care consult team (PCCT). The purpose of this study is to explain the process and content of spiritual care provided in a VA Medical Center from chaplains' perspectives. METHOD: Five Christian chaplains who provide care to patients at end of life were interviewed. Each interview was recorded and transcribed. Analysis based on the grounded theory was used to identify themes from each interview question. RESULTS: The PCCT in this study appeared to have a strong referral and communication system in which every palliative care patient was seen by a chaplain and the care plan was discussed with an interdisciplinary team. Chaplains reported providing a range of services, which addressed religious, spiritual, emotional, family, and illness concerns. Chaplains were aware of the unique spiritual needs of veterans, including working through guilt for killing in war and requiring forgiveness. Chaplains' ideas for improvement of spiritual care services included increasing time to provide care, providing bereavement care and support to families, and adding chaplains with different religious backgrounds. Chaplains reported how their own spirituality influenced the care they provided. SIGNIFICANCE OF RESULTS: Spiritual care in the VA can include a range of services and should consider the unique needs of the veteran population. Future studies can build upon our findings from chaplains to learn about the perspectives of patients, family, and other healthcare providers of spiritual care. This information would allow identification of strengths of current spiritual care practices and areas for care improvement, and ultimately could improve the well-being of patients at the end of life.

Psychobiological changes from relaxation response elicitation: long-term practitioners vs. novices.

OBJECTIVE: The relaxation response (RR) is a physiological state that is the counterpart to the stress response. We investigate the psychological and biological effects, as well as the correlation between these two effects that are associated with short-term vs. long-term practice of techniques that elicit the RR ("RR practice"). METHODS: The study comprised both a cross sectional and an 8-week prospective design. The study sample included individuals with a long-term RR practice ("long-term practitioners" n = 28) and those with no prior RR practice experience ("novices" n = 28). The novices received 8 weeks of RR-elicitation training ("RR training") for the prospective analysis (short-term practice). RESULTS: Long-term practitioners reported lower levels of psychological distress than the novices before they received RR training. As a result of the 8-week RR training, novices significantly reduced their psychological distress to levels comparable to that of long-term practitioners. Long-term practitioners had greater immediate (after listening to a RR-eliciting CD) decreases in psychological distress level than the 8-week trained novices. Furthermore, the reduction in psychological distress levels for long-term practitioners correlated with a reduction in biological measures of stress, after controlling for baseline values. There was no reduction in biological measures and no correlation with psychological measures in the 8-week trained novices. CONCLUSIONS: While our data indicate that even a short-term 8-week RR-eliciting practice can decrease psychological distress levels, only after years of RR practice does psychological distress reduction coincide with biological change.

Stress management versus lifestyle modification on systolic hypertension and medication elimination: a randomized trial.

Isolated systolic hypertension is common in the elderly, but decreasing systolic blood pressure (SBP) without lowering diastolic blood pressure (DBP) remains a therapeutic challenge. Although stress management training, in particular eliciting the relaxation response, reduces essential hypertension its efficacy in treating isolated systolic hypertension has not been evaluated. We conducted a double-blind, randomized trial comparing 8 weeks of stress management, specifically relaxation response training (61 patients), versus lifestyle modification (control, 61 patients). Inclusion criteria were >or=55 years, SBP 140-159 mm Hg, DBP <90 mm Hg, and at least two antihypertensive medications. The primary outcome measure was change in SBP after 8 weeks. Patients who achieved SBP <140 mm Hg and >or=5 mm Hg reduction in SBP were eligible for 8 additional weeks of training with supervised medication elimination. SBP decreased 9.4 (standard deviation [SD] 11.4) and 8.8 (SD 13.0) mm Hg in relaxation response and control groups, respectively (both ps <0.0001) without group difference (p=0.75). DBP decreased 1.5 (SD 6.2) and 2.4 (SD 6.9) mm Hg (p=0.05 and 0.01, respectively) without group difference (p=0.48). Forty-four (44) in the relaxation response group and 36 in the control group were eligible for supervised antihypertensive medication elimination. After controlling for differences in characteristics at the start of medication elimination, patients in the relaxation response group were more likely to successfully eliminate an antihypertensive medication (odds ratio 4.3, 95% confidence interval 1.2-15.9, p=0.03). Although both groups had similar reductions in SBP, significantly more participants in the relaxation response group eliminated an antihypertensive medication while maintaining adequate blood pressure control.

The combined effect of relaxation response and acupuncture on quality of life in patients with HIV: a pilot study.

OBJECTIVES: Treatment advances have transformed human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) into a chronic manageable disease; quality of life (QoL) has become an important health outcome. Some studies have shown the individual effects of acupuncture and the relaxation response (RR) in improving QoL of patients with HIV/AIDS. In light of the presumed shared features of acupuncture and the RR, we conducted a pilot study to examine the effects of adding the RR to usual acupuncture treatment on improving the QoL of HIV/AIDS patients. DESIGN: Two-arm double-blind randomized controlled trial. SETTINGS/LOCATION AND SUBJECTS: We enrolled 119 patients with HIV/AIDS (mean age 46 years, 85% male) who had at least 1 of the highly prevalent HIV-related symptoms and who were receiving acupuncture treatment in an acupuncture clinic in Boston, MA. INTERVENTION: We randomized patients into intervention (N = 58) and control (N = 61) groups. All participants received individualized acupuncture treatments prescribed by their acupuncturists. While receiving acupuncture treatment, the intervention group wore earphones to listen to tapes with instructions to elicit the RR followed by soft music that was routinely played in the clinic; the control group listened only to soft music. OUTCOME MEASURES: Three (3) QoL scales: the Medical Outcomes Study HIV health survey, the Functional Assessment of HIV Infection, and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being, measured at baseline, 4-week, 8-week, and 12-week follow-ups. RESULTS: At the 12-week follow-up, the intervention group showed significant improvements in emotional (p = 0.0002), spiritual/peace (p = 0.02), physical (p = 0.003) and mental health (p = 0.0003) QoL from baseline. Results of mixed effects regression models indicated linear trends of improvement over time in these dimensions of QoL for the intervention group (p < 0.02). In the control group, the only significant improvement was observed in the emotional QoL (p < 0.01). The intervention group showed trends of greater improvements than the control group (p = 0.07 for 12-week physical health QoL). CONCLUSIONS: Data from this pilot trial suggested that adding the RR to acupuncture may enhance improvement in QoL of patients with HIV/AIDS. Further investigation on this putative synergistic effect is warranted.

Relaxation response with acupuncture trial in patients with HIV: feasibility and participant experiences.

OBJECTIVES: The study of complementary and alternative medicine (CAM) using a randomized, controlled trial (RCT) design poses challenges, such as treatment standardization and blinding. We designed an RCT, which avoided these two common challenges, to evaluate the effect of adding the relaxation response (RR) to usual acupuncture treatment. In this paper, we report on the feasibility and patients' experience from the study participation. DESIGN, SETTING, AND SUBJECTS: Our study was a two-arm, double-blind RCT conducted in an acupuncture clinic in Boston. Study subjects were patients with human immunodeficiency virus/autoimmunodeficiency syndrome (HIV/AIDS), who reported having at least one of the highly prevalent HIV-related symptoms, and were receiving acupuncture treatment. INTERVENTION: The intervention group wore earphones to listen to tapes with instructions to elicit the RR and also soft music while receiving acupuncture treatment, while the control group only listened to soft music. The intervention group was also required to listen to the RR tapes at home daily. OUTCOME MEASURES: A study evaluation was completed upon termination of the 12-week study (36 intervention and 44 control patients). RESULTS: A majority of participants in both groups reported: no discomfort wearing earphones (82.9%, 81.8%); the study met their expectations (87.1%, 85.4%); and they would recommend the study to others (91.1%, 90.5%). Intervention participants reported better experiences with the tapes than the control group (p = 0.056) (72.4% versus 52.8% felt better with tapes; 3.5% versus 16.7% felt better without tapes; and 24.1% versus 30.6% felt no difference). Intervention participants were also more likely than the control group (p = 0.02) to report positive emotional/physical/spiritual changes (45.5% vs. 20.9%) and relaxed/peaceful/calm feelings (30.3% vs. 25.6%) from the study participation. CONCLUSIONS: We demonstrated the feasibility of conducting a unique trial that examined the synergistic effects of two types of CAM practices. The intervention group reported more positive study-related experiences than the control group.

Correction: Relaxation Response Induces Temporal Transcriptome Changes in Energy Metabolism, Insulin Secretion and Inflammatory Pathways.

[This corrects the article DOI: 10.1371/journal.pone.0062817.].

Predictors of Employment Burnout Among VHA Peer Support Specialists.

OBJECTIVE: This study evaluated three domains of job burnout (emotional exhaustion, depersonalization, and personal accomplishment) and factors associated with burnout in a national sample of peer specialists (PSs) employed at 138 Veterans Health Administration (VHA) health care systems in 49 states. METHODS: Data were drawn from an observational study in which participants (N=152) completed online, self-report surveys about their mental health recovery, quality of life, and employment experiences at baseline, six months, and 12 months. Levels of burnout were analyzed at each time point, and regression analyses that controlled for baseline levels identified potential predictors of burnout (demographic, clinical, and employment characteristics) at six and 12 months. RESULTS: Compared with previously published burnout levels of other mental health workers in the VHA, PSs reported similar levels of emotional exhaustion, depersonalization, and personal accomplishment. At baseline, increased burnout was correlated with white race, fewer hours providing direct services, greater psychiatric symptoms, and lower self-efficacy. However, analyses did not reveal strong predictors of burnout scores at six or 12 months. CONCLUSIONS: In the first study to prospectively examine job burnout among PSs employed by the VHA, results illustrate the nuanced experience of burnout over a 12-month period and suggest the need for replication and further research on employment experiences of this emerging workforce.

Job satisfaction of Department of Veterans Affairs peer mental health providers.

OBJECTIVES: Department of Veterans Affairs (VA) peer specialists and vocational rehabilitation specialists are Veterans employed in mental health services to help other Veterans with similar histories and experiences. Study objectives were to (a) examine job satisfaction among these employees, (b) compare them to other VA mental health workers, and (c) identify factors associated with job satisfaction across the 3 cohorts. METHODS: The study sample included 152 VA-employed peer specialists and 222 vocational rehabilitation specialists. A comparison group included 460 VA employees from the same job categories. All participants completed the Job Satisfaction Index (11 aspects and overall satisfaction ratings). Linear regression was used to compare job satisfaction and identify its predictors among the 3 cohorts. RESULTS: Job satisfaction was fairly high, averaging "somewhat satisfied" to "very satisfied" in 6 (peer specialists) and 9 (vocational rehabilitation specialists) of the 11 aspects and overall job ratings. Adjusting for length of employment, age and gender resulted in no significant group differences with 2 exceptions: White peer specialists were less satisfied with pay and promotion opportunities than vocational rehabilitation specialists and comparison-group employees. Across all cohorts, shorter length of time employed in the job was associated with higher job satisfaction. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The high job satisfaction levels among the 2 peer cohorts suggest support for the policy of hiring peer specialists in the VA. Furthermore, the results are consistent with those of the nonveteran samples, indicating that integrating peer providers into mental health care is possible in VA and non-VA settings.

Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration?

OBJECTIVES: To identify the extent of inappropriate prescribing using criteria for proper use developed by the Agency for Healthcare Research and Quality (AHRQ) and dose-limitation criteria defined by Beers, as well as to describe duration of use and patient characteristics associated with inappropriate prescribing for older people. DESIGN: Retrospective national Veterans Health Administration (VA) administrative database analysis. SETTING: VA outpatient facilities during fiscal year 2000 (FY00). PARTICIPANTS: Veterans aged 65 and older having at least one VA outpatient visit in FY00 (N=1,265,434). MEASUREMENTS: Operational definitions of appropriate use were developed based on recommendations of an expert panel convened by the AHRQ (Zhan criteria). Inappropriate use was identified based on these criteria and inappropriate use of drugs per Beers criteria for dose-limitations in older people. Furthermore, duration of use and patient characteristics associated with inappropriate use were described. RESULTS: After adjusting for diagnoses, dose, and duration, inappropriate prescribing decreased from 33% to 23%. Exposure to inappropriate drugs was prolonged. Pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents constituted 61% of inappropriate prescribing. Whites, patients with psychiatric comorbidities, and patients receiving more medications were most likely to receive inappropriate drugs. Women were more likely to receive Zhan criteria drugs; men were more likely to receive dose-limited drugs CONCLUSION: For the most part, the Zhan criteria did not explain inappropriate prescribing, which includes problems related to dose and duration of prescriptions. Interventions targeted at prescriptions for pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents may dramatically decrease inappropriate prescribing and improve patient outcomes.

Mental health and quality of life among veterans employed as peer and vocational rehabilitation specialists.

OBJECTIVE: The study compared employment experiences, mental health recovery, and quality of life among peer specialists and vocational rehabilitation (VR) specialists hired by the U.S. Department of Veterans Affairs (VA), the VR specialists under the Homeless Veterans Supported Employment Program. Employment characteristics associated with mental health recovery were examined. METHODS: The study was a national, observational survey of 152 peer specialists and 222 VR specialists across 138 VA health care systems in 49 states. The survey, administered over the Internet, included measures describing participant characteristics, employment factors, mental health, and quality of life. The two cohorts were compared by using t tests or chi square tests. Multiple regression analysis controlling for participant characteristics was used to identify employment factors associated with mental health and quality of life. RESULTS: Peer specialists were more likely than VR specialists to share recovery stories, serve as a role model or mentor, and advocate for veterans. Activities by VR specialists tended to focus more narrowly on job skills. Overall, after adjusting for multiple comparisons, the analysis found high levels of mental health and average quality of life for both cohorts, with no significant differences between the groups. Satisfaction with amount of supervision was consistently associated with aspects of mental health recovery, including work-related and helping-related quality of life, for both cohorts. CONCLUSIONS: The results highlight the value of work and the importance of supervision in realizing both the adoption of recovery-oriented services and the promotion of mental health in a community of veterans serving each other.

Patient recruitment to a randomized clinical trial of behavioral therapy for chronic heart failure.

BACKGROUND: Patient recruitment is one of the most difficult aspects of clinical trials, especially for research involving elderly subjects. In this paper, we describe our experience with patient recruitment for the behavioral intervention randomized trial, "The relaxation response intervention for chronic heart failure (RRCHF)." Particularly, we identify factors that, according to patient reports, motivated study participation. METHODS: The RRCHF was a three-armed, randomized controlled trial designed to evaluate the efficacy and cost of a 15-week relaxation response intervention on veterans with chronic heart failure. Patients from the Veterans Affairs (VA) Boston Healthcare System in the United States were recruited in the clinic and by telephone. Patients' reasons for rejecting the study participation were recorded during the screening. A qualitative sub-study in the trial consisted of telephone interviews of participating patients about their experiences in the study. The qualitative study included the first 57 patients who completed the intervention and/or the first follow-up outcome measures. Factors that distinguished patients who consented from those who refused study participation were identified using a t-test or a chi-square test. The reason for study participation was abstracted from the qualitative interview. RESULTS: We successfully consented 134 patients, slightly more than our target number, in 27 months. Ninety-five of the consented patients enrolled in the study. The enrollment rate among the patients approached was 18% through clinic and 6% through telephone recruitment. The most commonly cited reason for declining study participation given by patients recruited in the clinic was 'Lives Too Far Away'; for patients recruited by telephone it was 'Not Interested in the Study'. One factor that significantly distinguished patients who consented from patients who declined was the distance between their residence and the study site (t-test: p <.001). The most frequently reported reason for study participation was some benefit to the patient him/herself. Other reasons included helping others, being grateful to the VA, positive comments by trusted professionals, certain characteristics of the recruiter, and monetary compensation. CONCLUSIONS: The enrollment rate was low primarily because of travel considerations, but we were able to identify and highlight valuable information for planning recruitment for future similar studies.

Relaxation response for Veterans Affairs patients with congestive heart failure: results from a qualitative study within a clinical trial.

Fifty-seven veterans with congestive heart failure were interviewed about their experiences and changes after participating in a three-armed randomized trial: relaxation response (RR) training, cardiac education, and usual care. The interviews were tape-recorded, transcribed, and analyzed. Half of the 20 RR group interviewees reported physical improvements, and 13 reported emotional improvements. These improvements went beyond disease management to lifestyle changes and improved family/friends relationships. Five of 16 cardiac education group interviewees reported physical improvements, and eight reported emotional improvements. These improvements consisted of a better understanding of the disease and resulted in feeling more at ease. None of the usual care group interviewees reported any improvement from study participation. Although group support contributed to the benefits reported by RR and cardiac education groups, the use of the RR techniques seems to be the factor that distinguished the improvements. The value of the RR in congestive heart failure health care is suggested by the results.

Service utilization among disabled Puerto Rican elders and their caregivers: does acculturation play a role?

OBJECTIVE: This study examined the relationship between language acculturation of disabled Puerto Rican elderly and their caregivers, their length of residence in mainland United States, and the utilization of formal services. METHODS: Language acculturation was measured by language use, understanding, and preferences. The sample of this study consisted of 194 dyads of disabled Puerto Rican elders 60 years and older, and their primary caregivers in an urban center in the northeast. RESULTS: Length of residence in the United States, but not language acculturation, of the disabled Puerto Rican elder and the caregiver was related to elder's use of formal services. Caregivers, whose own children were born in Puerto Rico as opposed to mainland United States, were more likely to use formal services. DISCUSSION: Language acculturation, although a commonly used measure of acculturation, may be of decreasing importance in explaining service utilization, as bilingual services become increasingly available. Practice implications are discussed.

Relaxation response induces temporal transcriptome changes in energy metabolism, insulin secretion and inflammatory pathways.

The relaxation response (RR) is the counterpart of the stress response. Millennia-old practices evoking the RR include meditation, yoga and repetitive prayer. Although RR elicitation is an effective therapeutic intervention that counteracts the adverse clinical effects of stress in disorders including hypertension, anxiety, insomnia and aging, the underlying molecular mechanisms that explain these clinical benefits remain undetermined. To assess rapid time-dependent (temporal) genomic changes during one session of RR practice among healthy practitioners with years of RR practice and also in novices before and after 8 weeks of RR training, we measured the transcriptome in peripheral blood prior to, immediately after, and 15 minutes after listening to an RR-eliciting or a health education CD. Both short-term and long-term practitioners evoked significant temporal gene expression changes with greater significance in the latter as compared to novices. RR practice enhanced expression of genes associated with energy metabolism, mitochondrial function, insulin secretion and telomere maintenance, and reduced expression of genes linked to inflammatory response and stress-related pathways. Interactive network analyses of RR-affected pathways identified mitochondrial ATP synthase and insulin (INS) as top upregulated critical molecules (focus hubs) and NF-κB pathway genes as top downregulated focus hubs. Our results for the first time indicate that RR elicitation, particularly after long-term practice, may evoke its downstream health benefits by improving mitochondrial energy production and utilization and thus promoting mitochondrial resiliency through upregulation of ATPase and insulin function. Mitochondrial resiliency might also be promoted by RR-induced downregulation of NF-κB-associated upstream and downstream targets that mitigates stress.