Medicine and Health Sciences Commons^™

Bioenergetics And Neuroimaging Research: A Neuropathophysiological Linkage In The Setting Of Cocaine Use Amongst Persons With Hiv, Cory J. White, Karl Goodkin

School of Medicine Publications

Despite innovations in antiretroviral therapy (ART) that have transformed HIV infection from an acute illness with high mortality risk into a chronic, largely manageable disease, the viral reservoir that persists in brain continues to pose a risk for neurocognitive impairment and other deleterious clinical outcomes. ART regimens can inhibit viral integration and suppress replication to nondetectable levels in plasma and cerebrospinal fluid (CSF) but do not eliminate viral reservoirs, including that in brain ^[1]. Moreover, HIV transcripts within CSF cells have been associated with brain injury despite suppressive ART ^[2]. Comorbid HIV and cocaine use exacerbates brain atrophy …

Influences Of Chronic Stress On Irritable Bowel Syndrome, Anxiety, Depression, And The Microbiome, Julia A. Semaan

Masters Theses

IBS effects approximately 5% of the world’s population with symptoms ranging from unexplainable constipation to daily abdominal pain. Though treatment options are available and have been proven beneficial for certain individuals, discovering the root cause of IBS has been difficult to accomplish due to the variety of symptoms that differ from case to case. This study aims to increase understanding of the influence that chronic stress has on irritable bowel syndrome, anxiety, depression, and the microbiome in the college-age population since this group is likely to experience daily stressors, anxiety- and depressive-like thoughts, as well as IBS symptoms. Current research …

One-Year Outcomes Following Intravenous Ketamine Plus Digital Training Among Patients With Treatment-Resistant Depression: A Secondary Analysis Of A Randomized Clinical Trial, Rebecca B Price, Meredith L Wallace, Sanjay J Mathew, Robert H Howland

Staff and Researcher Publications

This secondary analysis of a randomized clinical trial examines whether automated self-association training can prolong the antidepressant effect of a single infusion of ketamine beyond 1 month in patients with treatment-resistant depression.

The Comorbidity Of Depression And Neurocognitive Disorder In Persons With Hiv Infection: Call For Investigation And Treatment, Karl Goodkin, Teresa H. Evering, Albert M. Anderson, Ann Ragin, Cynthia L. Monaco, Christina Gavegnano, Ryan J. Avery, Sean B. Rourke, Lucette A. Cysique, Bruce J. Brew

School of Medicine Publications

Depression and neurocognitive disorder continue to be the major neuropsychiatric disorders affecting persons with HIV (PWH). The prevalence of major depressive disorder is two to fourfold higher among PWH than the general population (∼6.7%). Prevalence estimates of neurocognitive disorder among PWH range from 25 to over 47% – depending upon the definition used (which is currently evolving), the size of the test battery employed, and the demographic and HIV disease characteristics of the participants included, such as age range and sex distribution. Both major depressive disorder and neurocognitive disorder also result in substantial morbidity and premature mortality. However, though anticipated …

Phq -9 Utilization In The Primary Care Setting, Michael Armstrong, Ramisa Rahman, Ceferino Cruz Iv, Afsha Rais Kaisani

North Texas GME Research Forum 2023

INTRODUCTION: The Patient Health Questionnaire-9 (PHQ-9) is a tool used to help diagnose depression and assess a patient’s response to treatment. Quality metric (QM) 371 is a measure of PHQ-9 utilization in patients with depression, and Medical City Family Medicine tracks QM 371 in order to improve the quality of care provided to our patients. This project sought to assess utilization of the PHQ-9 in our clinical practice. At the time of this QI project’s inception, QM 371 was reporting at 0%.

METHODS: Our intervention was to give an educational presentation regarding depression, the PHQ-9, as well as how to …

Management Of Anxiety And Depression In Post Coronary Artery Bypass Graft Surgery, Mansour Jannati, Amir Aslani

Journal of Mind and Medical Sciences

Depression and anxiety are common events in 30-40 percent of post coronary artery bypass graft (CABG) surgery patients. Depression symptoms in patients with CAD are expected to be significantly more, comparing the public incidence rate. Impaired remedy after coronary artery events may partly be attributed to depression and anxiety. If anxiety continues, it may lead to elevate metabolism and oxygen consuming. High level of anxiety increases the pain sensation in post CABG patients. This paper aimed to review results and findings of previous studies in the field of anxiety and depression management of post coronary artery bypass graft surgery. Up …

Evaluation Of Burning Mouth Syndrome And Salivary Chromogranin A In Major Depressive Disorder Patients, Ameer Ali Althabhawee, Taghreed Fadhil Zaidan

Maaen Journal for Medical Sciences

Major depressive disorder represents a growing concern as its prevalence keeps rising worldwide; with this rising, there is also an increased demand in the field of oral medicine in developed countries, and since many disorders and orofacial pain have been linked to be associated with psychiatric disorders and conditions, this study was aimed to evaluate burning mouth syndrome and salivary chromogranin A in major depressive disorder patients. The study sample included 49 patients who received a diagnosis of major depressive disorder, being under treatment for at least two weeks. The control group consists of 34 healthy subjects with no signs …

The Utilization Of Depression Screening Tools In Patients With Diabetes Type 2, Hanna Book, Kennedy Eldridge, Margaret Harvey Phd, Aprn, Acnp-Bc, Chfn, Artangela Henry Dnp, Agacnp-Bc, Fnp-C, Laura Reed Dnp, Fnp-Bc

Doctor of Nursing Practice Projects

Purpose/Background

Diabetes and depression are highly prevalent and concerning conditions impacting millions worldwide. Evidence-based guidelines recommend regular depression screening of individuals with type II diabetes (DM2) to appropriately diagnose and treat depression and proactively enhance clinical outcomes. The gold standard for determining depression in patients with chronic disease is the diagnostic clinical interview; however, many clinicians have turned to brief, self-reported screening tools such as the PHQ-2 and the PHQ-9 whose use are recommended by evidence-based guidelines. This study aims to assess the utilization of the PHQ-2 and PHQ-9 versus no screening on DM2 patients in a primary care setting. …

Mixed Depression In The Post-Covid-19 Syndrome: Correlation Between Excitatory Symptoms In Depression And Physical Burden After Covid-19, Alessio Simonetti, Evelina Bernardi, Stella Margoni, Antonello Catinari, Antonio Restaino, Valentina Ieritano, Marta Palazzetti, Federico Mastrantonio, Delfina Janiri, Matteo Tosato, Francesco Landi, Gabriele Sani

Faculty, Staff and Students Publications

The relationship between depression and post-COVID-19 disease syndrome (post-COVID-19 syndrome) is established. Nevertheless, few studies have investigated the association between post-COVID-19 syndrome and mixed depression, i.e., a specific sub-form of depression characterized by high level of excitatory symptoms. Aims of the present study are: (a) to compare the post-COVID-19 syndrome's burden in depressed and non-depressed patients, and (b) to investigate the correlation between post-COVID-19 syndrome's burden and the severity of mixed depression. One thousand and forty six (n = 1460) subjects with post-COVID-19 syndrome were assessed. Subjects were divided into those with (DEP) or without (CONT) depression. Sociodemographically, post-COVID-19 syndrome's …

The Effects Of School-Based Art Therapy On Depressed Adolescents, Jasmine Nicolas

Nursing | Student Research Posters

Depression in adolescents is associated with deficient behavioral and health outcomes (Fletcher, 2019). Art therapy has been shown to be effective in treating mental health condition such as depression. A student’s academic success heavily depends on treating their depression. Community health nurses can play a vital role in advocating for adequate mental health support to improve a student’s overall well-being and academic success. The literature review contains six articles on the prevalence and impact of depression among adolescents, art therapy as an intervention for improving psychological outcomes and resilience among adolescents, and experiences of adolescent clients in art therapy within …

Comorbidities And Risk Factors Associated With Insomnia In The Elderly Population., Neil Mookerjee, Nicole Schmalbach, Gianna Antinori, Subhadra Thampi, Dylan Windle-Puente, Amy Gilligan, Ha Huy, Megha Andrews, Angela Sun, Roshni Gandhi, William Benedict, Austin Chang, Ben Sanders, Justin Nguyen, Maanika Reddy Keesara, Janet Aliev, Aneri Patel, Isaiah Hughes, Ian Millstein, Krystal Hunter, Satyajeet Roy

Cooper Medical School of Rowan University Departmental Research

INTRODUCTION/OBJECTIVES: Sleep disorders affect around 50 to 70 million Americans, with chronic insomnia being the most common, especially in the elderly population. With an 11-fold increase in the US office visits due to insomnia, from 0.8 to 9.4 million, between 1993 and 2015, it is imperative to identify the modifiable risk factors. The aim of our study was to examine the association of risk factors and comorbid medical conditions with insomnia in patients 65 years, and older.

METHODS: We performed a retrospective electronic medical record review of the patients aged 65 years and older, who visited our suburban internal medicine …

Mechanisms Linking Threat- And Deprivation-Related Childhood Adversity And Depression: The Biopsychosocial Model, Cut N. Kemala, Marijtje L.A. Jongsma, Donny Hendrawan, Eni Becker

Psychological Research on Urban Society

Childhood adversity involves a wide range of negative experiences that pose a serious threat to a child’s wellbeing. It has been consistently shown to predict (chronic) depression in subsequent stages of development, but mechanisms underlying the relationship are still less clear. Moving from a cumulative approach of lumping heterogeneous categories of childhood adversity to a dimensional approach of classifying negative experiences into two major dimensions (threat and deprivation) has facilitated the identification of specific processes by which childhood adversity can predict depression. This review aims to provide an integrative overview of how childhood adversity increases the risk for depression using …

The Effect Of Covid-19 On Substance Use And Mental Health On A College Campus, Georgia L. Coffman

Butler Journal of Undergraduate Research

In this research, the author surveyed a university population to determine the impact that COVID-19 has had on substance use and mental health. Current research provides significant data indicating worsening mental health and substance use. This paper looks at how applicable those trends are to a small private university in Indianapolis, Indiana. The data included 261 respondents composed of students, faculty, and staff of the university. The results reveal that college students, faculty, and staff experienced statistically significant increases in feelings of unhappiness, depression, loneliness, hopelessness, agitation, and irritability during the pandemic compared to before the pandemic. Data analysis of …

Sleep Apnea And Substance Use Disorders Associated With Co-Occurrence Of Anxiety Disorder And Depression Among U.S. Adults: Findings From The Nsduh 2008–2014, Chun Xu, Priscila Acevedo, Liang Wang, Nianyang Wang, Kaysie Ozuna, Saima Shafique, Annu Karithara, Victoria I. Padilla, Chunxiang Mao, Xin Xie, Kesheng Wang

Health & Biomedical Sciences Faculty Publications

Few studies have focused on sleep apnea and substance use disorders with co-occurrence of anxiety disorder and depression. This study included a total of 270,227 adults, 9268 with co-occurrence of anxiety disorder and depression in the past year, from the combined 2008–2014 National Survey on Drug Use and Health (NSDUH) data, which are the latest datasets with measures of anxiety disorder and sleep apnea. Weighted multinomial logistic regression analyses were used to estimate the associations between anxiety disorder and depression and their co-occurrence. Comorbidity was highly prevalent: 40.4% of those with depression also met the criteria for anxiety disorder, whereas …

Progressive Muscle Relaxation Exercises In Patients With Covid-19: Systematic Review And Meta-Analysis, Abubeker Alebachew Seid, Ahmed Adem Mohammed, Aragaw Asfaw Hasen

Faculty, Staff and Student Publications

BACKGROUND: Patients with COVID-19 will experience high levels of anxiety and depression and poor levels of sleep and quality of life (QoL) due to isolation treatment and uncertain outcomes. Progressive muscle relaxation (PMR) exercises show promising treatment effects on mental health and sleep problems and overall QoL in COVID-19 patients. This study aimed to evaluate the efficacy and safety of PMR exercises in patients with COVID-19.

METHODS: Both experimental and non-experimental studies related to PMR and COVID-19 were systematically searched in the PubMed, Cochrane Library, PEDro and HINARI databases for studies published from the occurrence of the pandemic to December …

Geriatric Depression Screening And Chief Complaint: What Is The Risk For 30- And 90-Day Readmission?, Eric James, Joan Michelle Moccia, Victoria Lucia

Journal of Geriatric Emergency Medicine

Abstract

Background:

Readmission to the hospital within 30-days has a high cost and represents a gap in care for older adults. Older adults are at significant risk for depression, particularly given their medical comorbidities and social factors such as isolation due to SARS-CoV-2. Many patients who screen positive for depression may have no known history of depression. This investigation examines the relationship between a positive geriatric depression screen and chief complaint as a function of 30- and 90-day readmission risk.

Methods:

We examined the electronic medical record of 329 older adults aged 65 and older from February 1, 2020, to …

Co-Occurrence Of Depression, Anxiety, And Perinatal Posttraumatic Stress In Postpartum Persons, Shelby Howard, Caitlin Witt, Karla Martin, Ateshi Bhatt, Emily Venable, Sarah Buzhardt, Andrew G. Chapple, Elizabeth F. Sutton

School of Medicine Faculty Publications

Background: The study aim was to describe the incidence of depression, anxiety, perinatal-post-traumatic stress disorder (PTSD), and their co-occurrences in the early postpartum period in a low-resource OB/GYN clinic serving majority Medicaid-eligible persons. We hypothesized that postpartum persons screening positive for depression will have an increased risk of a positive screen for anxiety and perinatal PTSD. Methods: A retrospective study of postpartum persons receiving care in Baton Rouge, Louisiana was conducted using responses abstracted from the electronic medical record (EMR) of the Patient Health Questionnaire-9 (PHQ9), Generalized Anxiety Disorder-7 (GAD7), and Perinatal Post Traumatic Stress Disorder Questionnaire-II (PPQII). Categorical distributions …

Cross-Sectional Study To Assess Depression Among Healthcare Workers In Lusaka, Zambia During The Covid-19 Pandemic, Sandra Simbeza, Jacob Mutale, Musunge Mulabe, Lazarus Jere, Chama Bukankala, Kombatende Sikombe, Izukanji Sikazwe, Carolyn Bolton-Moore, Aaloke Mody, Elvin H. Geng, Anjali Sharma, Laura K. Beres, Jake M. Pry

2020-Current year OA Pubs

OBJECTIVES: We sought to assess depression among healthcare workers (HCWs) in the context of COVID-19 in Lusaka Province, Zambia.

DESIGN: This cross-sectional study is nested within a larger study, the Person-Centred Public Health for HIV Treatment in Zambia (PCPH), a cluster-randomised trial to assess HIV care and outcomes.

SETTING: The research was conducted in 24 government-run health facilities from 11 August to 15 October 2020 during the first wave of the COVID-19 pandemic in Lusaka, Zambia.

PARTICIPANTS: We used convenience sampling to recruit HCW participants who were previously enrolled in the PCPH study, had more than 6 months' experience working …

Assessment Of Psychosocial And Neonatal Risk Factors For Trajectories Of Behavioral Dysregulation Among Young Children From 18 To 72 Months Of Age., Julie A. Hofheimer, Monica Mcgrath, Rashelle Musci, Guojing Wu, Sarah Polk, Courtney K. Blackwell, Annemarie Stroustrup, Robert D. Annett, Judy Aschner, Brian S. Carter, Jennifer Check, Elisabeth Conradt, Lisa A. Croen, Anne L. Dunlop, Amy J. Elliott, Andrew Law, Leslie D. Leve, Jenae M. Neiderhiser, T Michael O'Shea, Amy L. Salisbury, Sheela Sathyanarayana, Rachana Singh, Lynne M. Smith, Andréa Aguiar, Jyoti Angal, Hannah Carliner, Cindy Mcevoy, Steven J. Ondersma, Barry Lester, Program Collaborators For Environmental Influences On Child Health Outcomes

Manuscripts, Articles, Book Chapters and Other Papers

IMPORTANCE: Emotional and behavioral dysregulation during early childhood are associated with severe psychiatric, behavioral, and cognitive disorders through adulthood. Identifying the earliest antecedents of persisting emotional and behavioral dysregulation can inform risk detection practices and targeted interventions to promote adaptive developmental trajectories among at-risk children.

OBJECTIVE: To characterize children's emotional and behavioral regulation trajectories and examine risk factors associated with persisting dysregulation across early childhood.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study examined data from 20 United States cohorts participating in Environmental influences on Child Health Outcomes, which included 3934 mother-child pairs (singleton births) from 1990 to 2019. Statistical analysis …

Implementing Cognitive Behavioral Therapy For Insomnia With Motivational Interviewing In The Mental Health Setting, Kassandra E. Ransom

Doctor of Nursing Practice Projects

Can you imagine not sleeping well for weeks or months at a time? Insomnia impacts approximately one-third of adults and is considered the most prevalent of all sleep disorders. With a lack of consistent, quality sleep, insomnia has significant negative consequences that impact a person’s overall mental well-being, like increased anxiety, depression, chronic pain, and daily coping. Cognitive Behavioral Therapy for Insomnia (CBT-I) allows patients to reduce or eliminate insomnia or related symptoms without needing medication to obtain quality and consistent sleep. CBT-I is difficult, so partnering it with Motivational Interviewing (MI) techniques provides patient engagement and compliance to strike …

Perimenopausal Depression Screening And Treatment Efficacy Between Antidepressants And/Or Hormone Replacement Therapy, Mandy Stenehjem

Physician Assistant Scholarly Project Posters

During perimenopause, women are at increased risk of depression due to complex and multifactorial factors, such as HPA axis dysregulation and fluctuations in hormones, like estradiol. Antidepressants are currently used to treat depression, but hormone replacement therapy may also have comparable antidepressant effects based on hormonal mechanisms. Perimenopausal depression is a unique subtype of depression and needs to be routinely screened by OBGYNs and primary care providers. The literature review found mixed results on the efficacy of HRT, antidepressants, and a combination of both; all treatments have shown promising benefits and specific screening may be needed to tailor treatment.

Psychology University Students’ Mental Health Status During Covid-19 Pandemic In Karachi, Pakistan, Aisha Noorullah, Mubarak Mansoor, Ayesha Zahid

Department of Psychiatry

Purpose: The COVID-19 pandemic has brought challenges in various domains of life but for low and middle-income country university students very demanding situations have emerged. University students’ psychological well-being has always been an area of concern worldwide and higher rates of anxiety and depression have been extensively reported among this cohort.
Objective: To determine the frequency of depressive symptoms, anxiety symptoms, and quality of sleep and the association of sleep quality and personality traits with anxiety and depressive symptoms among university students in Karachi, Pakistan in the context of the pandemic COVID-19.
Method: This web-based cross-sectional study was conducted among …

Covid-19 Lockdown: Impact On College Students’ Lives, Wendy C. Birmingham, Lori L. Wadsworth, Jane H. Lassetter

Faculty Publications

Objective: In light of COVID-19, leaders issued stay-at-home orders, including closure of higher-education schools. Most students left campus, likely impacting their employment and social network. Leaders are making decisions about opening universities and modality of instruction. Understanding students' psychological, physiological, academic, and financial responses to the shut-down and reopening of campuses can help leaders make informed decisions. Participants: 654 students from a large western university enrolled during the pandemic shutdown. Methods: Students were invited via email to complete an online survey. Results: Students reported stress, depression, loneliness, lack of motivation, difficulty focusing on schoolwork, restless sleep, appetite changes, job loss …

The Association Between College Age Students' Nutrition Intake And Depression, Mackenzie Allen

Honors Projects

The research performed was to determine a correlation between depression and nutrient intake in college age students. This study used NHANES publicily available data and IBM's SPSS statistical software to analyze a correlation between depression and nutrition/lifestyle variables: vitamin D, vitamin B12, saturated fatty acids, unsaturated fatty acids, fiber, and exercise. The study found that fiber and unsaturated fatty acid intake had a negative correlation with depression, meaning that as the intake of these nutrients increased, depression decreased. This research reveals key factors to improve the nutritional status of college age students, along with their emotional wellbeing.

Serotonin Reuptake Inhibitor Increases Pseudarthrosis Rates In Anterior Cervical Discectomy And Fusions, Mark J. Lambrechts, Nicholas D. D'Antonio, Gregory R R. Toci, Brian A. Karamian, Josuhu Pezzulo, Dominic Farronato, Jose Canseco, Ian David Kaye, Barrett Woods, Jeffrey A. Rihn, Mark Kurd, Joseph K. Lee, Md, Alan S. Hilibrand, Christopher K. Kepler, Alexander R. Vaccaro, Gregory D. Schroeder

Rothman Institute Papers

STUDY DESIGN: Retrospective cohort.

PURPOSE: To determine (1) the effects of serotonin reuptake inhibitors in pseudarthrosis rates after anterior cervical decompression and fusion (ACDF) and (2) to identify patient-reported outcome measures in patients taking serotonin reuptake inhibitors.

OVERVIEW OF LITERATURE: Recent literature suggests that selective serotonin reuptake inhibitors (SSRIs) may inhibit fracture healing via downregulation of osteoblast differentiation. Spinal fusion supplementation with osteoblast-rich substances enhances spinal fusion, thus SSRIs may be detrimental.

METHODS: Patients with 1-year postoperative dynamic cervical spine radiographs following ACDF were grouped into serotonin reuptake inhibitor prescriptions (SSRI, serotonin-norepinephrine reuptake inhibitor [SNRI], or tricyclic antidepressant [TCA]) and …

Implementation Of Collaborative Care Intervention Within A Fqhc To Achieve Uniform Data System (Uds) Measure Of Depression Remission, Rasha A. Kafi Msn, Rn, Fnp-C

Doctor of Nursing Practice Projects

Background: Depression is one of the most common and treatable mental health conditions. Untreated depression causes emotional suffering, reduced productivity, lost wages, increased comorbidity risks, and increased healthcare costs.

Purpose: The purpose of this project was to implement Collaborative Care Interventions (CCI) to achieve the Uniform Data System (UDS) Measure of Depression Remission.

Aims: The AIMS of this project were: (a) Increases the percentage of nursing staff compliance and completion of the educational training; (b) increases nursing staff knowledge of recognition of depression signs and symptoms, early identification of depression, and administration to all adult patients; (c) Increase the percentage …

The Musical Touch On Mental Illness, Skylar Dunn

Senior Honors Theses

To understand the relationship amongst anxiety, depression, and music therapy, this integrative review synthesizes the major themes and relevant education of articles discussing mental health and the benefit of music. While most existing studies focus on using music therapy to treat pain and clinical anxiety, the content of this paper is written to emphasize how the same principles can be used in unmanageable stress and emotional decomposition. Each topic is analyzed and reviewed individually, pooling several sources for a thorough examination, and understanding of the subject. Once each area is fully summarized, the gap is addressed by pulling evidence from …

Exploration Into The Relationship Between Colitis And Depression: A Potential Role For The Aryl Hydrocarbon Receptor, Kasie Lynn Roark

Theses and Dissertations

Inflammatory Bowel Disease (IBD) is a group of chronic gastrointestinal disorders with unclear etiology comprised of two defined disorders – Crohn’s Disease (CD) and Ulcerative Colitis (UC). IBD leads to chronic pain, socially isolating symptoms, and an overall reduction in patient quality of life. There is currently no cure for IBD. Due to decreased mucous production and weakening of the colonic epithelial lining, gut-microbiota and their metabolites can invade the intestinal lamina propria and circulate systemically, a term known as “leaky gut”. Recent studies show a relationship exists between peripheral inflammation, such as IBD, and depression. The gut-brain axis (GBA) …

Examining Associations Between Social Needs And Mental Health Among Youth And Young Adults With Diabetes, Andrea Danielle Brown

Theses and Dissertations

Household food insecurity (HFI) disproportionally affects people with diabetes living in the United States and is more likely to occur in households with children and in minority race/ethnicity households. Food insecure people with youth-onset diabetes likely have increased risk for poor mental health due to dealing with stress and cost related to diabetes management, especially if facing additional health-related social needs that intersect with HFI. If left untreated, poor mental health among youth and young adults (YYA) with diabetes can lead to diabetes-related complications, increased health care costs, and mortality. Yet few studies have examined associations between HFI and mental …

Psychosocial Predictors Of Early Postpartum Depressive And Anxious Symptoms In Primiparous Women And Their Partners., Erin J Henshaw, Marie Cooper, Teresa Wood, Stacey N Doan, Sanchita Krishna, Marie Lockhart

OhioHealth Research Institute Articles

BACKGROUND: While the majority of research on postpartum depressive and anxious symptoms has focused on mothers, a growing body of research suggests a need to understand the role of the partner's health and relationship quality as predictors of postpartum maternal depression, while also better understanding correlates of partner or paternal depression in the postpartum period. The purpose of the current study is to evaluate mother and partner stress, anxiety, mood, infant care support, and relationship quality as predictors of perinatal depressive and anxious symptoms in first time mothers and partners during the postpartum hospital stay.

METHODS: First time parent couples …