Review latest data regarding the intersectionof pediatric obesity epidemic with telemedicine expansion to meet the need of equitable obesity care in children. Prevalence of pediatric obesity in the USA continues to worsen particularly in rural, underserved areas. Although there is an increasing number of obesity medicine specialists over the last decade, availability varies by geographic location. Pre-pandemic centers were limited, rarely located in rural areas, and required in-person visits for reimbursement. Telemedicine changes, responding to pandemic needs, provided increase in telemedicine utilization and acceptance with similar or improved obesity care outcomes. Given pediatric obesity prevalence and need for chronic, effective obesity care, leveraging telemedicine to expand reach and decrease access barriers provides a critical and creative remedy. Data cites similar outcomes between telemedicine and in-person care. The time to reimagine a full spectrum of care delivery for pediatric obesity is now.

We explore the historical connection of Andrew Taylor Still, hereafter referred to as Still, with Indigenous peoples of the Central Plains, USA, notably the Shawnee, Pawnee, Kickapoo, Cherokee, and Pottawatomie. These nations had well-developed forms of hands-on healing and practicing lightning bone setting. We trace evidence through Still for his connectedness with these people and respect for their traditions. We use an autoethnographic approach to explore the traditional hands-on therapies of these nations and discovered that they are quite similar to osteopathy. The authors compared practices, finding that American osteopathy was strikingly similar to what is practiced by traditional Cherokee hands-on healers. We propose that Still did not invent osteopathy de novo but built it on Indigenous practices already existing among the tribes of Missouri. We believe this is important because the osteopathic community does not acknowledge any contribution of Indigenous people to their field, which should change.

Mental health treatment is a service for military service members who have experienced psychological injury or trauma. Unfortunately, the stigma associated with treatment can prevent many service members from seeking and receiving treatment designed to help them recover. Previous studies have examined the impacts of stigma among military personnel as well as civilians; however, stigma among service members currently receiving mental health treatment is unknown. The purpose of this study is to understand the relationships between stigma, demographic variables, and mental health symptoms in a sample of active duty service members receiving mental health services in a partial hospitalization program. This cross-sectional, correlational study collected data from participants in the Psychiatric Continuity Services clinic at Walter Reed National Military Medical Center, which offers a four-week partial hospitalization program specializing in trauma recovery for active duty service members of all branches. The data from behavioral health assessments were gathered over a 6-month timespan, including the Behavior and Symptom Identification Scale-24, Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, and Post-traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Stigma was measured using the Military Stigma Scale (MSS). The demographic data collected included military rank and ethnicity. Pearson correlations, t-tests, and linear regression were used to further explore the relationships between the MSS scores, demographic covariates, and behavioral health measures. In unadjusted linear regression models, non-white ethnicity and higher behavioral health assessment intake measures were associated with higher MSS scores. However, after adjusting for gender, military rank, race, and all mental health questionnaires, only Post-traumatic Stress Disorder Checklist for DSM-5 intake scores remained associated with MSS scores. No relationship between gender or military rank and average stigma score was observed in either the unadjusted or adjusted regression models. One-way analysis of variance detected a statistically significant difference between the white/Caucasian group and Asian/Pacific Islander group and a near significant difference between white/Caucasian group and black/African American group. The rates of stigma were higher in non-whites than whites. In this active duty military cohort, greater mental health stigma was associated with greater severity of mental health symptoms, especially post-traumatic stress symptoms. Some evidence found that ethnicity may also play a role in stigma score differences, particularly in the Asian/Pacific Islander group. Service providers could consider assessing mental health stigma to meet the clinical needs of their patients within the context of their willingness to obtain and adhere to treatment. Anti-stigma efforts to reduce stigma and its impacts on mental health are discussed. Additional research investigating the effect stigma has on treatment outcomes would help guide the relative importance of assessing stigma, in addition to other behavioral health realms.

To improve quality of care and patient outcomes, and to reduce costs, hospitals in the United States are trying to mitigate readmissions that are potentially avoidable. By identifying high-risk patients, hospitals may be able to proactively adapt treatment and discharge planning to reduce the likelihood of readmission. Our objective in this study was to derive and validate a predictive model of 30-day readmissions for a small rural psychiatric hospital in the northeast. However, this model can be adapted by other rural psychiatric hospitals-a context that has been understudied in the literature. Our sample consisted of 1912 adult inpatients (1281 in the derivation cohort and 631 in the validation cohort), who were admitted between August 1, 2014, and July 31, 2016. We used deidentified data from the hospital's electronic medical record, including physician orders and discharge summaries. These data were merged with community-level variables that reflected the availability of care in the patients' zip codes. We first considered the correlates of 30-day readmission in a regression framework. We found that the probability of readmission increased with the number of previous admissions (vs. no readmissions). Moreover, the probability of readmission was much higher for patients with a depressive disorder (vs. no depressive disorder), with another mood disorder (vs. no other mood disorder), and/or with a psychotic disorder (vs. no psychotic disorder). We used these associations to derive a predictive model, in which we used the regression coefficients to construct a score for each patient. We then estimated the predicted probability of 30-day readmission on the basis of that score. After validating the model, we discuss the implications for clinical practice and the limitations of our approach.

Introduction: Within family medicine it is generally accepted that the more we know about patients' lives, the better the care we provide. Few studies have sought to quantify this historical assumption. We wondered if knowing their chronic pain, patients' life stories would improve the physician-patient relationship in a family medicine residency training program clinic. Methods: We selected patients in chronic pain with depression and/or anxiety who were considered difficult. After a lead in period to establish stability of ratings, we obtained a life story interview for 125 such patients after administering the doctor-patient relationship questionnaire to them and their physicians. Patients completed the McGill Pain Inventory (MPQ), the Zung Anxiety Inventory, and the Center for Epidemiological Studies Depression Scale. Physicians completed the Jefferson Physicians Empathy Scale. Questionnaires were repeated every 4 months. Results: The quality of the physician-patient relationship increased significantly over the course of the year for patients (increase of 0.60, standard deviation [SD] = 0.13, 95% confidence interval [CI] = 0.57 to 0.63, p < 0.001) and for doctors (increase of 0.77, SD = 0.20, 95% CI = 0.72 to 0.81, p < 0.001). The perceived level of pain on the MPQ decreased significantly on the sensory component (71.2 ± 7.6 to 11.7 + 9.4, 95% CI = 0.589 to 9.411, p = 0.0270 and the affective component (4.2 + 3.4 to 2.1 + 4.3, 95% CI = 0.131 to 4.069, p = 0.037). Anxiety and depression ratings did not change. Physicians' empathy ratings increased significantly over the course of the year from a mean of 117.2 (SD = 10.2) to 125.1 (SD = 16.1) for a difference of 7.90, which was significant at p = 0.0273 with a 95% CI of -14.85 to -0.915. Discussion: Knowing the patient's life story improves the physician-patient relationship for both patients and physicians. When the physician-patient relationship improves, the perceived level of pain decreases. Physicians' empathy ratings increase. While the interview requires 90-120 min, it is billable, and can be done by medical students, medical assistants, social workers, or behavioral health. Conclusions: Obtaining life stories of chronic pain patients is a cost-effective way to reduce pain while simultaneously improving the physician-patient relationship and increasing physician empathy.

Abstract Introduction Late-life depression has been proposed as a precursor to amnestic Mild Cognitive Impairment (aMCI), the prodrome of Alzheimer’s disease. Both conditions are associated with sleep and cognitive problems. We hypothesized that MCI and current depressive symptoms would co-occur more frequently, but express distinct sleep phenotypes. Methods Independently living older adults (N=80), age 62-90 (M=71.78, SD=5.98), were recruited from a geriatric psychiatry clinic and the community for a home sleep study. A clinical decision board and neurocognitive battery were used to determine MCI status. Participants completed the CES-D and depression history interview where endorsement of current depression was considered positive. Sleep was examined with wrist actigraphy for 7 days. Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Stanford Sleepiness Scale (SSS) provided subjective sleep quality. Results Based on these criteria, 41.2% of the sample were determined to be MCI (n=33); the remainder were deemed normative for age (NC; n=47). Chi-square analyses showed a higher frequency of MCI were positive for current depression than expected (14.2%; p=0.017). Repeated-measures MANOVA, using current depression symptoms and MCI as factors, revealed MCI was associated with longer sleep latency (p=0.035) and wake bout time (p=0.039); whereas, current depression was associated with longer sleep latency, more fragmentation/WASO, and lower sleep efficiency (p’s&amp;lt;0.05), self-report of poorer daytime dysfunction (p=0.005), and greater daytime sleepiness (p=0.001). MCI x current depression interactions were found for sleep latency (p=0.029); and PSQI sleep disturbances (p=0.005) and sleep medication (p=0.025). Conclusion Despite distinct sleep disordered phenotypes, the interaction of MCI and current depression is associated with delayed sleep onset, use sleep medication and report of sleep disturbances. Support This project was sponsored by: NASA, Maine Space Consortium; AG 056176, AG 053164 Vice President for Research, U. Maine; Maine Technology Institute; DoD Phase I SBIR and R44AG059536-01 SBIR Phase II Award.

Medical student mistreatment continues to be a significant problem despite increased awareness and longitudinal efforts to address the issue. Through audience discussions of a previously published film depicting learner mistreatment, we identified challenges created by student behaviors that negatively impact the learning environment. In addition, the need to address cultural competency in a multigenerational clinical environment became apparent. We created a film of three vignettes based on perspectives shared in focus groups by faculty, residents, nurses, and staff who work with medical students. We used this film to develop student and faculty curricula elucidating generational differences in behaviors and expectations while also exploring the learner's role in creating a more positive learning environment. Our film was presented to medical education professionals at faculty development workshops and meetings, clerkship students at orientation sessions, residents as part of residents-as-teachers curricula, and faculty at departmental grand rounds. Evaluation data from 176 students and 42 faculty showed that a majority of our participants believed the film accurately reflected challenges they faced in the learning environment and felt better equipped to address them. Film is an effective way to stimulate discussion about complex interactions in the clinical learning environment. Divergent perspectives on behaviors depicted in the film served as a stimulus to create targeted curricula for faculty and student education. Stimulating dialogue through film may enhance understanding and empathy among disparate groups, which is likely to be a necessary step for lasting change.

Results of a study to determine factors that contribute to depressive symptoms among pharmacy residents are reported. In a time series study conducted during the 2015-16 residency year, pharmacy residents nationwide were invited to participate in a series of online surveys administered at 3 time points. Information specific to the residency program and external factors was compared with residents' scores on the 9-item Patient Health Questionnaire. Factors associated with depressive symptoms were determined using logistic regression controlling for history of depression and current use of medication for depression. The survey response rate in March 2016 was 21.2%. The strongest predictor of depressive symptoms was perceived stress level (odds ratio [OR], 2.45), while getting enough sleep was the strongest protective factor (OR, 0.39). In multivariate analysis, stress level (OR, 1.84) and not having family nearby (OR, 1.45) were significantly associated with depressive symptoms. High levels of stress, living with family or not having family within driving distance, a high number of hours worked, and a high number of days between having a full 24 hours off duty were associated with higher levels of depressive symptoms, while high levels of family support, an outpatient and/or clinic residency setting, supportive directors and preceptors, effective teaching methods, well-structured and organized programs, clear expectations of residents, having enough days off, and adequate sleep were associated with decreased reporting of depressive symptoms among pharmacy residents in a national study.

Sleep disorders (SD) are common in people with Mild Cognitive Impairment (MCI) from early Alzheimer’s disease (AD). This study investigated whether a new, inexpensive pressure-sensing technology of sleep monitoring could differentiate MCI patients from age-matched, cognitively normal controls. MCI-diagnosed (n=10) and age-matched controls with normal cognition (NC) (n=10), 65–85 years of age, recruited from a memory disorder clinic and community respectively, were studied in the home (2 nights) with a flat-sheet mattress pressure-sensor device and standard wrist actigraphy (7 nights). Resistive sensor technology, signal processing and statistical inference identified 2 distinct signature biomarkers of SD: high frequency (2–5’), low amplitude movement arousals (MAs) (not measured with standard actigraphy), and respiratory rate (RR). MA and spontaneous movement (SM)-RR coupling; a time series segmentation analysis of respiratory variability linked to MAs. Flat-sheet pressure sensor device-based sleep-wake and full arousals were based on the Kripke algorithm and compared to standard actigraphy. Standard actigraphy algorithm sleep scoring did not discriminate MCI from NC on any sleep variable although immobility trended higher in MCI (p<.06). SM-RR coupling index was significantly lower in MCI relative to NC group (M=0.51, SD=.07 vs. M=0.83, SD=.05) using General Linear Modeling with age as covariate (p<.02). Independent of group, lower SM-RR coupling index predicted higher self-reported sleepiness (p<.02) on the Stanford Sleepiness Scale (SSS) and device sleep fragmentation measure correlated positively with SSS average (r=0.49, p<.01). Home-monitoring in MCI revealed abnormal SM-RR coupling in MCI not detected by standard actigraphy. MA and sleep-related autonomic function (RR) time series suggest a neuroprotective function for this arousal neurocircuity to support respiratory tone, airway patency, and moderate hypoxia during sleep that is impaired in MCI relative to NC and may detect early cognitive decline. N/A.