Psychosocial Well-Being and HIV-Related Immune Health Outcomes among HIV-Positive Older Adults: Support for a Biopsychosocial Model of HIV Stigma and Health.

Evidence suggests that psychosocial stress negatively impacts immunological health in HIV-positive individuals. However, few studies have explored this association in substance-using older adults living with HIV (OALWH). We evaluated the effect of depression, loneliness, substance use problems, and HIV stigma on primary markers of immune function in a sample of 120 OALWH with substance-related issues. HIV stigma correlated with the greatest number of factors, including depression, loneliness, and substance use problems. Older age and antiretroviral adherence were associated with viral suppression, which was in turn associated with higher percentage of CD4 count. Multivariate path analyses demonstrated that lower HIV stigma and viral suppression were the only factors independently associated with higher percentage of CD4 count, with a significant indirect effect of adherence on CD4 through viral suppression. HIV stigma emerged as the most salient factor associated with both psychosocial well-being and immune health in the current study, suggesting that it is a critical factor to consider in future interventions for the rapidly growing population of OALWH.

"It's Never Just About the HIV:" HIV Primary Care Providers' Perception of Substance Use in the Era of "Universal" Antiretroviral Medication Treatment.

Antiretroviral therapy (ART) is recommended for all people living with HIV (PLWH), regardless of disease status. Substance use disorders (SUD) are common barriers to successful HIV treatment; however, few studies have comprehensively explored how HIV primary care providers take SUDs into account in the context of universal ART implementation. This study uses thematic analysis of qualitative interviews to explore providers' (N = 25) substance use assessment and factors associated with ART initiation. 64% of providers had 15 or more years of HIV treatment experience. Almost all providers agreed with the guidelines for universal ART initiation despite the presence of SUD. Still, identification and management of SUD is challenged by inconsistent assessment, providers' misperceptions about SUD and patients' willingness to discuss it, and lack of accessible treatment resources when SUD is identified. Greater guidance in systematic SUD assessment and management, combined with integrated addiction services, could enhance universal ART implementation among PLWH/SUD.

Outcomes of an inpatient medical nutritional rehabilitation protocol in children and adolescents with eating disorders.

BACKGROUND: Medical stabilization through inpatient nutritional rehabilitation is often necessary for patients with eating disorders (EDs) but includes the inherent risk of refeeding syndrome. Here we describe our experience of implementing and sustaining an inpatient nutritional rehabilitation protocol designed to strategically prepare patients with EDs and their families for discharge to a home setting in an efficient and effective manner from a general adolescent medicine unit. We report outcomes at admission, discharge, and 4-weeks follow-up. METHODS: Protocol development, implementation, and unique features of the protocol, are described. Data were collected retrospectively as part of a continuous quality improvement (QI) initiative. Safety outcomes were the clinical need for phosphorus, potassium, and magnesium supplementation, other evidence of refeeding syndrome, and unexpected readmissions within one month of discharge. The value outcome was length of stay (LOS). Treatment outcomes were the percentage median BMI (MBMI) change from admission to discharge, and from discharge to 4-weeks follow-up visit. RESULTS: A total of 215 patients (88% F, 12% M) were included. Patients averaged 15.3 years old (5.8-23.2y); 64% had AN, 18% had atypical anorexia (AtAN), 6% bulimia nervosa (BN), 5% purging disorder (PD), 4% avoidant-restrictive food intake disorder (ARFID), and 3% had an unspecified food and eating disorder (UFED). Average LOS was 11 days. Initial mean calorie level for patients at admission was 1466 and at discharge 3800 kcals/day. Phosphorus supplementation for refeeding hypophosphatemia (RH) was needed in 14% of inpatients; full-threshold refeeding syndrome did not occur. Only 3.8% were rehospitalized in the thirty days after discharge. Patients averaged 86.1% of a median MBMI for age and gender, 91.4% MBMI at discharge, and 100.9% MBMI at 4-weeks follow-up. Mean percentage MBMI differences between time points were significantly different (admission-discharge: 5.3%, p <0.001; discharge-follow-up: 9.2%, p <0.001). CONCLUSIONS: Implementation of the CHOP inpatient nutritional rehabilitation protocol aimed at rapid, efficient, and safe weight gain and integration of caregivers in treatment of patients with diverse ED diagnoses led to excellent QI outcomes in percentage MBMI at discharge and 4-weeks follow-up, while maintaining a short LOS and low rates of RH phosphorus supplementation.

Antiretroviral medication treatment for all HIV-infected individuals: a protocol using innovative multilevel methodologies to evaluate New York City's universal ART policy among problem substance users.

BACKGROUND: The intersection of HIV-related health outcomes and problem substance use has been well documented. New York City continues to be a focal point of the U.S. HIV epidemic. In 2011, the NYC Department of Health and Mental Hygiene (NYC DOHMH) issued a recommendation that all HIV infected individuals should be offered antiretroviral therapy (ART) regardless of CD4 cell count or other indicators of disease progression. This policy is based in the concept of "treatment as prevention," in which providing ART to people living with HIV (PLWH) greatly reduces the likelihood of HIV transmission, while also improving individual health. The "ART for ALL" (AFA) study was designed to inform modifications to and identify gaps in the implementation of universal ART, and specifically to help guide allocation of resources to obtain local policy goals for increasing viral suppression among PLWH who have problem substance use. METHODS/DESIGN: The AFA Study is informed by two complementary frameworks: Glasgow and colleagues' RE-AIM model, a multi-level framework developed to guide the evaluation of implementation of new policies, and Bronfrenbrenner's ecological systems model, which conceptualizes the bi-directional interplay between people and their environment. Using multi-level data and mixed methods, the primary aims of the AFA Study are to assess rates of viral load suppression, using the NYC HIV Surveillance Registry, within 12 months of HIV diagnosis with (a) yearly cohorts of high-risk-to-transmit, difficult-to-treat, substance using patients recruited from NYC Sexually Transmitted Disease clinics and a large detoxification unit and (b) yearly cohorts of all newly HIV diagnosed people in NYC. Further goals include (c) recruiting cross-sectional samples of HIV/AIDS service providers to assess ART initiation with problem substance users and d) examining geographic factors that influence rates of viral load suppression. An Implementation Collaborative Board meets regularly to guide study procedures and interpret results. DISCUSSION: The AFA Study has the unique strength of accessing and analyzing data at multiple levels using mixed methodology, taking advantage of NYC DOHMH biomedical surveillance data. If successful, others may benefit from lessons learned to inform local and state policies to improve the health of PLWH and further reduce HIV transmission.

Transcranial magnetic stimulation (TMS) in the treatment of attention-deficit/hyperactivity disorder in adolescents and young adults: a pilot study.

OBJECTIVE: Transcranial magnetic stimulation (TMS) uses a medical device that applies magnetic pulses noninvasively to the cortex of the brain to depolarize neurons. We tested its safety and efficacy in young persons with a diagnosis of attention-deficit/hyperactivity disorder (ADHD). METHODS: Transcranial magnetic stimulation was applied to the right prefrontal cortex at 10 Hz, at 100% of the observed motor threshold, for 2000 pulses per session, in a 10-session course over 2 weeks in a sham-controlled crossover design (n=9). There was 1 week of no TMS between the active and sham phases. Safety of TMS was assessed by means of serial audiometry, neuropsychological testing, and electroencephalogram (EEG) at baseline, midpoint, and end point of the study. Efficacy was assessed as a primary outcome by changes in the Clinical Global Impression-Improvement (CGI-I) scale and secondarily by change in the ADHD-IV scale. RESULTS: Transcranial magnetic stimulation was found to be safe, with no serious adverse events and no discontinuations due to adverse effects. All randomized subjects completed the full course of sessions. There were no significant changes in auditory thresholds or in electroencephalographic assessments. Neuropsychological testing showed no significant differences between active and sham groups. There was an overall significant improvement in the clinical global impression of improvement and the ADHD-IV scales across the study phases (active and sham TMS combined; P<0.01), but the change between active and sham TMS phases did not differ. CONCLUSION: Transcranial magnetic stimulation was found to be safe, with no serious adverse events observed in this pilot study. Improvement in symptoms was observed across the combined phases of the study, although there was no difference between the active and sham forms of TMS. Effects of clinical importance should be further assessed in larger controlled studies.

Treatment of anorexia nervosa in children and adolescents.

In this review, we discuss the treatment of anorexia nervosa (AN) in children and adolescents, highlighting inpatient and outpatient psychiatric treatment. AN is an illness that involves medical and psychological issues; hence, treatment often requires the seamless integration of several medical professionals. It is important that the treatment model be unified and consistent as patients transition from inpatient to outpatient treatment. We briefly describe the therapeutic principles involved in treatment of AN and then give examples of how we employ these principles across treatment settings and with multiple medical professionals.

Assessment of anorexia nervosa in children and adolescents.

Anorexia nervosa is a debilitating illness that affects mostly females and their families. Multiple physiologic disturbances are present and can be life-threatening. Nutritional rehabilitation is the foremost initial treatment goal. Assessment skills include understanding the physiologic, developmental, and psychiatric status of the individual as well as engagement of the family system. A comprehensive assessment that stimulates patient and family to successfully engage in treatment is the cornerstone of good clinical care for this highly disabling disorder.

Transcranial magnetic stimulation: a device intended for the psychiatrist's office, but what is its future clinical role?

Repetitive transcranial magnetic stimulation (TMS) is a novel, noninvasive, office-based device technology that delivers focused stimulation to the cortex of the brain by means of magnetic pulses. It is a promising therapeutic approach in a variety of neuropsychiatric disorders. A large number of clinical trials have examined repetitive TMS as a novel treatment for major depression, with additional significant work in schizophrenia, anxiety disorders and pain syndromes. In this review, we describe how repetitive TMS is administered clinically and discuss how excitatory and inhibitory forms of stimulation are applied depending on what is known of the underlying pathophysiology of the disorder. Future putative clinical applications of repetitive TMS in psychiatry are discussed, with the authors' perspective on its likely role in clinical practice. TMS is a promising form of neuromodulation therapy that will most likely become a significant part of clinical practice in the future.