Cannabis Grow

These guides were designed to help us understand any changes in our variables of interest and how they influenced self-management behaviors.Data analysis of the qualitative and quantitative data occurred at the same time, but were not integrated until both types of data were analyzed. In analyzing the quantitative data, we first assessed the distribution of all quantitative variables . We summarized baseline characteristics by using means, standard deviations, medians, interquartile ranges, and counts and percentages of women by substance use group , depending on the variable’s distribution. We used GEEs with an identity link function and an unstructured correlation structure to describe how social capital and substance use influences HIV self-management across the three time points. Separate models were fit for each HIV self-management outcome. In addition to the effect of social capital and substance use, we examined independent effects of age, discrimination, and traumatic events by adding these covariates to GEE models. All statistical analyses were conducted using Stata 14.0 with p values < .05 considered statistically significant. Qualitative data were managed using the qualitative data analysis program Dedoose and was analyzed by the research team using qualitative description methodology . Data were transcribed and examined by two research team members who coded the data using the constant comparative method, identifying patterns and themes . These team members met regularly during coding to discuss consistencies and inconsistencies in the data. A priori codes related to social capital, substance use, and self-management based on our literature review were initially applied, and then inductive codes were applied. Transcripts were revisited in a series of iterative steps to confirm coding classification and that theoretical saturation was reached. Variations on the themes and negative cases were identified to help understand the full range of data within codes.

A final codebook of themes, definitions,mobile grow systems and exemplar codes was created to aid analysis. Data were coded and analyzed using Dedoose version 8.0.42 . Study procedures are presented consistent with the Good Reporting of a Mixed Methods Study standards .Foundational to trust was the women’s communities and how the community could support or damage that trust. Many described their community as neighborly, “My neighborhood is a community, a family community. [There are] a lot of animals, people stay to themselves but say ‘hi, how you doing?’ We’re neighborly.” The community offered tangible resources to help women take care of their health needs. “I go to community meals once a month and see the same people there each time.” Less tangible but equally important was how community comes together and transmits information that helps WLHIV recover from their addictions. When describing a vigil held by her community to commemorate a tragedy, one woman said, “When you riding down the street and see a telephone pole with teddy bears, signs, and balloons, it makes you think . . . it [reminds] me of the things I was doing in the past, drugs and stuff.” By helping confer a sense of identity, the provision of resources, and ultimately value, a woman’s community can influence her trust, which can affect her self-management behavior. But some WLHIV reported detrimental aspects of her community, including safety, noise, and recently moving into a new neighborhood. For example, a WLHIV was hesitant to access her community resources because of perceived safety threats. “There is a community center but I don’t go there. I’m terrified because it’s a lot of guys who just hang out . . . .” Others did not feel the community helped improve health behaviors and described unhealthy community norms. “[To deal with hard times], my community gets high.” In these cases, community was still influential but in a way that did not promote healthy behaviors.In our mixed methods study examining the influence of social capital on HIV self-management among WLHIV, we observed that social capital is important for self-management, and we were able to integrate new qualitative data on how social capital does this.

Social capital has consistently been linked to improved health outcomes among adults living with HIV, but what has been missing from the literature is how it does that. Our quantitative data are consistent with this literature and clearly demonstrate that better social capital is associated with better self-management in WLHIV. Yet by qualitatively examining the components of social capital in-depth, we describe how three key components of social capital can improve HIV self-management in this population–trust as a powerful yet scarce resource, a WLHIV’s community directly influences that trust, and having a strong value of self. Each of these components required that WLHIV actively and positively engage with their social network. However, for women trying to overcome a substance addiction, this can be particularly challenging since aspects of her social network can trigger substance use either directly or via social capital mechanisms we describe. Furthermore, being identified as a current or former substance user may fracture existing social networks or prevent WLHIV from being more connected to their community, which could influence their access to certain types of social capital. Our qualitative data suggest that rebuilding a strong social network, one that enhances trust in others and in oneself, increases engagement with her community, and ultimately helps a WLHIV believe in her value as a person. Our data also provide insight into how nurses can help enhance social capital in this population, including having members of the health care team spend the time necessary to earn and keep the trust of WLHIV. Our quantitative data suggest that such efforts may help to improve HIV self-management behavior in this population. Recently, investigators described the importance of building trust in HIV care and engagement over time . Our data support those findings and highlight that the long-term trust-building process is critical for those living with chronic HIV infection, and perhaps this process may be even more critical among highly vulnerable populations. However, our qualitative data also reveal other ways to improve social capital, and obtain the benefits derived from it, that are more challenging to implement.Whether offering tangible goods, information, kindness, or effective use of the school infrastructure, our participants derived much-needed resources from their community, which led to an increased sense of value. This increased sense of value motivated WLHIV to engage in HIV self-management behaviors to help improve their health. These data suggest that continuing to advocate for policies and resources to connect neighbors to one another and emphasizing our similarities can help improve the health of WLHIV. We also found quantitative evidence that WLHIV face challenges to engaging in HIV self-management that may be influenced by recent traumatic events. While this is consistent with other studies that highlight that levels of trauma exposure influence HIV outcomes, lifetime trauma is also ubiquitous in this population. In high-resource settings, such as ours, trauma and interpersonal violence are estimated to be experienced by 68% to 95% of WLHIV .

Recognizing the influence of trauma on poor health outcomes in WLHIV and recognizing that trauma can be successfully treated,cannabis grow supplies clinicians and advocates are adopting trauma-informed care models for HIV care. Trauma-informed care models emphasize that both the clinician’s and the individual’s recognition of and response to trauma and create an environment that is safe and empowering for WLHIV . Our quantitative and qualitative data suggest that promoting social capital both within the clinic setting and in the community may temper the negative impact of trauma and provide previously untapped avenues for addressing substance use with WLHIV. However, we also found differences between our findings and existing literature. A key difference is that we did not find diminished HIV medication adherence between current and previous substance users. Substance use is considered one of the main barriers to achieving higher rates of viral suppression when an HIV diagnosis is established . The use of different substances in individuals with HIV is associated with lower antiretroviral therapy adherence , increased missed clinic visits , and decreased knowledge of HIV status . This previous research suggests that fundamental resources such as money, time, and energy will mainly be used to acquire and use substances with little attention directed to self-care. While we observed a relationship between substance use and global HIV self-management, we did not observe a relationship between substance use and HIV medication adherence. There are several possible explanations for this. First, the field of HIV has done a phenomenal job of teaching all PLHIV of the primary need to take HIV medications every day. As the medications have improved and many PLHIV are taking one HIV medication once a day, it has gotten easier to adhere to these medications. So despite many WLHIV facing personal and structural barriers to HIV medication adherence, the importance of adherence coupled with simplified regimens may help them overcome these barriers. In addition, our sample of volunteer participants is small, and though we saw a negative effect of substance use on HIV medication adherence, our study may have been under powered to detect a statistically significance effect. In addition to our small sample size, there are several other limitations that should be considered. First, all WLHIV were recruited from a single site in the Midwestern United States. The demographics and substance use patterns of our sample limit generalizability of our findings. We also did not use member checking to help enhance the rigor of our findings. However, we tried to overcome these limitations by employing several strategies including triangulating both qualitative and quantitative data, having prolonged engagement between the community of WLHIV and research team, and having multiple team members engaged in our data integration. Integration of quantitative data with our rich qualitative data led to new insights into how social capital can be fostered among WLHIV and how it can be used to overcome challenges faced by them. This would not have been possible without data integration. In conclusion, social capital was associated with better HIV self-management and HIV medication adherence over time, perhaps offsetting the negative effects of substance use. Social capital increased trust, fostering a strong sense of community, and helped WLHIV feel valued. These findings enhance understanding of how nurses can support WLHIV who are addicted to illicit substances and to help them maintain sobriety and improve their HIV self-management.The epidemic of vaping-related acute lung injury is a public health disaster. As of October 3, 2019, the CDC had received reports of 1,080 lung injury cases from 48 states and one U.S. territory, with 18 deaths confirmed in 15 states . Almost 80% of the cases are younger than 34 years of age, with 38% younger than 21 years. Many, but not all, of the cases involved vaping of products containing tetrahydrocannabinol . The research letter by Triantafyllou and colleagues in this issue of the Journal describes the features of six cases seen this past summer at the University of Pittsburgh Medical Center . The cases are emblematic of those reported to the CDC. They were young men who presented with respiratory and gastrointestinal complaints who reported regular use of vaporized cannabis and nicotine products. The patients showed evidence of a systemic inflammatory response with leukocytosis, and chest imaging showed bilateral, multi-focal ground-glass opacifications. The patients were treated with antibiotics until cultures came back as negative, and most patients received corticosteroids. Two of the patients required mechanical ventilation. Fortunately, no one died. The case descriptions from the University of Pittsburgh team are similar to those of a larger case series published earlier this year . One common finding in the two published case series is the prevalence of use of a cannabis product known as “Dank Vape.” What are Dank Vapes? According to the CDC, Dank Vapes are the most prominent in a class of largely counterfeit brands, with common packaging that is easily available online and used by distributors to market THC-containing cartridges . Public health officials in Wisconsin and Illinois, two of the states hit hardest by the vaping-related acute lung injury epidemic, interviewed 86 patients, and 66% said they had used THC products labeled as Dank Vapes .

Having examined the cutting experience of six among the 27 youths who narrated cutting and/or self-harm, it is evident that each has a highly distinctive profile while often invoking common themes of family relations and bodily experience, and we shall elaborate shortly a characteristic problematic of agency. Are these youths typical in any way, and if so typical of what? The challenges faced by many adolescents, certainly in the “Land of Enchantment” that is New Mexico’s self-description, are recognizable among these young people often in amplified form and complicated by additional factors that amount to extraordinary conditions both personal and structural . Their situations are often vulnerable and precarious, but there are various forms of vulnerability and precarity. They are, for example, not children who live “in the streets” like homeless children without families but children who are “in the system” with a trajectory back and forth from home to various settings of institutional care. These institutions vary along the axis of emphasizing what Hejtmanek has characterized as psychiatric custody and therapeutic process, terms that bear overtones of the carceral and the caring respectively. Indeed, conditions in some of the facilities where we interviewed study participants were sufficiently oppressive to count as just as much a form of structural violence as conditions of poverty, gender violence, and gang activity. Yet the larger scale politics of health care created another form of structural violence in the form of severe contraction of services under the regime of “managed care” that was ongoing throughout the duration of our project. Payment for both residential treatment and day treatment was approved with decreasing frequency, and the average length of covered stay decreased drastically. From the standpoint of CPH clinicians,vertical grow system this meant that patients were often being discharged to disorganized family environments which did not provide sufficient opportunity for their condition to stabilize or to less intensive levels of care for which they were not prepared .

Yet whether the experience leans toward the carceral or the caring depends not only on the character of the institution but on the different pathways into the hospital including through the police, the courts, physicians, families, and in some instances, volunteering. Once in the system, all are exposed to and inculcated with discourses of diagnosis, coping skills, and medication.5 Finally, although cutting is prominent among these youths who have been psychiatric inpatients, on the one hand not all of them are cutters and on the other not all cutters come to be psychiatric patients.What is critical in making anthropological sense of their experience is that suffering is not a barrier to interpretation and understanding because it partakes of the broader spectrum of human experience. Moreover, while we have a specific existential, ethical, and political concerns for the “extraordinary conditions” of this particular group of adolescent self-cutters who are psychiatric inpatients , their experience enacts and partakes of “fundamental human processes” and may highlight them in a way from which we can learn as much about the human condition as about a distinct pathological or cultural process. In other words, regardless of how troubled any one of them might be or appear to be, a careful look at their experience reveals the operation of fundamental human processes in a way that allows them to be seen not just as idiosyncratic individuals or representatives of a marginal category of afflicted subjectivity, but as having much in common with those who might more readily be classified as “typical.”With these considerations in mind, we must outline the range of issues that define the domain of cutting for these youths in treatment as a first step in understanding similarities and differences in their modes of bodily being in the world. Is cutting a learned behavior, and if so can it be called a “technique of the body” in the sense in which Mauss used that term? The answer is yes in situations where it is associated with the cultural complex defined by young people who define themselves as “emo,” “goth,” or “scene.” In this circumstance, the delicate cuts are, as one participant’s mother said, like a “badge of honor.”

There is indeed an element of technique evident in one girl’s report that while hospitalized another girl patient told her “you are cutting yourself the wrong way, you are supposed to cut down.” Particularly among SWYEPT participants, this learning could take place among peers in the hospital or residential care facility as well as at school or from siblings at home, and the mother of one of our male participants acknowledged that all three of her sons were “cutters.” Nevertheless, it is possible for cutting to be primarily a self-discovered practice, evident in one girl’s comment that “I was shaving my arm and I accidentally cut myself and I liked the way that it felt and that is when I started cutting. That is when I started purposefully cutting myself on my wrist.” These findings compare with a study of participants in online message boards that indicated a substantial group of cutters who had never heard of the practice before engaging in it, some even reporting they thought they “invented” it, not knowing they would feel better before they cut for the first time even if it was accidental, while a third of respondents had heard of or knew someone who cut before they began; self-learners typically began cutting at age 16 while those who learned from others began at age 14 . Cutting as an Emo technique is also most often associated with the apparently careful use of a razor blade and fits the model of “delicate cutting,” whereas among SWYEPT participants, there was in addition a range of implements used: fingernails, pencil, knife, toothpick, thumbtack, scissors, paperclip, binder ring, and broken glass. Using such a range of implements is not unique to these youths . Also in relation to Emo/Goth culture, cutting stands in relation to tattooing and body-piercing, the principal diacritics being that the latter are typically done by others and not by oneself and that the latter are often for performative display while cutting is typically concealed.Girls who wear “lots of bracelets” may be both adorning themselves and concealing the scars on their wrists. Placement is stereotypically on arms and legs, wrists and ankles, and one is inclined to interpret as more idiosyncratic instances such as those we recorded of poking under one’s fingernails, cutting one’s thumb, or cutting one’s stomach. Hodgson’s survey respondents often tried to pass by concealing their scars or created cover stories but sometimes also disclosed their cutting with an excuse for doing something wrong or a justification that it was a way to deal with emotional pain,cannabis grow rack but these disclosures did not include display as with stylized body modification.

With respect to severity, the continuum between delicate and deep cutting is significant among participants. On the mild end of the continuum, there are reports of scratching without drawing blood. Even dangerously deep cutting may be unintentional and, in the words of one mother, an instance of “going overboard” rather than aimed at serious self-harm or suicide. Likewise, even superficial cuts can be overdone, as in the report by one mother that her daughter had cut herself lightly with 63 times on various parts of her body. A final element of excess is the instance in which a boy carved his name in his leg and another in which a girl carved her boyfriend’s name in her arm. These are perhaps too conveniently expressive of gender stereotypes, specifically of the narcissistic boy and the infatuated girl.Onset of cutting can occur at quite a young age, and its duration varies as well. We have observed participants with only one transient episode of cutting, those in which it is habitual and compulsive and those who have had on-and-off periods of cutting with varying durations. This periodicity may occur either because conditions of stress may wax and wane or because the relieving effect of the cutting endures for a period of time before it in effect needs to be renewed.An instance of the former is a girl who, although she had been cutting herself periodically for several years, indicated that a recent episode was in relation to the conjunction of her grandfather dying and her boyfriend breaking up with her. A habitual instance is the boy who used a pencil or a toothpick as his instruments, though according to his mother he scratched but never broke his skin. He said, “Two months ago I started cutting myself. I just couldn’t stop cutting myself. I had the opportunity to do it, I couldn’t help it . . . sometimes it’s just no reason, other times, it’s just because I want to. It’s because I feel like it.” Notably, this boy indicated that the cutting did not make him feel better. The intentionality of cutting is complex, and as was the case among SWYEPT participants, cutting may be associated with other forms of self-harm such as head-banging, self-choking, bulimia, eraser burns, or drug abuse. The motivations typically reported for cutting in this study were depression, anger, frustration, stress, and tension. The intended results included relief, to feel good, to feel pain, to hurt oneself, and to see the blood. Notably, three of the participants reported that cutting did not make them feel better. With respect to integration of cutting into one’s identity as a mode of self-orientation, it was more common to hear that a young person “started cutting,” “cut myself,” or even “ended up cutting,” but there were instances of girls and a boy who declared either that “I am a cutter” or “I was a cutter.” The only other study of intentionality among adolescent inpatient cutters we have beenable to identify used the self-injury motivation scale II developed by Osuch, Noll, and Putnam , which taps factors including affect modulation, desolation, punitive duality, influencing others, magical control, and self-stimulation. The researchers found that the mean number of reasons cited for cutting themselves was 20 out of the 36 listed in the instrument as contributing to these factors and that 56% described their cutting as impulsive while 60% reported feeling emotional relief after cutting . Notably, males and females cited comparable reasons for self-injury, with a trend for females to use cutting for controlling negative affects more than males . Self-cutting is also not invariably linked to suicidality. Among girls who were SWYEPT participants, 18 reported suicidality, and 17 reported cutting; three of the cutters were not suicidal, and four of the suicidal girls were not cutters. Among boys, 14 participants reported suicidality, and 10 reported cutting; three cutters were not suicidal, and seven of the suicidal boys were not cutters. Moreover, cutting was by no means the only or the most common method for suicide attempts by participants. In this respect, we note the study by Gulbas et al.which expressly focuses on the relation between suicidal behavior and nonsuicidal self-injury among Latina adolescents in the United States.Gulbas and colleagues identify a series of factors relevant to both NSSI and suicide that correspond to features we found among the SWYEPT participants, including family fragmentation, conflict, physical and sexual abuse, and domestic violence. The relationships among these factors are complex and are found cross-culturally, though they tend to be more severe with suicide than with NSSI . Given the multiple challenges faced by our study participants in New Mexico, and the extraordinary conditions that define the contours of struggle for coherence in their lives, a focus on the specific act of cutting offers a necessarily limited but existentially critical insight into the nature of their experience. Without a doubt this requires attending to the question of children’s agency as a capacity with which youth are endowed, as we have invoked by citing childhood studies literature and in our analysis of individual vignettes. Childhood studies scholars embrace a concept of agency as a reaction against models of childhood with more structural and chronological substrates, allowing children to be recognized as meaning makers rather than passive recipients of action .

While this supports provider concerns over an increase in antibiotic utilization, hospital CDI rates actually decreased by a mean of 5.5 nosocomial infections per 10,000 patient hours during the study period. Although some practitioners may feel some relief knowing that this study failed to find a CDI epidemic as the result of an overall protocol change, these results may be only one small piece in an overall concerning trend. Instead, it is important to recognize that there are more risks than just CDI with antibiotic exposure, risks that were not measured in this study. Subsequent studies should focus on rate of antibiotic use and the other risks that are involved with these mandated prescribing practices.Some of these include protonpump inhibitor exposure and poor compliance with the use of personal protective equipment.Healthcare facilities frequently implement new practices and staff educational procedures, which may have had an impact on the results and CDI rates.Although this study showed that rates of antibiotic administration increased explained by practice improvements and staff education. While the study was not designed to look at these effects, it provides hope that ongoing facility practices may be mitigating CDI risk despite increased antibiotic exposure. The use and abuse of stimulants has been increasing across the United States.Introduction: Our goal in this study was to identify stimulant abuser patients who are at specifically high risk of suicide attempt ,pots for cannabis plants in order to prioritize them in preventive and risk mitigation programs. Methods: We used the California State Emergency Department Database to obtain discharge information for 2011.

The SEDD contains discharge information on all outpatient ED encounters, including uninsured patients and those covered by Medicare, Medicaid, and private insurance. We identified SAT and stimulant abuse by using the relevant International Classification of Diseases, Ninth Revision, codes. Results: The study included 10,124,598 outpatient ED visits. Stimulant abuse was observed in 0.97% of ED visits. Stimulant abuse was more common among young and middle-aged males and people with low median household income. Moreover, it was more common among Native American and Black , followed by non-Hispanic White patients. The prevalence of SAT was 2.0% for ED visits by patients with a history of stimulant abuse, and 0.3% for ED visits without a history of stimulant abuse . The SATs were directly associated with stimulant abuse, younger age , and non-Hispanic White and Native American race. Association of SAT with stimulant abuse was stronger in female patients. Conclusion: Stimulant abuse was the only modifiable risk factor for suicide attempt in our study. Reaching out to populations with higher prevalence of stimulant abuse to control the stimulant abuse problem, may reduce the risk of SAT. In this regard, people who are at higher risk of SAT due to non-modifiable risk factors should be prioritized. Moreover, controlling stimulant abuse among women may be specifically effective in SAT prevention. [West J Emerg Med. 2022;23X–X.] cocaine use along with medical and non-medical amphetamine consumption. The risk, severity, and type of stimulant abuse have been shown to vary across different populations.1Various trends have been established in regard to different population demographics. For example, it has been shown that methampheta-mine is more prevalent in the western US, although this has been trending eastward.Cocaine and amphetamines have different mechanisms of action but similarly affect monoamine transporters.

Cocaine blocks the reuptake of neurotransmitters, while amphetamine releases more into the synapse.Therefore, when comparing the two drugs, methamphetamine affects dopamine balance in the brain for a longer period of time. This is one of the many factors that have led to the differential effects of these stimulants.In recent years, there has been an increase in overall prescriptions to college students, especially to those in academically stressful situations.Misuse of stimulants has been shown to cause multiple issues including tissue ischemia and long-term neurological changes. An apparent correlation has been observed between the increase in overall stimulant prescription to patients of varying ages and demographics and misuse of these stimulants, resulting in both physiological and neurological changes that could be prevented.Particularly, the neurological changes that result from stimulant abuse may increase their risk of suicide. Globally, suicide is the third leading cause of death in the 15-44 age group.6 Although a strong correlation between stimulant abuse induced neurological changes and suicide exists, various other factors contribute to the onset of suicidal thoughts. The rising concern with regard to impulsive suicidal thoughts, and their potential to claim lives, has spurred public health intervention efforts to provide support to these most vulnerable and at risk populations. Public health interventions in populations suffering from stimulant abuse can facilitate a reduction of suicide attempts in this demographic.Specific, targeted preventive efforts may reduce SAT in at-risk populations and help maintain mental and physiological health. An association between stimulant abuse and SAT has already been reported.We expanded on this work, accessing the 2011 State Emergency Department Database to determine which subgroups, if any, of stimulant-abuse populations are at increased risk of SAT. This subgroup analysis may inform targeted public health efforts focused on the most at-risk individuals. Analysis of over 10 million ED visits in California gave us insight into the relation between SAT and stimulant abuse in different patient populations.

Our findings cohere with previous findings and indicate that depressed or suicidal individuals are more likely to abuse stimulants and are increasingly susceptible to SAT. As the only modifiable risk factor in our study, stimulant abuse was more common in young and middle-aged, male, Native American, and Black patients with lower household income. We also found that stimulant abuse puts females at higher risk of SAT. The risk of SAT is prevalent across patient populations and increases with factors such as stimulant abuse.5 Not only does a SAT endanger the life of a vulnerable individual, it also psychologically affects the individual, families, communities, and society as a whole. The substantial impact that suicide has on the community necessitates public health intervention efforts to target high-risk populations. Young populations have been deemed increasingly at risk of suicide due to a variety of psychosocial stressors.Research stipulates that within these diverse, young populations,cannabis flood table females have proven to be the most vulnerable group.Suicide remains the second leading cause of death in individuals between the ages of 10- 34.Stimulant abuse contributes to the numerous stressors that young populations face.Public health prevention efforts within this demographic group may reduce the economic and human cost of suicide. The rising national trend in non-medical prescription stimulant abuse has allowed experts to discern the psychological factors that contribute to the start of recreational substance consumption.This work indicates that the initiation of abuse often follows discrete traumatic events.Therefore, the inefficiency of prescription medication as a coping mechanism may be attributed to these higher suicidal rates. A prominent correlation between lower median household income state quartile and increased stimulant abuse exists . Poor access to healthcare and high rates of depression in individuals of lower socioeconomic status contribute to psychological effects prompting non-medical stimulant abuse.Non-medical stimulant use has also been associated with other harmful habits including tobacco, alcohol, and other illicit drug use.Each of these habits has also been correlated to increased suicide risk, all of which may be contributing factors.Multi-variable analysis showed SAT is associated with stimulant abuse and younger age. One potential reason for this result may involve the absence of impulse control correlated with drug abuse.Meanwhile, the proportion of ED visits with associated stimulant abuse was higher in younger age groups. This pattern corroborates past research indicating increased non-medical stimulant use among college populations.Association of SAT with stimulant abuse , and higher prevalence of stimulant abuse in those who are younger in age indicates that young people should be targeted for active stimulant-abuse prevention and treatment interventions. We found a stronger association between SAT and stimulant abuse in females, in all age groups. Previous literature coheres with this finding. Gender differences in stimulants have been established both behaviorally and pharmacologically. Women have been known to undergo the telescoping effect, which stipulates that in the long term, females escalate from low-dose use to addiction faster than men.

The quicker increase in consumption rates has been attributed to hormonal fluctuations inherent with the menstrual cycle. This hormonal fluctuation has been shown to subject women to differential drug effects dependent on their menstrual phase.Women have been shown to be significantly more susceptible to physiological dependence, which is the most extreme classification of drug use in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. This is associated with an increase in extreme lifestyle changes attributable to drug administration and consumption.Suicide attempts are associated with Native American and White race. At the same time, stimulant abuse was more common in Native American, and to a lesser extent, White patients. This pattern indicates active stimulant-abuse prevention and treatment interventions could specifically reduce SAT in those racial groups. It has been well established in the literature that race plays a significant role in the type of substance being abused.The increased rate of cocaine abuse in Black populations has been attributed to distribution networks and the historic, structurally driven prevalence of cocaine in Black communities.White and Hispanic populations, on the other hand, have more commonly used amphetamines or are considered dual users of both stimulants.Interestingly, Asian/Pacific Islanders have also experienced a sharp increase in non-cocaine stimulant admissions to treatment centers.We were not able to differentiate the exact type of the stimulant in this study.During the research and writing of this paper, I had the opportunity to read and hear from other contributors to this volume reporting on other western states. I have been struck by the contrasts between the situation in Montana and that of other states, most notably New Mexico. The political situation in Montana is moving in the opposite direction of New Mexico. In November 2020, Montana experienced a political tsunami. After 16 years of mostly Republican controlled legislatures and a moderate Democratic governor, Republicans won solid control of both houses and the election of a “Make America Great Again” Republican Greg Gianforte. In sharp contrast to New Mexico, where at least in some instances progressive Ds defeated incumbent moderates in primaries, in Montana the trend curved in the opposite direction, with extreme right-wing candidates defeating a number of moderate Rs. The Rs swept all the races for statewide offices. At the national level, our one House member is a far-right Republican, and so is one of our senators. Trump carried the state by over 16 points. Montana has finally turned red and few if any seasoned hands anticipate this changing any time soon. Republicans hold 67 of 100 House seats and 31 of 50 Senate seats. This is the most lopsided Republican legislative majority since 1931.It is important to point out for readers not familiar with Montana politics of the significant changes in the state’s political landscape born of the 2020 electoral results. Montanans had grown accustomed to Republicans proposing far-right legislation but what legislation passed, or passed and survived the Democratic governor’s veto, was significantly tempered over the course of the previous 16 years. In the years previous to that, when Republicans held both the governor’s office and legislative majorities in one or both houses, the Montana Republican Party was different: it was much more heterodox. While it contained far-right voices, it also contained a number of moderate voices who often voted with Democrats to pass or stymy legislation favored by more right leaning Republicans. During the 2019 session, the “solutions caucus” was composed of 20 Republicans in the House and 10 in the Senate. We can get a view into the tone of Montana’s hard right turn from a story that garnered high media coverage in November 2021. Rep. Derek Skees, a prominent Republican, currently expected to run soon for the Public Service Commission, referred to the Montana State Constitution as a “socialist rag” that should be thrown out and replaced. The source of his ire was his accusation that state courts use it to defend a women’s right to choose, but I suspect the sources of his wrath run to other constitutional provisions as well. Journalist Eric Dietrich reported that “Spokespeople for the Legislature’s Republican majority leadership, Gov.

Based on this feedback, the baseline education expectations were revised to include completion of a percentage of resident post-shift assessments over the academic year, inversely proportional to a faculty member’s clinical load. During the first year , the requirements included only conference and module participation.Table 1 lists the final baseline education expectations required of faculty members. Before employing these education requirements, all faculty members were notified of the consequences of not fulfilling expectations, which included ineligibility for any academic incentive and an inability to participate in the voluntary ARVU system.In May 2018, stage two began, which involved the creation of an ARVU system to encompass all other academic activities. It was decided that the ARVU system would be voluntary, but to participate the baseline education expectations outlined in stage one had to be fulfilled. For the first step of this stage, the vice chair for education created a list of preliminary activities to be included in the ARVU system, such as teaching, lecturing, publications, grants, committee memberships, and leadership positions. These additional activities were ones in which faculty were already participating that aligned with the academic mission of the department, but had not been captured within the baseline education expectations, did not earn clinical hours reduction from the department or institution, or were not an implicit part of a faculty member’s role based on his or her leadership position. The thought was that activities that earned a clinical reduction in hours were already being financially rewarded, and this system was designed to recognize activities not yet distinguished. An example includes fellowship activities, which were not included because fellowship directors have a reduction in clinical hours to support their leadership role. After the initial list was assembled, it was shared with a select group of 11 leaders within the department,ebb and flow flood table including residency leadership, undergraduate medical education leadership, fellowship directors, the research division, and the pediatric emergency medicine division.

The participants were selected due to their various leadership roles in the department, their dedication to scholarly achievement in their own careers, and the high priority they placed on these activities within their respective divisions. These qualifications placed these faculty members in a prime position to help generate a comprehensive list of activities relevant to each division. After multiple discussions and written communications using a modified Delphi method, the group reached consensus on the activities that were to be included. As expected, some subjectivity was involved in the voting for various reasons, such as the activity being one in which the responsive faculty member participated in himself or herself, or differing opinions regarding how much preparation time might be needed for such things as a lecture. To help reduce this bias, the survey was sent to many faculty members with different roles and responsibilities to obtain a consensus and to diluteidiosyncratic points of view. Furthermore, the knowledge of and dedication to each activity that the chosen faculty members had and the descriptions provided helped to further reduce bias in the points system. The survey also included free-text fields where faculty could input additional activities that they felt should be added to the list. Of the 60 faculty members surveyed, 49 responded and completed the survey in its entirety. The activities, ranked from highest to lowest based on the mean score including standard deviations, are presented in Table 2.Activities with higher means earned more points. Any activities that were similar in description and mean score were assigned the same number of final points. We introduced the final list and point system at a faculty meeting prior to implementing, and after this final feedback round, we launched the system in December 2018. The free-text responses were also reviewed, and these activities were added to the list and also voted on by the faculty group to create the final list with points. The next steps for the project included creating a database where faculty could log their completed activities. We created a Google form that listed all activities in the ARVU system where faculty members could select the activity in which they participated.

Each activity had an associated drop down menu that asked for additional information, such as title, date, location, description, proof of activity, and an ability to upload documents. We then created a dashboard in the analytics platform Tableau , containing all activities. Statistics for the baseline educational expectations automatically loaded into the dashboard and could not be edited by faculty members.The full dashboard displayed each faculty member’s baseline education expectations, whether they had met requirements, the activities that they had entered into the ARVU point system, and total points earned to date . Final points were earned after academic leadership reviewed, approved, and signed off on each submitted activity. Each month, the system automatically e-mailed a link to each individual’s dashboard notifying faculty how many points they had earned to date and of any participation deficiencies. The medical school requires a teaching portfolio for faculty seeking promotion on the scholar track. This portfolio requires faculty to document their achievements in the following categories: teaching effort, mentoring and advising, administration and leadership, committees, and teaching awards. All ARVU activities were reviewed and categorized based on the elements of the teaching portfolio. These activities not only show up as itemized items with points, but they are also grouped into the appropriate portfolio category and are displayed on each individual faculty member’s dashboard. This allowed each faculty member to see how much scholarship they had completed within each of the teaching portfolio categories and in which areas they were lacking that deserved more attention. This provided faculty with a readily accessible repository of activities that could be transferred directly into the correct category of their teaching portfolio,hydroponic drain table facilitating tracking of activities upon which one needed to focus for promotion. This project has resulted in preliminary positive effects on both education and documentation of scholarly work within our department. The first stage resulted in an overall increase in conference attendance and participation even prior to implementing the ARVU system.

It is possible that these positive findings were a result of the academic incentive being dependent on meeting education expectations. However, in offline discussions with multiple faculty members, it appears that there was a shame factor that also contributed to improved attendance. Multiple faculty expressed their relief that many were being called out on their low attendance and participation and that faculty who had historically carried much of the teaching responsibility were now being recognized. In the same vein, resident assessments increased in the second year by a considerable amount, without any other changes being made to the system, and therefore were likely a result of the new expectations. The increase in assessments does not necessarily mean better quality, and this will need to be evaluated going forward to determine full impact. The improved participation in educational activities as a result of financial incentives or other measures is consistent with reports from other institutions and existing literature. There is a clear correlation between faculty documentation of scholarly output and the ARVU system, as there was no system in place prior that allowed tracking of activities. The increase in activities and documentation will need to be followed from year to year to draw conclusions on overall scholarly activity among individual faculty members and throughout the department. Unlike previous literature describing ARVU systems, our project has emphasized the ability to house activities in one place that can be transferred into a faculty member’s teaching portfolio, thereby further incentivizing the use of this system outside of financial rewards. We will continue to track baseline education expectations and the ARVU system across the department as well as continuously seek feedback from faculty and make changes as needed. This process will continue to be refined over time based on faculty feedback and departmental and institutional priorities. The majority of faculty who did not qualify for the academic bonus last year worked more than 28 clinical hours per week, and thus time issues may have affected compliance. To further probe this finding and facilitate educational commitments, we will solicit additional feedback from this group of faculty members to explore participation barriers that may be addressed in the future. We hope to follow the scholarly output of the department over time using the ARVU system as an estimate of faculty productivity. Our longer-term goals will be to see the effects of this system on the promotion process within the department with an expectation that more junior faculty will become eligible for advancement. These effects will be evaluated by tracking the progress and content of junior faculty teaching portfolios compared to previous years and time to successful promotion. With a bottom-heavy young faculty group, our expectation is that this system will better prepare people for promotion as they can track their activities and determine where they need to place more effort to enhance their portfolio. Finally, this system will be used to improve the mentorship infrastructure within the department. Assigned faculty mentors will use the ARVU dashboard to mentor junior faculty on their progress for promotion.

This dashboard will provide another data point for mentors to advise junior faculty where they need to focus their efforts in order to progress professionally. There was likely subjectivity and bias in faculty assigning points to activities based on effort. Faculty may have ranked certain activities higher than others due to their own participation in the activity in question. In addition, faculty have different opinions on what type of effort may go into an activity; for example, a lecture may be easily prepared by some and take a lot of effort for others. We attempted to remove some of this subjectivity and bias by including faculty in this process who are the most committed to academics in our department. Many of these faculty participate in these activities on a regular basis and, therefore, we believed they were most committed to creating a fair transparent system to reward achievements. Furthermore, the standard deviation for each activity was not large enough to have created significant discrepancies in where a particular activity was ranked. This was a project initiated at a single site, which may limit its generalizability to other institutions. However, similar methods could be used to create site-specific prioritized activities that may enhance its use at other institutions. Finally, it is possible that the increase in conference attendance and resident assessments was confounded by other factors. The changes could have been simply due to faculty feeling the need to attend more conferences or better evaluate our learners, but the effects coinciding with the implementation of new expectations is unlikely to be coincidental. Gender disparities exist in academic medicine.Previous studies in other professional fields have shown that there are differences in language used in describing men and women in letters of recommendation.Additional studies have shown that evaluations of women medical students are more likely to describe women as “caring,” “compassionate,” and “empathetic,” in addition to “bright” and “organized,” than male medical students.In addition, women are more often portrayed as teachers and students, and less often portrayed as researchers or professionals compared to men.Within emergency medicine the letter of recommendation, including both standardized letters and traditional letters, has been cited as one of the top four most important factors in selecting applicants to residency, along with EM rotation grade, interview, and clinical grades.10 More specifically, the letter of recommendation has been cited as the most important factor in selecting applicants to interview.Historically, in EM, letters of recommendation were written without guidelines or restrictions. In 1996, the Council of Residency Directors in Emergency Medicine implemented the standardized letter of recommendation , which was renamed the standardized letter of evaluation in 2013. The SLOE contains both a quantitative evaluation of an applicant and a narrative portion of 250 words or less.The SLOE narrative provides a focused assessment of the noncognitive attributes of potential residency candidates.The standardized format and universal instructions make the SLOE a good text sample to study for variation in language by gender.

Study team members included the following: an emergency physician and investigator with expertise in qualitative methodology ; an internal medicine physician with many years of experience working at the refugee clinic ; a third-year emergency medicine resident with three years of experience working bimonthly at the refugee clinic ; a second-year EM resident with no experience at the refugee clinic , an MD/PhD student with three years of experience working at the refugee clinic and content expert on refugee studies ; and an undergraduate student with two years of experience working at the refugee clinic . The study team composition allowed for a range of expertise with individuals who had experience working with refugees and those who did not. Questions were vetted among the all members of the study team and revised to ensure that content reflected the goals of the study. Prior to interviewing resettlement and post-resettlement employees, a resettlement/post-resettlement employee interview guide was developed using the same process.Refugee interviews were conducted in person at a refugee clinic, and refugees were recruited during the study period when an interviewer was present during clinic hours. Refugees were asked to participate if a room and interpreter were available. If the aforementioned conditions were met, all refugees awaiting clinic appointments or available after their appointment were asked to participate. All of the refugees who were asked agreed to consent and participated. Interviews with refugees were conducted by two members of the study team using the Refugee Interview Guide and lasted approximately 30 minutes. A phone interpreter was used for verbal consent prior to participation and for the interview. Demographic information was collected about each participant . After interviews were completed for refugee patients, a second phase of semi-structured, open-ended,grow tray stand interviews were conducted in person at local resettlement and post-resettlement agencies in the region.

We obtained a list of employees involved in case management, health coordination, and program development for refugees/immigrants from resettlement healthcare teams. These employees were contacted via email with information regarding the study and consent form. Of 13 employees contacted, 12 participated. Employee interviews were conducted at their respective agencies, and verbal consent was obtained prior to participation. Interviews with resettlement employees were conducted by two members of the study team using the Resettlement/Post-resettlement Employee Interview Guide and lasted approximately 20 minutes. This study was approved by the institutional review board at the University of Pennsylvania.Our principal findings identify barriers throughout the process of accessing acute care for newly arrived refugees. Overall, refugees face uncertainty when accessing acute care services because of prior experiences in their home countries and limited understanding of the complex U.S. healthcare system. The unfamiliarity with the U.S. healthcare system drives refugees to rely heavily on resettlement employees as an initial point of triage or, if they are very sick, to call 911. At the resettlement agency, employees express concern about identifying the appropriate level of care to which to send a refugee client. They report challenges obtaining timely access to sick visits with primary care doctors and urgent visits with specialists and dentists. Additional barriers that make obtaining unscheduled care challenging include identifying clinics that offer comprehensive interpretation services, accept Refugee Medical Assistance, and are geographically convenient. Scheduling appointments over the phone, specifically automated services, is particularly challenging for refugees with limited English proficiency. On arrival to the ED, the same language barriers create challenges to understanding care received. In addition, the lack of trauma informed care can hinder the appropriate workup and treatment of symptoms. Finally, after obtaining care in any acute care setting, refugees face significant financial risk due to limited understanding of the health insurance system.

It is important to highlight that some of the aforementioned barriers to acute outpatient care reported exist among U.S.-born individuals, including geographical and insurance barriers, and difficulty accessing mental and dental services. However, these challenges are exacerbated for refugees due to language and cultural barriers. The U.S. healthcare system is new and often quite different from health systems refugees have used in the past, adding an extra layer of complexity to understand. The lack of interpretation services limits already limited resources such as appointments with specialists, dentists, and mental health providers. Additionally, refugees have unique mental healthcare needs given their history of trauma that adds an additional challenge when identifying appropriate mental health services. There is limited existing data on the utilization of acute care services by refugees in the U. S. In Australia a study evaluating the use of emergency services by refugees suggested that some refugees know how to call for emergency help, yet have significant fear of calling for help because of security implications faced previously in their home countries.In our study, refugees identified knowing how to call 911 if they were ill but did not express fear as a barrier to using this service. It is possible that the study population perceived less fear because the resettlement employees recommended the use of 911. A qualitative study in the U.S. evaluating healthcare barriers of refugees one year post resettlement also identified individual and structural barriers to accessing health services. Barriers included challenges with language, acculturation processes, and cultural beliefs.Similarly, our study found that language and acculturation were significant barriers when accessing health services. Our study differed in that we were specifically focusing on barriers to acute care access and that we identified additional barriers related to health insurance and perceived poor access to prompt outpatient clinic options.

Additionally, our results identified the important role of resettlement agencies in addressing these barriers. Notably, our study occurred early in the resettlement process, a time when resettlement agencies are typically more involved, as opposed to one year after resettlement. Respondents identified several areas for improvement to reduce barriers to accessing care for newly arrived refugees . Areas for improvement within the acute care system include establishing partnerships with resettlement/post resettlement agencies to assist with triage of refugees with acute conditions, and developing specific protocols that may help resettlement employees direct patients to appropriate levels of care. Finally, respondents recommended incorporating cultural competency and trauma-informed care training for providers. Trauma-informed care is based on the premise that past exposure to trauma can have long-lasting effects on the physical and mental health of patients. Thus,garden racks wholesale providers and organizations can respond by adopting trauma-informed models of care. A trauma-informed organization acknowledges that trauma is pervasive, recognizes the signs and symptoms of trauma, and integrates knowledge about trauma into policies, procedures and practices with the goal of avoiding retraumatization.While it is challenging to accurately estimate the number of refugees who have experienced trauma prior to resettlement, estimates suggest that the prevalence rate may be as high as 35%.This does not account for trauma associated with the resettlement process. ED specific approaches of trauma-informed care have been suggested for violently injured patients who have been injured due to violence and are treated in the ED; and some components may be applicable to refugee populations.While more research is needed to establish trauma-informed models of care for refugees in the ED, providers should acknowledge a patient’s history of trauma, ongoing signs and symptoms, and avoid practices that may result in retraumatization.Refugees and resettlement employees describe challenges at all points of acute care access due to language barriers and a lack of appropriate interpretation services. Revisions to the Affordable Care Act in 2016 mandated that healthcare facilities must offer qualified interpreters to limited English proficient patients16 and the 2010 Joint Commission standards also require qualified interpreter services in hospital settings.However, patients with LEP have worse clinical outcomes and receive a lower quality of care.18 In the ED formal interpretation should be offered to all patients who do not identify English as their primary language, and operation teams should ensure interpretation services are embedded throughout a refugee’s ED course, and that all members of the ED team are routinely trained on how to use in-person and phone interpreters. Similarly, clinic teams can ensure that interpretation services are available during clinic visits, but also when refugees call to schedule appointments or ask questions. Another common barrier reported by resettlement employees and refugees is that refugees struggle to understand health insurance, which is also supported in prior studies.More education for refugees was suggested as a potential intervention to address this concern, and may be useful. However, additional policy changes may be required to avoid insurance-related barriers to accessing care. For example, refugees who live in states without Medicaid expansion have a much smaller chance of enrolling in health insurance once Refugee Medical Assistance ceases.Additionally, it has been reported that in states where Medicaid requires reapplication annually, refugees often have a gap in insurance coverage.A study evaluating health coverage for immigrants suggests that expanding universal coverage may actually reduce net costs for LEP patients by increasing access to primary prevention and reducing emergency care for preventable conditions.

For refugees, the cessation of Refugee Medical Assistance after eight months occurs at a difficult time of transition. At six to eight months, cash assistance from the government typically ends as does support from the resettlement agency based on the expectation that refugees are self-sufficient after six to eight months of support.A study evaluating unmet needs of refugees demonstrated that refugees in the U.S. for a longer period of time are more likely to report a lack of health insurance coverage and a delay in seeing a healthcare provider.Policymakers should consider extending Refugee Medical Assistance beyond the first eight months as an additional strategy to improve access to health insurance and ensure stable access to care. Finally, additional research is needed to understand networks of care for refugees. In order to understand ED utilization by refugees and barriers to acute care, future studies should focus on prospectively following refugees after arrival to identify patterns of use and integration long term. This would then help guide types of interventions at locations where refugees most frequently seek acute care. Systematic identification of refugees in national datasets would assist with understanding variations in patterns of utilization between different regions and identifying areas of particular importance. We obtained the data from this study from one city. This limits the generalizability as results may be specific to the refugee experience in this location and healthcare system. However, our sample engaged refugees from a variety of countries, representing the current distribution of refugees resettled to locations throughout the country. This study did not specifically evaluate differences in access to acute care barriers for refugees based on country of origin, gender, educational, cultural, or economic background; however, all of these factors may influence experiences and are important to consider in future studies. Interviews with refugees occurred at a refugee clinic affiliated with a local resettlement agency and did not include refugees without access to care and services. Similarly, resettlement agency employees were recruited by the study team, largely consisting of physicians. Interviews with refugees were conducted mostly within three months of their arrival, thus only targeting newly arrived refugees. Barriers to access may differ at different stages of the resettlement process. However, this early period is likely to be the most vulnerable time with significant language, acculturation, and financial challenges. In addition, refugees typically see a physician within 30 days of arrival in the U.S. Many resettlement agencies work with specific clinics to meet this goal, making this the optimal time to capture a diverse population receiving care at one location. Some members of the study team had significant experience working at the refugee clinic and may have been influenced by potential biases from previous work with refugees, specifically when identifying themes. To counter these potential biases, members of the study team included individuals who did not work at the refugee clinic. Transcripts were double coded by both a clinic and non-clinic investigator and reviewed by a non-clinic investigator. Additionally, the use of interpreters may have altered responses from refugee patients. In some languages, a direct translation for specific words or meanings may not exist and as a result may be translated in a meaning that is different than what was intended. Finally, as with all qualitative studies, results generate hypotheses from the experience of the participants rather than testing or measuring a hypothesis.

Different vulnerabilities may interact to influence experiences of the pandemic. All participants were enrolled in a clinical trial, were not experiencing severe medical problems from their substance use, owned smartphones, and were proficient in English. Hence, findings may not generalize to more impoverished, medically complicated, or diverse groups. Future research into pandemic-related stressors and substance use should aim to recruit a more diverse sample. Smoking and alcohol misuse often co-occur. In the United States, the prevalence of nicotine dependence among individuals with alcohol dependence is 45.4%, while the prevalence of any alcohol use disorder among adults with nicotine dependence is 22.8% . These co-dependent individuals have more difficulty quitting smoking . An outstanding problem among those with substance use disorders is their disproportionate valuation of the drug and their disproportionate allocation of resources to obtaining the drug compared to participating in other daily activities . This imbalance between drug-related vs. regular activities reflects reinforced drug consumption patterns , and the differences in how drugs and nondrug reinforcers exhibit differential reinforcement strengths can be operationalized using a concept known as Relative Reinforcing Efficacy . One validated laboratory approach to measuring the RRE of drugs is hypothetical purchasing tasks, which assess changes in drug purchase and consumption as a function of increasing drug price . The consumption pattern can yield the demand curve modeled by Q = Q0∗10k , an exponentiated version of the classic equation by Hursh and Silberberg . Q represents consumption at price C; Q0 represents consumption at or near price zero,grow rack α represents the rate of change in demand elasticity, and k is the span of consumption values in log units. Other demand indices derived from the demand curve include: break point , Omax , and Pmax .

Pmax also indicates the price at which the slope of the demand curve becomes <-1, indicating a shift from relatively inelastic demand where changes in consumption is resistant to increases in price to relatively elastic demand. Research using the alcohol purchase task has found alcohol demand to be associated with alcohol use. For example, college students with recent heavy drinking exhibited greater intensity, Omax, and break point than recent lighter drinkers , and the APT’s reliability and validity was further confirmed among college students . Importantly, heavy drinking smokers exhibited greater Omax, Pmax, and break point for alcohol compared to heavy drinking nonsmokers , suggesting that smoking may increase the demand for alcohol. Research using the cigarette purchase task has suggested that cigarette demand indices are associated with smoking behaviors. Nicotine dependence severity was positively associated with the break point, intensity, Pmax, and Omax among young light smokers and among moderately heavy smokers .For instance, it was shown that smokers with schizophrenia reported higher intensity, consumption, and expenditure than smokers without schizophrenia . Researchers have further studied the latent structure of the demand indices to identify higher-level factors in the RRE domain that potentially better explain drug use behaviors. Two latent factors, labeled Persistence and Amplitude, have been identified for different drugs, including marijuana , alcohol , and cigarettes . The Persistence factor was found to consist of break point, Omax, Pmax, and elasticity. Higher levels of break point, Omax, and Pmax, and lower elasticity values were associated with higher Persistence scores, reflecting more persistent demand for the studied drug. However, the Amplitude factor appears to be more heterogeneous. The demand index that loads to this factor is the intensity, and thus it may reflect the maximum possible amount acquired and consumed by users, but other demand indices, such as Omax and elasticity , were found to load on the Amplitude factor.

While many studies have evaluated the RRE of alcohol and cigarettes separately, most were conducted in nonclinical samples, particularly among younger college students. Smokers with alcohol use disorder represent a special population known to be more treatment resistant because of their dual dependency . Recently, there have been several attempts studying the demand for alcohol and cigarettes among populations with concurrent use of alcohol and cigarettes. For instance, it was found that smokers showed greater demand for alcohol than nonsmokers among a college student sample . Extending these results from university settings to communities, Amlung et al.provided further evidence of increased demand for alcohol among smokers compared to nonsmokers. Recently, in a larger community sample of non-treatment seeking heavy drinking smokers, Green et al.found that alcohol and cigarette demand indices were positively correlated and more importantly, they found that compared to alcohol-related dependence measures, smoking-related measures accounted for more variance in alcohol demand’s Persistence factor, suggesting that smoking may play a reinforcing role in increasing alcohol demand among non-treatment seeking heavy drinking sample. These three studies have provided important insights for the interrelationships between the demand for alcohol and cigarettes, shedding light on developing interventions for alcohol and tobacco co-dependence. To complement these findings, we evaluated the demand for alcohol and cigarettes among treatment-seeking smokers with AUD, a clinical population that has not been examined previously. Specifically, the current study used the APT and CPT to examine the baseline demand for alcohol and cigarettes among smokers with AUD enrolled in a clinical trial for the concurrent treatment of AUD and smoking. We aimed to compare the alcohol and cigarette demand indices and their latent factor structures and examine each drug’s demand metrics’ relationship with the dependence severity of alcohol and nicotine. Our finding that participants had higher Omax and elasticity in the APT than in the CPT suggests that they were willing to allocate more economic resources toward alcohol than cigarettes and were less sensitive to the price escalation of the alcohol than that of cigarettes. These results suggest that alcohol had relatively greater RRE than cigarettes among smokers with alcohol use disorder.

Our results were consistent with an earlier study among alcohol-dependent individuals . They used a multiple-choice questionnaire to assess the crossover point between drug and monetary values and found that the crossover point for the monetary option was higher for a drink than for a cigarette, suggesting that alcohol had greater RRE than cigarettes did among a similar population. The greater values of Omax and lower elasticity scores in the APT than those in the CPT suggested that smokers with AUD had greater demand for alcohol than cigarettes. Consistent with difference in elasticity between alcohol and cigarette demand, our findings support the notion that smokers with AUD were more resistant to the price elevation in terms of reducing their alcohol consumption compared with their cigarette consumption. Notably, greater and more sustained demand for alcohol may be related to one’s smoking status per se, as previous research showed that heavy drinking smokers reported greater alcohol demand than heavy drinking nonsmokers . Although our participants reported lower intensity of alcohol than that of cigarettes,microgreens shelving this difference in intensity may reflect the inherent difference in characteristics between alcohol and cigarettes, such as packaging and consumption patterns specific to the products. The relative difference in intensity between alcohol and cigarettes demand, as well as their relative difference in baseline consumption patterns is consistent with previous research using a similar sample—heavy drinking smokers . Our PCA suggested a robust two-factor latent structure for the APT that accounted for 80.65% of the variance. This finding is consistent with previous research that identified a two-factor solution for marijuana , alcohol , and cigarettes . Moreover, consistent with these studies, the first factor includes break point, Omax, Pmax, and elasticity for both alcohol and cigarette demands. These four indices reflect the sensitivity to the increasing prices of alcohol and cigarettes. Thus, this factor indicates the persistence of alcohol and cigarette use behaviors among this population. The second factor has been commonly referred to as Amplitude , which reflects individuals’ consumption levels when the cost was minimum. This factor was mainly attributable to the intensity index. However, previous research identified differential contributions from a second demand index. Three studies found extra loading from Omax , one study found elasticity , and one found no extra indices . Unlike these studies, we found that the Amplitude factor had extra loading from the break point and Pmax, although three studies found similar non-significant negative loadings from Pmax . These results highlight the heterogeneity of the second factor, despite the consistent loading from intensity. For the cigarette demand’s PCA, we replicated a two-factor . Overall, the loadings to the first factor were similar to our findings with the APT’s PCA. However, the Persistence factor accounted for 52.55% of the variance in alcohol demand vs. 46.67% of the variance in cigarette demand, which suggests that smokers with AUD are characterized by higher persistence use of alcohol than cigarettes, consistent with the differences of Omax and elasticity between APT and CPT.

Perhaps the most interesting finding with the cigarette demand’s PCA was the second factor. This factor pattern is unique because it has been partially reported. For example, Bidwell et al.and O’Connor et al.reported Omax, while González-Roz et al.reported elasticity to load to the second factor. Except for the same factor loading to the second factor, the loading from the other four demand indices have a complementary pattern . These differential loading patterns highlight the heterogeneity of the Amplitude factor, and distinct latent factors may contribute to the observed differential demand for alcohol and cigarettes. We found that cigarette demand indices were significantly correlated with FTND scores, baseline smoking rate, and smoking withdrawal . These positive correlations have been reported in several studies , and suggest that smokers who were more dependent on nicotine have more demand for cigarettes. Notably, the correlations between cigarette demand indices and WSWS negative affect scores have not been previously reported. Although our participants were relatively satiated with smoking when they completed the CPT, these findings suggest that smokers’ withdrawal experience was positively associated with their demand for cigarettes. In contrast, we did not find alcohol demand indices and latent factors were correlated with alcohol-dependence measures except for the SAWS scores. Several studies have reported positive correlations, such as drinks per week , monthly binge drinking days , and AUDIT scores . Although the exact reasons for this discrepancy are unclear, we speculate that two factors may be relevant. The first is that the APT used in our study is different from other studies in terms of its instruction about framing the hypothetical drinking context, which will be discussed more in the study limitations later. Briefly, our generic description of the drinking situations may be insufficient to allow participants to imagine their typical drinking scenarios thus that they could not accurately report their alcohol demand. The other possible reason might be differences between study populations. Unlike previous studies , our participants were treatment seeking, and thus their motivation of quitting/reducing drinking and smoking may have changed how they responded in these purchase tasks. Besides the difference of motivations, our participants were more dependent on alcohol than the undergraduate samples tested previously —the average AUDIT score in our sample was almost twice that of theirs. Similarly, all of our participants had a diagnosis of AUD, while only about 50% who were dependent or abusing alcohol in the study by Amlung et al. . Additionally, our participants were also heavy smokers and importantly, several studies found that smoking resulted in higher demand for alcohol than nonsmoking . Thus, smoking may have resulted in a higher and more uniform alcohol use demand, masking a possible linear relationship between dependence and demand. Consistent with this possibility, we did not find any relationships between alcohol demand and alcohol misuse diagnoses. Although this possibility exists, future studies evaluating this population will help address whether heavy smoking can indeed mask the relationship between alcohol dependence measures and alcohol demand indices. The positive correlations between alcohol and cigarette demand indices suggest that those who had higher demand for alcohol tended to have higher demand for cigarettes too. This co-demand pattern is consistent with a recent study which revealed the same positive correlations among a similar sample of heavy drinking smokers . Moreover, by conducting hierarchical multiple regression analyses, their study found that smoking had a positive impact on the alcohol demand, but not the other way around .

This intervention combines different elements of effective approaches including cognitive and behavioral treatment using accurate information on the effects of stimulants, relapse prevention skills training, 12-step program participation, and family education. Its manualized treatment protocol ensures fidelity when the model is implemented in different settings.Using SMS text messages with people who use methamphetamine has been shown to reduce methamphetamine use and HIV-related sexual transmission behaviors and increase retention in HIV care among some key populations. Scripted unidirectional texts outperform bidirectional interactive text-messaging conversations in reducing methamphetamine use and HIV sexual risk behaviors and are more cost-effective than in person therapies. Theory-driven messaging might better benefit people in the early stages of behavior change than people who are already seeking help.Despite some demonstrated efficacy, few studies have shown ways to optimize and combine treatment approaches for methamphetamine use disorders. Qualitative reports show patients found contingency management beneficial when combined with motivational interviewing and cognitive behavioral techniques for methamphetamine use disorders. Combined motivational interviewing and cognitive behavioral treatment show efficacy in reducing methamphetamine use in HIV-positive MSM. Evidence supports combining psychosocial treatment with medication-assisted treatment in people with OUD, but it is unclear whether patients with comorbid methamphetamine use disorder will experience similar benefits. Integrating screening and brief interventions, contingency management or conditional cash transfer,grow table and cognitive behavioral therapy for the management of substance use disorders requires trained health professionals.

This is challenging in settings where human resource for mental health/substance use is scarce. Therefore, besides identifying optimal combination of EBI, it is essential to recognize potential barriers to the implementation of these strategies. Our study named “Screen, Treat and Retain people with opioid use disorders who use methamphetamine in methadone clinics” proposes to explore these questions.The study deploys a type-1 effectiveness-implementation hybrid design to evaluate the effectiveness of the proposed adaptive interventions and gather data on the implementation. To evaluate the effectiveness of the interventions, the study employs a Sequential Multiple Assignment Randomized Trial design. In the first phase, participants will be randomized into two front line interventions for 12 weeks. Based on their outcome at the end of this phase, they will be placed or randomized into three adaptive strategies for another 12 weeks . The economic evaluation that addresses Aim 2 aims to weigh public health and societal costs against public health and societal benefits attributed to the interventions of different intensities with a time horizon of 12 months. To address Aim 3, we will conduct an ethnographic evaluation to identify the multi-level factors that influence the adoption and scale-up of the interventions in methadone clinics. The CFIR assesses five domains of interventions, outer settings, inner settings, provider characteristics, and participant characteristics. The evaluation includes pre- and post intervention in-depth interviews with key informants who participate in the study and ethnographic observation with participants in their daily activities at the clinics and in the community settings.In each selected clinic, a physician, two counselors, and one nurse will participate in the study as intervention providers. The physician will ensure referral to HIV and psychiatric services when necessary; two counselors will run motivational interviewing, group education sessions, and Matrix meetings; the nurse will collect urine twice a week and conduct contingency management based on the UDS results.

Before the start of the intervention, to ensure the accuracy,integrity, and fidelity to the EBIs, all intervention staff at methadone clinics will receive didactic training on the theory behind the approach, evaluate their comprehension of the concepts within and behind the approach, watch a video of a Master Behavioral Counselor conducting intervention sessions and discuss the details of the session, and conduct at least two pilot intervention instances. All intervention sessions, except contingency management, will be audio-recorded, transcribed, and coded to ensure intervention fidelity. Intervention staff who have lower levels of intervention integrity or who have significant drift will be provided detailed feedback and supervision until there is parity with other staff.Sample sizes were chosen to compare primary outcomes based on first-stage randomization into one of two groups: high intensity or low intensity front line interventions. Sample size calculations are conducted in PASS 2008 for a two-group comparison of binary outcomes, a power of 80%, a 5% alpha level, and a conservative attrition rate of 20%. Using estimates from our prior work, we anticipate base rates of 80 to 90% for substance use and 60 to 70% for viral suppression. Based on these assumptions and a proposed sample of 200 HIV-positive participants , we can detect randomization group differences of 20% or more for binary outcomes, such as substance use and viral load suppression. We can detect even smaller group differences for substance use outcomes in the proposed sample of 400 HIV-negative participants and the combined sample of HIV-positive and HIV-negative participants. If estimated outcome probabilities are similar between first-stage randomization groups at 12 weeks, we will pool 12-week results for even greater power in evaluating second-stage randomization differences.Different datasets collected from different sources will be linked through a unique identification code using RED Cap for quantitative data. Data will be uploaded in real-time from the 20 study clinics onto our database. The study data manager will assess transferred data for completeness, query sites regarding any inconsistencies, and code merged data files for analysis. For qualitative data, field notes written on site are expanded and recorded electronically within 24 h.

After removing all personal identifiable information, the research team will upload password-protected transcripts on a secured database. The transcripts will be uploaded into Atlas.ti software to organize data and facilitate analysis.We will use a time-varying mixed-effects model that will be fitted to the participants’ common outcome measures over time. The unadjusted model will include indicators of first-stage and second-stage intervention conditions,vertical rack time of the assessment , and intervention indicators-by-time interaction terms. An additional interaction term of the two intervention indicators will be included to account for any interaction effect between the first and the second stage interventions. The adjusted model will include patients’ socio-demographic characteristics, drug use history, HIV-serostatus, and location as fixed effects. The mixed effects models will include a participant-level random effect to account for repeated observations of each participant, as well as a clinic-level random effect to account for the nested nature within the clinics. We will conduct subgroup analyses among HIV positive and HIV-negative participants. For the HIV positive subgroup, the specific outcomes of interest include HIV viral load suppression and adherence to antiretroviral treatment, and specific outcomes for HIV-negative subgroup include frequency of HIV testing and HIV seroconversion. Substance use will be the common outcomes in models including participants of both HIV statuses.Our data monitoring committee is composed of members of the Data and Safety Monitoring Board for Addiction Medicine of the University of California – Los Angeles. These members are not connected to the study in any way. The DSMBAM is independent from the National Institute on Drug Abuse —the sponsor of this study. The DSMBAM meets quarterly to monitor subjects’ progress in the trial and considers whether adverse social harms differentially accrue by condition. Although there are no prospective stopping rules for this trial, the DSMBAM is within its charge to review aggregate data, request statistical tests of differences in social or other harms, and then advise changes in intervention type or intensity if statistically significant differences emerge in adverse events by condition. Prior to each meeting, the study team will submit a performance report including all reports of SAEs for DSMBAM’s consideration. After each meeting, recommendations will be made in writing to the principal investigators.Hanoi Medical University and the staff in the STAR-OM study provide oversight of financial management. The Vietnam teams and US teams maintain frequent communication via emails and bi-weekly online meetings to report updates on the study progress, discuss scientific aspects of the study, and troubleshoot issues when they arise. The teams in Hanoi and HCMC meet online once weekly and in-person quarterly during monitoring visits to discuss the study conduct. We submit annual research progress reports to the Ethics Committee of Hanoi Medical University. Any protocol amendments need to get ethical approval before implementation. The UCLA Addiction Medicine Data Safety Monitoring Board independently review our data and data management twice a year.Serious adverse events are defined as life-threatening events such or other events that have a negative impact on participants’ life such as incarceration or compulsory drug rehabilitation.

The clinic staff will communicate information about adverse events and serious adverse events to the study team right after they are informed by participants or participant families. The study coordinators in Hanoi and HCMC are responsible to report adverse events within 7 days and serious adverse events within 24 h on REDCap with the time of onset, seriousness, duration, and outcomes. The principal investigator will decide what serious adverse events need to be reported to the Ethics Committee.Prior to participation in the trial, the participant will be informed about the research. Participants will complete a short questionnaire about the study objectives and main activities to show how they understand the study. Research assistants will provide more explanation based on the results of the questionnaire. If participants agree to join the study, they will sign a consent form. Each participant will be assigned a unique identifier at the time of screening. Participant data will be linked to this identifier only. Participant personal identifiable information is stored in a separate locked cabinet to which only responsible study staff have access. All study staff sign a confidentiality agreement to non-disclosure of participant information. We make extra efforts to ensure nodisclosure of drug use information to anyone other than participants and the study staff.Between July and October 2020, we conducted 4 focus group discussions of a convenience sample of participants from four methadone clinics in the downtown and suburbs of Hanoi and HCMC to inform intervention content and refinement. Respondents reported information on local taxonomy and patterns of methamphetamine use, triggering situations, methamphetamine related sexual risks, motivations for seeking treatment, and perceived acceptability of the adaptive interventions. The pilot implementation lasted 12 weeks from November 2020 through February 2021. It identified issues to be addressed before the full implementation. At the conclusion of the pilot, we conducted 2 FGD with patients and 1 FGD with providers participating in the pilot to gauge their feedback about the interventions.With the cut-off point of ASSIST ≥ 4 and methamphetamine-positive UDS as originally proposed, there were 26 and 52 eligible participants in two pilot clinics in Hanoi and HCMC, respectively . For the pilot implementation, we randomly recruited 42 participants with ASSIST score ≥ 4 or methamphetamine-positive UDS. After the front line intervention, 16 participants were non-responders and randomized into adaptive interventions. At least 50% of the original sample must transition to the adaptive phase for sufficient statistical power. Thus, we decided to recruit more participants with severe use of methamphetamine, as evidenced in both ASSIST score ≥ 10 and methamphetamine-positive UDS. Furthermore, to recruit enough participants for the front line intervention phase, given most other clinics are smaller than the two pilot ones, we decided to use ASSIST score “OR” UDS instead of “AND” to increase the pool of potential participants. We kept the criterion of methamphetamine-positive UDS to compensate for participants with lower ASSIST scores due to desirability bias.The STAR-OM study is among the first studies to evaluate different combinations of EBIs for methamphetamine use among methadone patients in low-and-middle-income countries. The study will provide effectiveness and cost-effectiveness evidence for scaling up these interventions. The SMART design assesses different treatment strategies for participants who respond differently to front line interventions. The combination of trial and ethnographical study will provide insights on factors at multiple levels that need to be considered in decision making. The adaptation and pilot implementation of EBIs will make them culturally sound to local participants. As the interventions will be delivered by methadone providers at methadone clinics, they can be readily implemented if the trial demonstrates they help. The participation of some participants can be interrupted due to drug-related police arrest or methadone treatment fatigue. This limitation can be minimized as we will select clinics with low drop-out rates.

The association between greater PA and lower stress was consistent with hypotheses and with the extensive literature on the positive effects of PA on stress reduction in non-COVID contexts . Engaging in PA may have significantly reduced stress incurred by COVID-19. Alternatively, participants with fewer stressors may have found it easier to be physically active. In this study, participants meeting PA guidelines were older, more likely to be White and to drink alcohol, had greater educational attainment and higher household income, and were less likely to be employed . These participants may represent a subset of adults with greater resources and fewer demands on their time during SIP, leading to lower stress and increased ability to engage in PA. Nonetheless, the association between PA and stress remained statistically significant after accounting for age, race, past-month alcohol use, education, household income, and employment status.Engaging in PA may have contributed to stress management, even for participants who already had many advantages. This study suggests that the well-documented positive effects of PA on stress management persist even in the highly unusual circumstances of SIP. Active and less active participants also differed in the stress management strategies they employed. A majority of active participants reported that they used PA—especially outdoor PA — to manage stress. Active participants were four times more likely than less active participants to report managing stress using outdoor PA than inactive participants. Active participants were also more likely to report use of indoor PA, yoga, meditation, or prayer, gardening, and reading. Most of these activities involve a physical activity component. Additionally,indoor garden table physically active participants were less likely to cope with stress by eating more or sleeping more.

Disruptions in diet are common during stressful times. Similar to the present study, a study of Belgian university students found students with more stress and less physical activity were at greatest risk for increased snacking during a stressful final exam period . COVID-19 SIP is a more widespread, disruptive, long-term stressful circumstance than a final exam period, yet similar results were found. Sleep disruptions have also been linked to stress during COVID-19 self-isolation . Indeed, in the current study, participants who managed stress by eating more, sleeping more, or watching TV/movies were more likely to report increased stress. Eating, sleeping, and watching TV/movies may have been used to manage stress by participants who were already experiencing a great deal of stress. These activities require less energy to initiate than the more active strategies and may have felt more manageable. Concurrently, these less active strategies may have been less effective than strategies involving physical activity. Participants who coped with stress using PA or reading were less likely to report increased stress. Making PA—especially outdoor PA— more accessible during COVID-19 SIP may help ease stress. Recent changes in SIP policies in the San Francisco Bay Area have opened up local parks and activity areas . Overall level of PA during SIP, rather than change in PA, was associated with stress. Specifically, participants who became active or became less active during SIP did not significantly differ in likelihood of increased stress from those who were active throughout SIP. On the other hand, those who were less active both before and during SIP were more likely to experience increased stress. Low physical activity may be associated with other risk factors for stress, such as long work hours, that persisted during SIP. The study period was short and may not have been sufficient to show long-term associations. Other research has found that improvement in stress management over time is associated with increases in PA .

As people adjust to COVID-19 and its associated restrictions, stress management and PA may improve. Although PA remained fairly consistent over the one-month study period , the proportion of participants reporting increased stress during SIP decreased substantially . Engaging in PA throughout SIP may further decrease stress. Stress management is crucial during COVID-19, as stress can increase susceptibility to viral infection . This study was observational and precludes causal conclusions about the role of PA in reducing stress. Analyses adjusted for numerous potential confounding factors; however, analyses were correlational.Most participants resided in Northern California, where the weather is generally conducive to outdoor PA year-round. The sample was predominantly middle-aged, female, White or Asian, and highly educated, with high household incomes. Although PA has nearuniversal benefits, disparities in the ability to engage in PA during COVID-19 are likely. To our knowledge, such disparities have not yet been studied. Future research is needed to examine the role of PA in COVID-19 stress management among more socio-demographically and geographically diverse populations. Participants were surveyed at the beginning of SIP and one month into SIP. Longer follow-up may show different patterns of results. The measure of stress used in this study was designed to capture changes in stress specific to SIP in a single item, with high face validity. Validated measures of stress, while less specific to SIP, should be used in future longitudinal research to expand upon the present study.Substance use among women living with HIV is a major public health concern that is both an independent and aggravating risk factor for HIV transmission . Although fewer women than men use drugs, women are more likely to experience detrimental health effects from drug use, and may become addicted to substances more quickly . Compared with men, women may have unique reasons for initiating drug use, including the use of substances to lose weight, to cope with anxiety and exhaustion, and to deal with higher rates of chronic pain that has been treated with prescription drugs . In one study, 37% of WLHIV had substance-use problems, which was significantly higher than men . Substance use increases the risk of HIV infection while diminishing the ability of PLHIV to adhere to their medications and self-manage their illness . However, few investigations have examined substance use among WLHIV. Illicit substance use negatively affects HIV self-management tasks, including HIV medication adherence and initiation and retention in HIV primary care . Recently, data from the Women’s Interagency HIV Study reinforced that women who use illicit substances encounter sub-optimal medication adherence, despite simplification of HIV drug regimens .

Social capital is the aggregation of potential resources, linked to a durable network of relationships of mutual acquaintance or recognition. While debated , components of social capital include reciprocity, trust, safety, social agency, social networks, value of life, and employment connections . Research on social capital and HIV has predominantly focused on preventing HIV transmission with increased social capital being associated with decreased HIV transmission . High social capital was the strongest predictor of HIV self-management in WLHIV and specifically on HIV medication adherence . Social capital has also been negatively associated with substance use among youth and African Americans . Discrimination was associated with illicit drug use in African American women, and aspects of social capital protected women against its effects . However, in rural Appalachia,grow rack illicit drug use was associated with greater social capital , highlighting the need to carefully assess social capital and its relationship to substance use behaviors. Given that most examinations of social capital among PLHIV are quantitative and cross sectional, there is a need to gather more qualitative and mixed methods data to better understand its relationship to health outcomes .Potential subjects were from an existing HIV-research registry of approximately 300 adults living with HIV in Northeast Ohio. All registry participants had contacted the study team about previous research opportunities and had given written consent to be included in the registry. All women in the registry were sent an institutional review board -approved letter explaining the study and asking them to contact the study team via telephone if they were interested in participating. Those who responded were screened via telephone for illicit drug use using the Drug Abuse Screening Test-10 . Subjects scoring > 1 were included in the current illicit drug use strata, and those scoring a 0 were included in the not using illicit drugs strata. If we found out during the qualitative interview that the participant has used illicit substances within the past 12 months, she was given a DAST score > 1 regardless of the screening form or the surveys. If a woman met eligibility criteria, she was scheduled for a research visit. At the first research visit, a research assistant explained the study and obtained written informed consent. Next, she completed a battery of surveys in REDCap and an open-ended social capital interview. Interviews were guided by a semi-structured interview guide and audio-recorded. Quantitative surveys were completed prior to interviews to introduce the concepts that were to be discussed and to standardize the data collection. At the conclusion of the visit, participants were compensated with $20 cash for their time and travel. Data were collected between July 2015 and June 2016. All procedures were approved by the Institutional Review Board at the Medical Center.To quantitatively describe how social capital influences HIV self-management and substance use patterns over time among WLHIV, we assessed the following variables, based on the literature described earlier: social capital, HIV self-management, substance use, and potential confounding variables. Participants completed study assessments at baseline and then approximately 3 and 6 months later.

Social capital was measured using the 36-item Social Capital Scale. This widely used and psychometrically validated instrument generates a total social capital score and measures eight sub-scales, including participation in the local community, social agency, feelings of trust and safety, neighborhood connections, friends and family connections, tolerance of diversity, value of life, and workplace connections . Participants rated each item on a 1-to-4 Likert-type scale. Higher mean scores indicate more social capital. Cronbach’s alpha reliability for the social capital scale in adults living with HIV is 0.88 . We examined two aspects of HIV self-management, HIV medication adherence and a global measure of HIV self-management. HIV antiretroviral medication adherence was assessed with a 30-day adherence visual analog scale . To measure HIV self-management more globally, participants also completed the 20-item HIV Self-Management Scale, which generates a total score from items measured on a 0-to-3 scale and measures three domains of HIV self-management . This scale has been previously examined and was found to be psychometrically valid for use among WLHIV . Substance use was assessed with the valid and reliable 11-item self-report Drug Use Disorders Identification Test developed to screen individuals for drug problems . Total scores range from 0 to 44, with higher scores being suggestive of a more severe drug use problem. Descriptive and potential confounding variables included demographic and medical characteristics, traumatic events, and experiences of discrimination, and were selected based on previous literature reviewed earlier. Demographic characteristics were self-reported and included race, education level, family composition, employment, sexuality, and housing status. Medical characteristics, abstracted from the participant’s electronic medical record, included year diagnosed with HIV, current CD4+ T cell count, HIV viral load, HIV medication history, and retention in HIV primary care. Recent traumatic events were assessed with the 20-item List of Threatening Experiences Scale, which lists the experience of traumatic events in the past month. Each of these 20 items are summed, and higher scores indicate more traumatic experiences . Experiences with discrimination were assessed with the widely used and valid nine-item Everyday Discrimination Scale . Participants noted how often they experienced acts of discrimination. All items are summed , and higher scores indicate more discrimination. To qualitatively describe how social capital influenced HIV self-management and substance use patterns, we developed a semistructured qualitative interview guide based on existing literature to guide in-person interviews. Prior to using it with participants, experts in substance use and women and in WLHIV assessed the interview guide for clarity, relevance, and appropriateness. The baseline interview guide initially focused on early substance use, current health practices, past and current social networks, and social capital dimensions . After several interviews, based on new themes spontaneously emerging from the interviews, it was revised to include more probes related to how trust influences health behaviors and the specific role of faith and its influence on health behaviors. In other words, in the first few interviews, WLHIV discussed the role of trust and faith on their health behaviors, and we deemed it so important that we wanted to give all respondents a chance to discuss these topics.

Favazza provided cases of extreme and highly unusual forms of self-mutilation in excruciating detail, with an attempt to classify types based on severity. With the provisional emergence of non-suicidal self-injury disorder criteria in the fifth version of the Statistical and Diagnostic Manual of Mental Disorders DSM-V ,the distinction between self-harm as within a normative or pathological range remains equivocal. This is illustrative of the manner in which conceptualizations of self-cutting continue to be embedded in a complex cultural history of changes in the incidence, popular awareness, and social conditions in which such phenomena occur.While it is possible to find clinical, psychometric, survey, and historical approaches to the phenomenon of self-cutting, we lack an ethnographic account with a substantive locus in the interactions of individuals, grounded in the specificity of bodily experience and the immediacy of struggle in the face of existential precarity . In this article, we take a step toward such an account with a discussion situated at the intersection of two anthropological concerns. First is the ethnographic understanding of experiential specificity through anthropological adaptation of phenomenological method . Drawing on this approach, we understand experience as meaningful sensory perception in temporal context and within particular cultural, social, and interpersonal settings and subjectivity as the more or less enduring structure of experience. With respect to mental illness, this approach invites anthropological recognition of struggle as a fundamental human process that comes to light in the context of lived experience . Second is the ongoing anthropological concern with adolescence as a stage in the life course at which identity is consolidated and people approach full cultural membership but which is also fraught with challenges to well-being that anthropology can contribute to understanding in a way relevant to mental health policy and practice .

The contemporary anthropological approach to childhood is strongly influenced by child standpoint theory that aims at an account of society from where children are socially positioned and in which they are not passive social “others” but agentive participants in social life,cannabis grow set up hence co-constructors of social knowledge and by extension of knowledge generated by research. In particular, anthropologists have taken up the idea that “children have agency and manifest social competency” . Guided by these concerns, we will focus specifically on self-cutting among a group of adolescents who have been psychiatric inpatients; by attending to experience and subjectivity articulated in the youth’s own voices, we will come to understand self-cutting as a crisis of agency enacted on the terrain of their own bodies. There is scant literature on how young people conceive and understand mental health , let alone experiential accounts of adolescent mental illness from the standpoint of the child . In addressing the experience of cutting among a clinically defined and diagnosed group of youth, our stance is not to fall prey to accepting a false dichotomy between ethnographic and clinical sensibilities; that a young person is following a regimen of psychotropic medication is as much an ethnographic as a clinical fact, and that a young person lives in a fragmented family environment may have clinical as well as ethnographic implications. Self-cutting can be understood as a troubling symptomatic behavior or as a creative struggle for agency and may exhibit elements of both pathological obsession and ritual transformation, but in either case it is an enactment of a vexed relation between body and world.This discussion is based on SWYEPT, our study of youth in New Mexico who were inpatients in the state’s flag ship Children’s Psychiatric Hospital at the University of New Mexico . New Mexico is a state whose total population according to the 2010 United States Census was 2,059,179. In 2010, according to the US Census Bureau’s categories, by race the largest population proportions were designated “white” and American Indian/Alaska Native , with 23 federally recognized Indian tribes in the state comprising various groups of Pueblos, Navajos, and Apaches; other racial categories were minimally represented.

By ethnicity, Hispanics or Latinos accounted for the largest single block , while among non-Latinos the largest blocks identified themselves as generically white or American Indian . New Mexico is one of the poorest states in the nation. According to the US Statistical Abstract, as of 2008 the median household income was $43, 508 or 44th among the 50 states, and the proportion of persons living below the poverty level was 17.1% or 5th in rank among the states. New Mexico ranks as one of two states within the United States hardest hit by child poverty, with the rate of 30% in New Mexico . Relatedly, home foreclosures have also been inordinately high. Along with poverty comes a serious drug problem, with parts of the state severely afflicted by heroin and methamphetamine use, and the presence of violent gangs, with one anti-gang website listing 178 in the Albuquerque area. The SWYEPT study examines cultural meaning, social interaction, and individual experience among adolescent patients and their families, with the long-term goal of producing knowledge of broad use to those concerned with the treatment of adolescents suffering from mental illness in the context of significant cultural differences. The aspects of this knowledge include: types of problem, illness, or psychiatric disorder experienced by afflicted adolescents; trajectories of adolescent patients from the community into treatment and back into the community; patient experience of therapeutic process and family response to that process; alternative and complementary resources brought into play by families on behalf of patients; difference between the experience of afflicted adolescents and that of counterparts who have not been diagnosed or treated for emotional disturbance. Notably for present purposes, ours was not explicitly a study of self-cutting or self-harm, but cutting emerged within the ethnographic interviews as a theme deserving of the particular attention we devote to it here. We recruited participants for the study with the assistance of three clinicians at Children’s Psychiatric Hospital who referred to us patients aged 12–18 they judged as not so severely cognitively disabled or developmentally impaired as to be unable to participate in interviews and not so emotionally fragile or clinically vulnerable that their participation would be unduly stressful. We obtained informed consent from youth and their parent or primary guardian based on these referrals, grow rack systems recognizing the ethical responsibility of respecting the vulnerabilities of individual patients and the need for continued rapport in the relationship between therapists and families, as well as the importance of our respect as researchers for the clinical expertise of the referring therapists.

All participants entered the project as inpatients at CPH. Assisted by a team of graduate student ethnographers and clinically trained diagnostic interviewers, we conducted ethnographic interviews covering life history and experience with illness and treatment with the young people and their primary parent/guardian three times at approximately six months’ intervals.During this period, we also conducted the child version of the Structured Clinical Interview for DSMIV , a clinician-administered research diagnostic interview , the Adolescent Health Survey , and the Youth Self Report and Child Behavior Check List for children and their parent/guardian respectively. Although initial interviews occasionally took place in the hospital, it was rare for a participant still to be there at the time of the second and third ethnographic interviews. Yet it was not always the case that they were at home, since it was not uncommon for them to be placed instead at another treatment facility of in-treatment foster care. This often led us far a field from the hospital in Albuquerque, such that our ethnography ranged across the entire state of New Mexico and occasionally beyond. In this respect, our work was not strictly speaking a clinical ethnography in the sense of ethnography primarily situated in a clinical context that focuses on the institutional cultural milieu and interactions among patients and staff . Our focus was instead on the experience and subjectivity of the troubled youth along their trajectory back to their families, back again to the hospital, to other institutions, or to treatment foster care. Whenever possible we conducted interviews in participants’ homes both for their convenience and so that interviewers could conduct ethnographic observation of the domestic environment and neighborhood setting. Our primary ethnographic locus was thus the family rather than either the clinic or the community, following the methodological premise that families are the principal formative inter subjective locus for adolescents and for the mentally ill, no less for mentally ill adolescents . Given these caveats, our work could be described as clinical ethnography in a different sense, insofar as it synthesizes clinical and ethnographic sensibilities and approaches . This means not only a balanced attention to diagnostic profile and life experience, but recognition that narrative data generated by diagnostic and ethnographic interviews can be complementary by identifying different kinds of experientially relevant events and themes . The participants constituted an ethnically diverse group including New Mexican Hispanics and Latinos of Mexican descent, Anglo-Americans, and Native Americans. While an ethnically diverse group of youths whose economic and residential conditions vary, the life situations of most are shaped by features of structural violence . Of the 47 adolescents who participated in the research, 57% reported having cut or harmed themselves at some time, comparable to 61% among adolescents hospitalized for psychiatric problems in a previous study by DiClemente, Ponton, and Harley in another North American location. This rate can be understood against the background of a reported rate of 1–4% of self-injurious behavior in the general population , while the rate among adolescents has been placed by various researchers as ranging between 1 and 39% . Let us now take a closer look at cutting among several of these young people in order to get a sense of how they talk about it and what it means to them, its place in the overall configuration of their experience, and the similarities and differences among them that might allow us to characterize cutting as a crisis of agency.SWYEPT participants represent a wide range of diagnostic profiles from a clinical standpoint and a diversity of life experiences from an ethnographic standpoint , but our purpose here is to present a series of vignettes that summarize the range of experiences and utterances centered around the phenomenon of cutting. Lacking space to present full case studies, we briefly examine how they describe their own cutting behavior and what that behavior means in the context of their troubled lives and in the constitution of their subjectivity. We have selected these instances and interview excerpts based on the young person’s relative ability and/or willingness to elaborate on how cutting has been a part of their lives. Each profile includes the biographical and ethnographic context of the young person’s experience, their diagnostic and functional status, medication history, their own experiential commentary, and a brief interpretative commentary. We first met Maria, a Hispanic 17-year-old female, when she was living in a ranch style home in a lower-income neighborhood that was bustling with the activities of her extended family and infant son. During the course of the study, she later lived in an apartment with her son, boyfriend and mother, moving again two years later into a very small apartment with her toddler. Maria was the youngest of three daughters to a single mother with multiple boyfriends and father figures. She bore the physical and emotional marks of a major arm injury in mid-childhood from a car accident in which her extremely drunk mother was driving, as well as enduring severe and catastrophic stressors related to abuse, neglect, and sustained psychosocial instability in her early life. While Maria is close to her older sisters, they were not a significant source of personal or financial support and held an anti-psychiatric opinion about how Maria did not need medication. She relayed that she had to “grow up fast” since her mother had severe problems with alcohol. Indeed, her mother’s alcohol abuse severely affected their relationship. Maria was sexually assaulted at the age of 11 by her mother’s ex-boyfriend, which disturbed her greatly; she marks this as a time of pain and confusion. She grew up believing her adoptive father was her biological father, but when Maria was 15, her father went to fight in Iraq. While in Iraq, he wrote her two letters saying that she was not his biological daughter, and he was getting remarried and could not support her financially or otherwise. She said she was devastated by this, by the fact that he would “cut me out of his life.”

In contrast to the 36-year-old waiver policy that preceded it, GBR guarantees a hospital’s annual revenue by calculating global budget based on market share. Adjustments in global budgets are tied to changes in market share and the state’s gross domestic product. In some ways, GBR is an extension of TPR. However, GBR is not a voluntary program; it requires every Maryland hospital to participate. The main difference is that TPR was implemented in geographically isolated areas of the state where catchment areas are clear. Hospitals under GBR operate in more competitive market environments.In the online appendix, Table A1 lists the names of the Maryland hospitals that are under the GBR program. In the past, hospital revenue was directly linked to the number of medical services that the hospital provided. In contrast, under GBR and TPR, each hospital’s total annual revenue is defined by the HSCRC and known at the beginning of each fiscal year. The hospital margin is the difference between the global budget and annual cost. As a result, hospitals are motivated to control costs while maintaining or growing market share.In this study, we used the difference-in-differences method , which is widely used in healthcare management and policy analysis.DID determines two differences and calculates the treatment or policy effect by determining the difference of the two differences. Examples of studies using DID include that work by Tiemann and Schreyogg on the impact of privatization on hospital efficiency in Germany.

Buchner et al. used DID to study the impact of health system entry on hospital efficiency and profitability.In our study,vertical hydroponic system the first difference is the comparison of a GBR, hospital’s performance before and after GBR implementation. The second difference is the comparison of scores from a group of control hospitals in the same time frame. Finally, we used the second difference from the control group to rule out the part of the first score difference that is not influenced by GBR. This allowed us to estimate the treatment effect within the treatment group. More precisely, GBR adoption was considered the treatment, the hospitals implementing GBR constituted the treatment group, and hospitals not implementing GBR but otherwise similar were considered the control group. This allowed us to identify the treatment effect due to the impact of GBR as opposed to Medicaid expansion or other industry-wide trends. The treatment group was all Maryland hospitals that adopted GBR on January 1, 2014, but did not participate in the TPR program. According to the Annual Report on Selected Maryland General and Special Hospital Services Fiscal Year 2016,10 Maryland has 46 EDs located in general hospitals. Of those 46 hospitals, 10 rural hospitals have participated in the TPR program since July 2010 and are, therefore, excluded from the analysis. The control group includes hospitals from WV, RI, and DE. These three states adopted the original Medicaid expansion on January 1, 2014, at the same time as Maryland, but did not implement the GBR or TPR programs. The main reason that we chose these three as our control group is that Medicaid expansion might have caused and been accompanied by some unmeasurable changes in patient behavior. For example, people who were newly eligible for Medicaid after the expansion would have had different strategies for choosing healthcare providers. We assumed that people from the four states exhibited similar patterns in their reactions to Medicaid expansion. The online appendix section A2 provides the logic behind the selection of the control group.We formatted the final dataset into an unbalanced panel dataset and implemented a mixed-effects, linear regression model with a state-level fixed effect, a hospital-level random effect, and state-level heterogeneity to investigate the impact of GBR implementation on the ED1b scores of Maryland hospitals.

The variables considered in our model are listed in Table 2 .At the patient level, GBR implementation correlates with longer ED LOS for patients being admitted to the hospital. We believe that this implies that GBR has fundamentally changed the way emergency physicians and hospital staff approach the hospitalization decision. The Evaluation of the Maryland All Payer Model Second Annual Report funded by CMS in 2017 emphasized that GBR targeted both healthcare cost and quality.The model has encouraged more workup and interface with case managers in the ED; the objective is to ensure patient safety and high-quality care in the community in lieu of admission for appropriate patients. These changes were likely contributing factors to the increase in the total time span for the care of an ED patient. Future work includes a study on whether and how Maryland hospital EDs adopted new strategies or modified their procedures for healthcare service delivery in response to the implementation of GBR. It remains to be seen if the changes in Maryland hospital EDs had or will have a substantial impact on Maryland’s healthcare system. We found significant differences among the three Medicaid expansion states to which Maryland was compared.Delaware’s score was slightly longer. After applying sensitivity analysis using three alternative control groups, we found that the difference between Maryland’s ED1b and those different control groups remained significant. GBR, a state policy, is correlated with longer LOS for admitted patients. In our study, the state-level fixed effect is significant. Nevertheless, there may well be unidentified confounders that influenced our results. According to Benjamin C. Sun, professor of emergency medicine at Oregon Health and Science University in Portland, “It’s not really fair to compare, say, a public teaching hospital in the middle of New York City that sees 120,000 patients with one that is in a rural area that sees 5,000 patients.”Similarly, it may not be fair to simply compare ED scores across states. Our comparison across states assumes similar demographics and disease burdens, both of which could affect hospital utilization. Also, we are assuming similar admission practices across states.

More particularly, we assume the changes in Maryland inpatient census other than affected by the implementation of Medicaid expansion and GBR can be controlled by our control group. In February 2017, a news report stated that “Maryland ER wait times are the worst in the nation,” a conclusion derived by simply comparing the ED scores published by CMS Hospital Compare.Viewed in this light, interpreting the significant state-level fixed effect obtained in our study without clarifying factors that may be unique or particular to each state, cannabis grow set up might confuse, rather than clarify, perceptions of hospital ED performance. We acknowledge several other limitations in our study. The GBR policy was adopted on January 1, 2014, 10 days after Maryland began Medicaid expansion. The control group hospitals then had to come from neighboring states that also implemented traditional Medicaid expansion at the same time, thus, limiting our control group to WV, RI, and DE. Of these states, RI and DE have few hospitals. Another limitation was the incomplete report data. Overall, the reporting rate of the control group is 75%. According to KFF Total Hospital Reports,31 there should be 290 Hospital Compare data reports from CMS. However, we found only 218 complete reports. It is possible that the missing data might have some impact on our results. Another limitation is the possibility that unmeasured confounding factors may have affected ED LOS. Factors such as hospital closures, demographics, or shifts in access to care could have affected our results. To eliminate the effect of those possible confounding factors, the ideal measure would be the volume of each hospital’s ED visits. CMS started to collect volume data on January 22, 2015. However, some states in our study only started to report this measure on November 10, 2016. Therefore, we selected features other than volume data and note that we might not have been able to eliminate all effects. We were also limited in our choice of performance measure ED1b, which reflects the total time inpatients spend in the ED. Ideally our study would examine both ED1b and the corresponding outpatient measure, OP18. However, CMS only maintains Maryland State OP18 reports going back to January 1, 2014. As there is no data for the pre-treatment period, we cannot study the impact of GBR on the OP18 measure. Our design assumed that residents living in the four geographically close states shared similar reaction patterns to the Medicaid expansion. Then, from an aggregate point of view at the hospital level, we assumed that our control group could rule out the impact of Medicaid expansion on Maryland ED LOS. It is possible that not every hospital was affected by Medicaid expansion at the same proportion, which might have affected the estimates. Also, our secondary finding, the significant difference in time spent in EDs across the four states, should be further investigated by analyzing data from the Nationwide Emergency Department Database.Breaking bad news is considered to be one of the most important, stressful, and challenging responsibilities of a physician.Trainees and experienced physicians alike report being uncomfortable with this task, notably due to a lack of prior training.

For patients, the acknowledgment of this information and their comprehension and perception are of paramount importance to facilitate their psychological adjustment and a long-term quality relationship with medical caregivers.The BBN process has changed drastically over the past decades, moving from a paternalistic medical approach to one of greater patient empowerment, which acknowledges the need for information and results in a greater awareness and clearer understanding of their diagnosis and prognosis.Patients prefer to receive individualized, comprehensive information communicated with warmth and honesty.Patient and family expectations regarding the exact content of news have been shown to be highly variable,making it difficult for healthcare professionals to tailor the information to suit each patient.Bad news in an emergency department may consist in announcing that a relative has been admitted to the ED or in sharing with patients or their families news concerning the need for hospitalization or conditions that might lead to a life-threatening situation sooner or later.BBN in the ED is a particular challenge because the patient is generally meeting the emergency physician for the first time and neither of them enter into the relationship by choice. A recent survey revealed that 78.1% of BBN occurred without previous contact between the patient and the physician. Moreover, history taking, diagnosis, and the acknowledgment of bad news are usually accomplished within a very short time frame during which the physician is confronted with distractions, stress, or time constraints.EP training in communication skills to notify family members of a patient’s death has been reported to be poor at best,leading medical students, residents and young physicians to adopt inappropriate communication behaviors,which in turn significantly increase their stress levels.Inappropriate communication behavior does not take into account the needs of patients or their families. Several guidelines have been developed in oncology to help physicians deliver bad news.One of the most widespread BBN protocols is the SPIKES protocol.28 BBN training in the ED has scarcely been studied to date.The studies undertaken have included a limited number of participants,no validated assessment tools or control group, or were limited to death notification only.In this study, we assessed the effects of incorporating a four-hour ED BBN simulation-based training on self-efficacy, the BBN process, and communication skills among medical students and junior residents who rotated in the ED. We hypothesized that BBNSBT has the potential to increase self-efficacy, the BBN process, and communication skills. BBN skills were assessed in simulation exercises involving two standardized family members played by actors. A randomly selected BBN scenario was used to assess each participant in both pre- and post-test. The scenarios were as follows: 1) a life-threatening situation after a motorcycle accident; 2) a life threatening cardiogenic shock; and 3) brain damage after a fight. Each trainee performed in one random scenario. The scenarios for the pre-test and the post-test were different in order to avoid memorization bias. The BBN skills assessments were video recorded and anonymized. Two blinded raters assessed participants by using two assessment tools. The SPIKES competence form,with 14 items, assessed the participants’ compliance with the SPIKES protocol. Each item was scored as “yes” or “no,” resulting in an overall score . The experts determined a cut-off score using the modified Ang off method.A passing score was 11 and above, and a failing score was below 11. We used the modified Breaking Bad News Assessment Schedule to evaluate communication.