Decreasing body size is associated with reduced calving probability in critically endangered North Atlantic right whales.

Body size is key to many life-history processes, including reproduction. Across species, climate change and other stressors have caused reductions in the body size to which animals can grow, called asymptotic size, with consequences for demography. A reduction in mean asymptotic length was documented for critically endangered North Atlantic right whales, in parallel with declines in health and vital rates resulting from human activities and environmental changes. Here, we tested whether smaller body size was associated with lower reproductive output, using a state-space model for individual health, survival and reproduction that quantifies the mechanistic links between these processes. Body size (as represented by the cube of length) was strongly associated with a female's calving probability at each reproductive opportunity. This relationship explained 62% of the variation in calving among reproductive females, along with their decreasing health (20%). The effects of decreasing mean body size on reproductive performance are another concerning indication of the worsening prospects for this species and many others affected by environmental change, requiring a focus of conservation and management interventions on improving conditions that affect reproduction as well as reducing mortality.

Cancer Patient Perspectives on the Meaning of Healing and the Clinician as a Healer.

BACKGROUND: The experience of living with cancer is marked by suffering and loss, which creates a need for healing. Understanding what healing means to patients and how clinicians can play a role in the healing process is essential to holistic cancer care. OBJECTIVE: The aim of this study was to explore the perspectives of cancer patients on the meaning and experiences of healing and the qualities of a clinician and the clinician-patient relationship that are healing. METHODS: A qualitative study was conducted using semi-structured interviews with 14 cancer patients. Participants were asked about their illness experience, definition of healing, qualities of a healer, and relationships with clinicians that were healing. Interview transcripts were coded, and qualitative analysis was conducted to identify major themes. RESULTS: Participants defined the nature of healing as comprising aspects of physical, mental, emotional, and spiritual well-being. Participants described healing as alleviating pain and symptoms; promoting mental strength, emotional comfort, and spiritual connection; restoring and adapting to losses; and improving quality of life. The qualities of a clinician that contributed to a healing relationship included listening, empathy and compassion, understanding patients' values and goals, and caring for the patient as a whole person. CONCLUSION: Participants viewed healing as physical, psychosocial, and spiritual in nature and an important part of their cancer experience with an emphasis on quality of life. Clinicians played an important role beyond treating the cancer by helping in the healing process through their humanistic qualities and holistic approach to patient care.

Social support network factors associated with verbal fluency among vulnerable persons living with HIV.

Vulnerable persons living with HIV (PLWH) are at high risk of cognitive impairment and challenges accessing quality social support in later life. Impaired verbal fluency (VF), a cognitive domain linked to HIV, could impede social support associated with health and well-being for already vulnerable PLWH. We examined the structure of social support, using latent class analysis, and the associations among quantity, specific forms and quality of social support and VF among PLWH. Participants enrolled in the BEACON study (n = 383) completed the Controlled Oral Word Association test (COWAT) and a social support network inventory. Latent class analysis with count variables was used to determine the number of classes of PLWH based on their social network characteristics. The majority of PLWH were male (61.4%) and African American (85.9%). Two distinct latent classes, with a major distinction in the number of network members who were female, knew participants' HIV status and HIV medication usage. Fewer support network members (ß = -.13, p < 0.01), greater negative interactions (ß = -.16, p < 0.01), and less positive interactions with network members (ß = .15, p < 0.05) were significantly associated with lower COWAT scores. Comprehensive screening of high-risk PLWH and early intervention with those with cognitive impairment are important for addressing social support needs.

Patient-centered Engagement as a Mediator in the Associations of Healthcare Discrimination, Pain Care Denial, and Later Substance Use Among a Sample of Predominately African Americans Living with HIV.

Chronic pain is prevalent and often under-addressed among people with HIV and people who use drugs, likely compounding the stress of discrimination in healthcare, and self-medicating along with its associated overdose risk or other problematic coping. Due to challenges in treating pain and HIV in the context of substance use, collaborative, patient-centered patient-provider engagement (PCE) may be particularly important for mitigating the impact of pain on illicit drug use and promoting sustained recovery. We examined whether PCE with primary care provider (PCE-PCP) mediated the effects of pain, discrimination, and denial of prescription pain medication on later substance use for pain among a sample of 331 predominately African Americans with HIV and a drug use history in Baltimore, Maryland, USA. Baseline pain level was directly associated with a higher chance of substance use for pain at 12 months (Standardized Coefficient = 0.26, p < .01). Indirect paths were observed from baseline healthcare discrimination (Standardized Coefficient = 0.05, 95% CI=[0.01, 0.13]) and pain medication denial (Standardized Coefficient = 0.06, 95% CI=[0.01, 0.14]) to a higher chance of substance use for pain at 12 months. Effects of prior discrimination and pain medication denial on later self-medication were mediated through worse PCE-PCP at 6 months. Results underscore the importance of PCE interpersonal skills and integrative care models in addressing mistreatment in healthcare and substance use in this population. An integrated approach for treating pain and substance use disorders concurrently with HIV and other comorbidities is much needed. Interventions should target individuals at multiple risks of discriminations and healthcare professionals to promote PCE.

The changing epidemiology of opioid overdose in Baltimore, Maryland, 2012-2017: insights from emergency medical services.

INTRODUCTION: An estimated 100,306 people died from an overdose from May 2020 to April 2021. Emergency Medical Services (EMS) are often the first responder to opioid overdose, and EMS encounter records can provide granular epidemiologic data on opioid overdose. This study describes the demographic, temporal, and geographic epidemiology of suspected opioid overdose in Baltimore City using data from Baltimore City Fire Department EMS encounters with the administration of the opioid antagonist naloxone. METHOD: The present analyses used patient encounter data from 2012 to 2017 from the Baltimore City Fire Department, the city's primary provider of EMS services. The analytic sample included patient encounters within the city that involved naloxone administration to patients 15 years of age or older (n = 20,592). Negative binomial regression was used to calculate the incidence rates based on demographic characteristics, year, and census tract. Choropleth maps were used to show the geographic distribution of overdose incidence across census tracts in 2013, 2015, and 2017. RESULTS: From 2012 to 2017, the annual number of EMS encounters with naloxone administrations approximately doubled every 2 years, and the temporal pattern of naloxone administration was similar to the pattern of fatal opioid-related overdoses. For most census tracts, incidence rates significantly increased over time. Population-based incidence of naloxone administration varied significantly by socio-demographic characteristics. Males, non-whites, and those 25-69 years of age had the highest incidence rates. CONCLUSION: The incidence of naloxone administration increased dramatically over the study period. Despite significant cross-sectional variation in incidence across demographically and geographically defined groups, there were significant proportional increases in incidence rates, consistent with fatal overdose rates over the period. This study demonstrated the value of EMS data for understanding the local epidemiology of opioid-related overdose. Key MessagesPatterns of EMS encounters with naloxone administration appear to be an excellent proxy for patterns of opioid-related overdoses based on the consistency of fatal overdose rates over time.EMS plays a central role in preventing fatal opioid-related overdoses through the administration of naloxone, provision of other emergency services, and transportation to medical facilities.EMS encounters with naloxone administration could also be used to evaluate the impact of overdose prevention interventions and public health services.

Family Conflict Non-negotiation and HIV Disclosure Associated With ART Adherence in a Disadvantaged Population.

Adherence to antiretroviral therapy (ART) is vital for reducing racial and gender disparities in morbidity and mortality among people living with HIV/AIDS (PLWH). Little research attention has been given to aspects of family functioning affecting ART adherence among PLWH vulnerable to disparities. Data were from n = 313 participants (93% African American) in the BEACON study, which recruited injection-drug-using PLWH on ART. Using factor analysis and longitudinal structural equation modeling, we found that current substance use and negative family conflict tactics (i.e., non-negotiation) predicted PLWH's lower probability of ART adherence at 12-month follow-up; and greater HIV disclosure to support network members predicted a higher probability of adherence. These findings suggest the importance of family and other support network members in this vulnerable population's ART adherence. Social network-focused interventions promoting prosocial response to conflict and negotiation skills are important for improving vulnerable PLWH's HIV outcomes and reducing health disparities.

Caregiver role strain in caring for vulnerable persons living with HIV: correlates of caregiver and care recipient reports.

Informal care of family and friends is important for the health and well-being of disadvantaged persons living with HIV (PLWH). Caregiver role strain may threaten the function and continuity of their main relationships and their health impacts. Data were from a disadvantaged, primarily African American, sample of PLWH care recipients. Caregiver role strain was operationalized as a latent factor measured by variables including PLWH's perceptions of their caregiver not wanting or complaining about helping them or wanting a break. We found that greater caregiver role strain was associated with higher levels of HIV-related stigma and depressive symptoms. Lower role strain was associated with more collaborative problem solving and shared medical treatment decision-making. Caregiver role strain was linked to disadvantaged PLWHs' worse stigma and mental health; collaborative engagement in care and coping assistance were protective of role strain. Caregiving relationship-focused research and interventions are needed for resourcing and sustaining disadvantaged African American communities' caregiving and health.

Exploring the role of sex differences in the relationship between sex partner attitudes and current quit attempt among a sample of smokers.

INTRODUCTION: Limited research has explored sex differences in the relationship between partner support and smoking cessation among minority low-income population. Further, scarce attention has been given to the influence of partners who are not married. The purpose of this study is to examine the relationship between negative and positive social support provided by partners and smoking cessation among men and women smokers. METHODS: Data were collected as part of the Tobacco Use in Drug Environment (TIDE) study, a cross-sectional study conducted in Baltimore, Maryland, from September 2013 to May 2015. Interviews were administered with current smokers. The sample size for the current analysis was 134 men and 86 women. RESULTS: Approximately 33% of male participants (n=45) reported currently trying to quit smoking cigarettes and 29% of women were currently trying to quit. Having a sex partner who did not mind the participant's smoking was associated with decreased odds of trying to quit among men (AOR=0.35; 95% CI: 0.13-0.91, p=0.03). Having a sex partner who expressed concern about the participant's smoking (AOR=12.9; 95% CI: 3.49-47.0, p<0.01) and having a sex partner who encouraged the participant to quit smoking was significantly associated with current quit attempt among women. In supplementary analyses, we found that each type of partner support varied based on the type of partner - committed or casual. CONCLUSIONS: Understanding sex-partner support regarding smoking and their relationship to smoking cessation activities may provide insights for future tailored cessation interventions.

Decreasing body lengths in North Atlantic right whales.

Whales are now largely protected from direct harvest, leading to partial recoveries in many previously depleted species.1 However, most populations remain far below their historical abundances and incidental human impacts, especially vessel strikes and entanglement in fishing gear, are increasingly recognized as key threats.2 In addition, climate-driven changes to prey dynamics are impacting the seasonal foraging grounds of many baleen whales.2 In many cases these impacts result directly in mortality. But it is less clear how widespread and increasing sub-lethal impacts are affecting life history, individual fitness, and population viability. We evaluated changes in body lengths of North Atlantic right whales (NARW) using aerial photogrammetry measurements collected from crewed aircraft and remotely operated drones over a 20-year period (Figure 1). NARW have been monitored consistently since the 1980s and have been declining in abundance since 2011 due primarily to deaths associated with entanglements in active fishing gear and vessel strikes.3 High rates of sub-lethal injuries and individual-level information on age, size and observed entanglements make this an ideal population to evaluate the effects that these widespread stressors may have on individual fitness. We find that entanglements in fishing gear are associated with shorter whales, and that body lengths have been decreasing since 1981. Arrested growth may lead to reduced reproductive success4,5 and increased probability of lethal gear entanglements.6 These results show that sub-lethal stressors threaten the recoveries of vulnerable whale populations even in the absence of direct harvest.

Alcohol outlets, drug paraphernalia sales, and neighborhood drug overdose.

BACKGROUND: Alcohol outlets have been associated with various forms of injury and may contribute to neighborhood disparities in drug overdose. Few studies have examined the associations between alcohol outlets and drug overdose. This study investigated whether alcohol outlets were associated with the neighborhood drug overdose rate and whether the sale of drug paraphernalia contributes to this association. METHODS: A cross-sectional ecological spatial analysis was conducted within census block groups in Baltimore City (n = 653). Outcomes were counts of EMS calls for any drug overdose in 2015 (n = 3,856). Exposures of interest were counts of alcohol outlets licensed for off-premise and on-premise consumption and the proportion of off-premise outlets selling drug paraphernalia (e.g., blunt wrappers, baggies, pipes). Negative binomial regression was used to assess the relationship between outlet count and overdose rate, and if paraphernalia sales altered this relationship, controlling for other neighborhood factors. Spatial autocorrelation was assessed and regression inference adjusted accordingly. RESULTS: Each additional off-premise alcohol outlet was associated with a 16.6% increase in the neighborhood overdose rate (IRR=1.17, 95%CI=(1.11, 1.23)), adjusted for other neighborhood variables. On-premise alcohol outlets were not significantly associated with overdose rate when adjusting for off-premise alcohol outlets (IRR=1.01, 95% CI=(0.97, 1.06)). The proportion of off-premise outlets that sold drug paraphernalia was negatively associated with overdose rate (IRR=0.55, 95% CI=(0.41, 0.74)) and did not alter the relationship between off-premise outlets and overdose. CONCLUSION: This study provides preliminary public health evidence for informing policy decisions about alcohol outlet licensing and zoning. Alcohol outlets could be potential community partners for harm reduction strategies such as health communication in identifying overdose symptoms or Good Samaritan Laws.

'The Woman Gives': Exploring gender and relationship factors in HIV advance care planning among African American caregivers.

AIMS AND OBJECTIVE: Advance care planning (ACP) is the communication process of documenting future healthcare preferences in case patients are unable to make healthcare decisions for themselves. Research suggests ACP discussions among persons living with HIV (PLHIV) are infrequent overall and may differ by gender and/or race. BACKGROUND: Previous literature has displayed that African Americans are less likely than other racial groups to use advanced care planning, palliative care or hospice, but does not conclusively account for ACP among PLHIV. African American PLHIV rely on informal care that may be differ by gender and represents an important pathway to increase ACP. DESIGN: The study was mixed methods and observational. METHODS: Participants completed self-report surveys (N = 311) and were interviewed (n = 11). Poisson regression (quantitative) and grounded theory analyses (qualitative) were implemented, using COREQ checklist principles to ensure study rigor. RESULTS: Less than half had discussed ACP (41.2%; N = 267). More ACP knowledge predicted 76% lower likelihood of ACP discussions among women. Men who spent more time caregiving in a given week were nearly 3 times more likely to discuss ACP than men who spent less time caregiving. Women were more likely than men to be caregivers and were also expected to serve in that role more than men, which was qualitatively described as 'being a woman'. CONCLUSIONS: The present study is one of few studies exploring ACP among caregivers in African American populations hardest hit by HIV. Results suggest that ACP skill building and education are critical for African Americans living with HIV to promote ACP discussions with their caregivers. Knowledge about ACP topics was low overall even when healthcare had recently been accessed. Support reciprocity and gender-specific communication skill building may facilitate ACP in African American HIV informal caregiving relationships. RELEVANCE TO CLINICAL PRACTICE: Results underscore the need for ACP education which includes healthcare providers and caregivers, given African Americans' preference for life-sustaining treatments at end-of-life. ACP is crucial now more than ever, as COVID-19 complicates care for older adults with HIV at high risk of complications.

REVIEW: Assessing North Atlantic right whale health: threats, and development of tools critical for conservation of the species.

Whaling has decimated North Atlantic right whales Eubalaena glacialis (NARW) since the 11th century and southern right whales E. australis (SRW) since the 19th century. Today, NARWs are Critically Endangered and decreasing, whereas SRWs are recovering. We review NARW health assessment literature, NARW Consortium databases, and efforts and limitations to monitor individual and species health, survival, and fecundity. Photographs are used to track individual movement and external signs of health such as evidence of vessel and entanglement trauma. Post-mortem examinations establish cause of death and determine organ pathology. Photogrammetry is used to assess growth rates and body condition. Samples of blow, skin, blubber, baleen and feces quantify hormones that provide information on stress, reproduction, and nutrition, identify microbiome changes, and assess evidence of infection. We also discuss models of the population consequences of multiple stressors, including the connection between human activities (e.g. entanglement) and health. Lethal and sublethal vessel and entanglement trauma have been identified as major threats to the species. There is a clear and immediate need for expanding trauma reduction measures. Beyond these major concerns, further study is needed to evaluate the impact of other stressors, such as pathogens, microbiome changes, and algal and industrial toxins, on NARW reproductive success and health. Current and new health assessment tools should be developed and used to monitor the effectiveness of management measures and will help determine whether they are sufficient for a substantive species recovery.

A mixed-methods exploration of faith, spirituality, and health program interest among older African Americans with HIV.

BACKGROUND: Persons living with HIV (PLWH) are living into old age with more complex care needs that non-PLWH. Promoting quality of life should include advance care planning (ACP) education, particularly among African Americans. We explored faith/spirituality-related correlates of interest in a future quality of life program among African American PLWH. METHODS: Data were from the AFFIRM study. Participants were recruited from an HIV clinic and completed surveys, interviews, and focus groups. Quantitative analyses included Logistic regression. Qualitative data were coded using grounded theory. RESULTS: Nearly half of participants had less than a high school education (47.9%), and roughly 90% had heard of at least one ACP-related topic (86.6%; N = 315). Qualitative themes related to quality of life and faith/spirituality were: (1) Coping with life challenges; (2) Motivation to improve health for loved ones; and (3) Support programs for people with HIV (N = 39). Satisfaction with religion/spirituality was associated with greater interest in a future program (p < .05); discussing ACP before getting sick was associated with less interest (p < .05). CONCLUSIONS/PRACTICE IMPLICATIONS: Prioritizing skill-building and grounding in spirituality with input from faith leaders can reduce ACP inequities and improve health outcomes among African Americans.

Quality of Life Among Caregivers of a Vulnerable Population Living with HIV: Caregiving and Relationship Factors.

Literature on health-related quality of life (HRQOL) has focused on people living with chronic conditions, with less attention given to HRQOL among informal caregivers. We used cross-sectional dyadic data from both care recipients (CR) living with HIV and the person they identified as their primary informal (unpaid) caregiver (CG) to identify psychosocial and caregiving relationship factors (including, CG role ambivalence and caregiving-related stress) associated with CG HRQOL. We conducted confirmatory factor analysis and structural equation modeling testing. The results highlight interdependent effects of the CG-CR relationship and reveal pathways whereby relationship interactions positively and negatively impact CGs' HRQOL. Affiliative stigma, CG-CR communication, CRs' reciprocity of support and other psychosocial factors indirectly and differentially affected physical and mental HRQOL through effects on secondary stress and role ambivalence. Dyad-focused intervention on interpersonal communication and support exchange may improve HRQOL and resilience of CGs of vulnerable people living with HIV.

RESUMEN: La literatura sobre calidad de vida relacionada con la salud (CVRS) se ha centrado en las personas que viven con enfermedades crónicas, con menos atención a la CVRS entre los cuidadores informales. Utilizamos datos diádicos transversales de recibidores de cuidado (RC) que viven con VIH y de la persona que identificaron como su principal cuidador informal (no remunerado) (CI) para identificar los factores psicosociales y en la relación de cuidado (incluyendo la ambivalencia del rol de CI y del estrés) asociado con calidad de vida. Realizamos análisis factoriales confirmatorios y pruebas de modelación de ecuaciones estructurales. Los resultados demostraron los efectos interdependientes de la relación entre el cuidador y el recibidor de cuidado y revelan cómo las interacciones de la relación impactan la calidad de vida de los cuidadores. El estigma, la comunicación en la relación, la reciprocidad de apoyo de los recibidores de cuidado y otros factores psicosociales afectaron indirecta y diferencialmente la calidad de vida física y mental a través de los efectos sobre el estrés secundario y la ambivalencia de roles. Las intervenciones diádicas centradas en la comunicación interpersonal y la facilitación de apoyo pueden mejorar la calidad de vida y la capacidad de recuperación de los cuidadores de las personas vulnerables que viven con el VIH.

The Interaction of Smoking Cessation Norms and Nicotine Dependence on Quit Attempts: Gender-Stratified Results for Low-Income Smokers in Baltimore, MD.

Background: Declines in smoking prevalence among low-income adults lag behind national samples. Understanding the influence of social context factors such as gender, and normative influence on smoking attitudes and behaviors, can inform smoking cessation interventions. Objective: This study explored how gender, smoking dependence, and cessation norms influenced the likelihood of current quit attempts among urban-dwelling, predominately African American adults. Methods: Participants answered questions about their current quit attempts, smoking dependence (heaviness of smoking index [HSI]), and cessation norms (descriptive: having friends who quit smoking; injunctive: friends disapproving of smoking) as a part of a parent study exploring social and environmental factors in tobacco use. Logistic regression stratifying by gender and adjusting for demographics examined main and interaction effects of norms and HSI on odds of having a current quit attempt. Results: Among men, having a higher smoking dependence was associated with a reduced likelihood of trying to quit (AOR = 0.30 [0.15-0.59]), but this effect was moderated by having friends who had quit smoking (AOR = 2.40 [1.20-4.78]). When accounting for the effect of friends quitting smoking, men were not influenced by friends disapproving of smoking. Among women, currently attempting to quit was predicted by neither smoking dependence nor norms. Conclusions/Importance: Cessation norms and smoking dependence influenced the likelihood of quit attempts for men, but not women, in this study. This highlights the importance of conducting gender stratification in smoking cessation research so as to better understand how social and environmental factors differently impact cessation outcomes for men and women.

Effect of a Hospital-Initiated Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Patients Hospitalized With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial.

Importance: Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life. Objective: To evaluate whether a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers can improve outcomes. Design, Setting, and Participants: Single-site randomized clinical trial conducted in Baltimore, Maryland, with 240 participants. Participants were patients hospitalized due to COPD, randomized to intervention or usual care, and followed up for 6 months after hospital discharge. Enrollment occurred from March 2015 to May 2016; follow-up ended in December 2016. Interventions: The intervention (n = 120) involved a comprehensive 3-month program to help patients and their family caregivers with long-term self-management of COPD. It was delivered by nurses with special training on supporting patients with COPD using standardized tools. Usual care (n = 120) included transition support for 30 days after discharge to ensure adherence to discharge plan and connection to outpatient care. Main Outcomes and Measures: The primary outcome was number of COPD-related acute care events (hospitalizations and emergency department visits) per participant at 6 months. The co-primary outcome was change in participants' health-related quality of life measured by the St George's Respiratory Questionnaire (SGRQ) at 6 months after discharge (score, 0 [best] to 100 [worst]; 4-point difference is clinically meaningful). Results: Among 240 patients who were randomized (mean [SD] age, 64.9 [9.8] years; 61.7% women), 203 (85%) completed the study. The mean (SD) baseline SGRQ score was 62.3 (18.8) in the intervention group and 63.6 (17.4) in the usual care group. The mean number of COPD-related acute care events per participant at 6 months was 1.40 (95% CI, 1.01-1.79) in the intervention group vs 0.72 (95% CI, 0.45-0.97) in the usual care group (difference, 0.68 [95% CI, 0.22-1.15]; P = .004). The mean change in participants' SGRQ total score at 6 months was 2.81 in the intervention group and -2.69 in the usual care group (adjusted difference, 5.18 [95% CI, -2.15 to 12.51]; P = .11). During the study period, there were 15 deaths (intervention: 8; usual care: 7) and 339 hospitalizations (intervention: 202; usual care: 137). Conclusions and Relevance: In a single-site randomized clinical trial of patients hospitalized due to COPD, a 3-month program that combined transition and long-term self-management support resulted in significantly greater COPD-related hospitalizations and emergency department visits, without improvement in quality of life. Further research is needed to determine reasons for this unanticipated finding. Trial Registration: ClinicalTrials.gov Identifier: NCT02036294.

"We get tunnel vision": Emergency medical service providers' views on the opioid epidemic in Baltimore City.

OBJECTIVE: To understand the needs of Emergency Medical Service (EMS) providers caring for substance users in an urban setting. DESIGN: Qualitative interviews with EMS providers regarding perceptions of substance users and treatment programs. SETTING: Baltimore City. PARTICIPANTS: Twenty-two Baltimore City Fire Department EMS providers. INTERVENTIONS: Semistructured in-depth interviews were conducted with 22 EMS providers. Topics included experiences caring for substance-using patients and attitudes about local harm reduction approaches. MAIN OUTCOME MEASURE: Providers were asked their views on receiving training to deliver a brief motivational intervention to encourage patients to enter drug treatment. Interviews were transcribed and analyzed using constant comparison. RESULTS: Participants were mostly Male (68.2 percent), White (66.6 percent), and had Advanced Life Skills training (90.9 percent). Mean experience was 8.7 years. Many providers described EMS misusers as mostly male and middle-aged, although there were variations in substance use patterns among all races and income levels. Most stated that repeated care provision to a small number of substance-users negatively impacted care quality. Provider demands included departmental policies and resource limitations. Many expressed willingness to deliver motivational messages to substance-using patients to consider drug treatment. Other stated that behavioral interventions were beyond their job duties and most reported having little-to-no knowledge of local treatment programs. CONCLUSIONS: EMS providers may be uniquely positioned to deliver substance use treatment messages to substance users. This could be a life- and cost-saving improvement to EMS in Baltimore City with incentivized training. More research is needed to inform opioid use preparedness in urban settings, which remain at the center of the opioid epidemic.

Support Network Factors Associated With Naming a Health Care Decision-Maker and Talking About Advance Care Planning Among People Living With HIV.

CONTEXT: Little attention has been given to social environmental factors associated with advance care planning (ACP) among African Americans or people living with advanced HIV (PLHIV). OBJECTIVES: The present study aimed to identify support network factors that affect the likelihood of naming a decision-maker and of talking to family/friends and doctors about ACP among vulnerable PLHIV. METHODS: PLHIV were recruited from a large urban HIV clinic. A social support network inventory was used to calculate number of persons available for various types of support. Characteristics of network members were also collected. Multivariable logistic regression models were fit to examine associations between social network factors and ACP discussion, adjusting for age, sex, education, and total number of network members. RESULTS: The sample (N = 370) was mostly African American (95%), male (56%), and 48% had less than a high school education. Almost half the sample (48%) had talked to their family/friends or doctor about ACP, and 34% had named a medical decision-maker. Adjusted analysis revealed that talking about ACP with family/friends was associated with female sex and a larger closer support network who provided health information and physical assistance. Talking to doctors about ACP was associated with larger support networks who provided physical assistance but lower numbers from whom emotional support was received. Naming a decision-maker was associated with greater numbers of network members who provided emotional support, health information, and medication adherence reminders. CONCLUSION: The findings revealed aspects of family/support network structures and caregiving function associated with ACP in a population with often vital yet vulnerable networks.

Chronic Pain, Functional Status, and Life Satisfaction Are Associated With Patients Living With HIV Discussing Advance Care Planning With Their Family or Friends.

CONTEXT: In the era of effective antiretroviral therapy, persons living with HIV/AIDS (PLWHA) are living longer, transforming HIV from a universally fatal disease to a serious chronic illness, warranting discussions between patients and their loved ones about advance care planning (ACP). Evidence is needed on factors associated with patients' likelihood to discuss ACP with loved ones. OBJECTIVES: To further characterize factors associated with successful ACP in PLWHAs with their loved ones, we examined associations between patients having ACP discussions with the need for assistance with personal care, chronic pain, life satisfaction, prior family disagreements over health care decisions, sex, age, and interference in daily routines due to memory problems. METHODS: Data were from the Affirm Care study (N = 370), which examined social and environmental factors associated with health outcomes among PLWHAs and their informal caregivers. RESULTS: Slightly more than half of respondents discussed ACP with loved ones (57%). In adjusted analysis, higher levels of chronic pain (odds ratio [OR] = 2.09, P = 0.045), needing assistance with personal care (OR = 1.63, P = 0.023), greater life satisfaction (OR = 1.02, P = 0.002), prior family arguments over health care decisions (OR = 2.80, P < 0.001), and female sex (OR = 2.22, P = 0.001) were associated with higher odds of discussing ACP with loved ones, whereas age, drug use, education level, depression, and memory problems were nonsignificant. CONCLUSION: These results suggest that interventions to increase ACP among PLWHAs and their loved ones should target males. The findings also suggest PLWHAs with chronic pain, the need for assistance with personal care, and those with a history of prior family arguments over health care decisions may be primed for ACP.

Emotional Communication in HIV Care: An Observational Study of Patients' Expressed Emotions and Clinician Response.

Emotional support is essential to good communication, yet clinicians often miss opportunities to provide empathy to patients. Our study explores the nature of emotional expressions found among patients new to HIV care, how HIV clinicians respond to these expressions, and predictors of clinician responses. Patient-provider encounters were audio-recorded, transcribed, and coded using the VR-CoDES. We categorized patient emotional expressions by intensity (subtle 'cues' vs. more explicit 'concerns'), timing (initial vs. subsequent), and content (medical vs. non-medical). Emotional communication was present in 65 of 91 encounters. Clinicians were more likely to focus specifically on patient emotion for concerns versus cues (OR 4.55; 95% CI 1.36, 15.20). Clinicians were less likely to provide space when emotional expressions were repeated (OR 0.32; 95% CI 0.14, 0.77), medically-related (OR 0.36; 95% CI 0.17, 0.77), and from African American patients (OR 0.42; 95% CI 0.21, 0.84). Potential areas for quality improvement include raising clinician awareness of subtle emotional expressions, the emotional content of medically-related issues, and racial differences in clinician response.