Publications by authors named "Tamara Sussman"

70 Publications

Multi-disciplinary supportive end of life care in long-term care: an integrative approach to improving end of life.

BMC Geriatr 2021 05 22;21(1):326. Epub 2021 May 22.

Cumming School of Medicine, University of Calgary, Calgary, Canada.

Background: Optimal supportive end of life care for frail, older adults in long term care (LTC) homes involves symptom management, family participation, advance care plans, and organizational support. This 2-phase study aimed to combine multi-disciplinary opinions, build group consensus, and identify the top interventions needed to develop a supportive end of life care strategy for LTC.

Methods: A consensus-building approach was undertaken in 2 Phases. The first phase deployed modified Delphi questionnaires to address and transform diverse opinions into group consensus. The second phase explored and prioritized the interventions needed to develop a supportive end of life care strategy for LTC. Development of the Delphi questionnaire was based on findings from published results of physician perspectives of barriers and facilitators to optimal supportive end of life care in LTC, a literature search of palliative care models in LTC, and published results of patient, family and nursing perspectives of supportive end of life care in long term care. The second phase involved World Café Style workshop discussions. A multi-disciplinary purposive sample of individuals inclusive of physicians; staff, administrators, residents, family members, and content experts in palliative care, and researchers in geriatrics and gerontology participated in round one of the modified Delphi questionnaire. A second purposive sample derived from round one participants completed the second round of the modified Delphi questionnaire. A third purposive sample (including participants from the Delphi panel) then convened to identify the top priorities needed to develop a supportive end-of-life care strategy for LTC.

Results: 19 participants rated 75 statements on a 9-point Likert scale during the first round of the modified Delphi questionnaire. 11 participants (participation rate 58 %) completed the second round of the modified Delphi questionnaire and reached consensus on the inclusion of 71candidate statements. 35 multidisciplinary participants discussed the 71 statements remaining and prioritized the top clinical practice, communication, and policy interventions needed to develop a supportive end of life strategy for LTC.

Conclusions: Multi-disciplinary stakeholders identified and prioritized the top interventions needed to develop a 5-point supportive end of life care strategy for LTC.
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http://dx.doi.org/10.1186/s12877-021-02271-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140573PMC
May 2021

Prenatal environmental tobacco smoke exposure alters children's cognitive control circuitry: A preliminary study.

Environ Int 2021 May 6;155:106516. Epub 2021 May 6.

The Division of Child and Adolescent Psychiatry in the Department of Psychiatry, Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY 10032, USA.

Background And Objectives: Prenatal exposure to environmental tobacco smoke (ETS) is associated with increased attention problems in children, however, the effects of such exposure on children's brain structure and function have not been studied. Herein, we probed effects of prenatal ETS on children's cognitive control circuitry and behavior.

Methods: Forty-one children (7-9 years) recruited from a prospective longitudinal birth cohort of non-smoking mothers completed structural and task-functional magnetic resonance imaging to evaluate effects of maternal ETS exposure, measured by maternal prenatal urinary cotinine. Attention problems and externalizing behaviors were measured by parent report on the Child Behavior Checklist.

Results: Compared to non-exposed children, exposed children had smaller left and right thalamic and inferior frontal gyrus (IFG) volumes, with large effect sizes (p-FDR < .05, Cohen's D range from 0.79 to 1.07), and increased activation in IFG during the resolution of cognitive conflict measured with the Simon Spatial Incompatibility Task (38 voxels; peak t(25) = 5.25, p-FWE = .005). Reduced thalamic volume was associated with increased IFG activation and attention problems, reflecting poor cognitive control. Mediation analyses showed a trend toward left thalamic volume mediating the association between exposure and attention problems (p = .05).

Conclusions: Our findings suggest that maternal ETS exposure during pregnancy has deleterious effects on the structure and function of cognitive control circuitry which in turn affects attentional capacity in school-age children. These findings are consistent with prior findings documenting the effects of active maternal smoking on chidlren's neurodevleoment, pointing to the neurotixicity of nicotine regardless of exposure pathway.
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http://dx.doi.org/10.1016/j.envint.2021.106516DOI Listing
May 2021

The Crisis Facing Older People Living with Neurodiversity and Their Aging Family Carers: A Social Work Perspective.

J Gerontol Soc Work 2021 Jul-Aug;64(5):547-556. Epub 2021 Apr 26.

École De Travail Social Et De Criminologie, Université Laval, Québec City, Québec, Canada.

This commentary addresses barriers to care among older adults living with neurodiversity (ND), and their aging family carers in the context of the COVID-19 pandemic in Canada. Factors contributing to inequities are described and the significant negative consequences of current policy decisions on the social and mental health of older adults with ND and their aging family carers are highlighted. The commentary calls for a collective social work response that highlights the critical role of support and advocacy necessary to redress social exclusion.
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http://dx.doi.org/10.1080/01634372.2021.1920537DOI Listing
June 2021

Implementing Advance Care Planning Tools in Practice: A Modified World Café to Elicit Barriers and Recommendations from Potential Adopters.

Healthc Q 2021 Apr;24(1):60-68

A hospital-based general internist at the Division of General Internal and Hospitalist Medicine, Credit Valley Hospital, Trillium Health Partners in Mississauga, ON.

This paper reports findings from a modified World Café conducted at a palliative care professional conference in 2019, where input on tools to support advance care planning (ACP) was solicited from healthcare practitioners, managers and family members of patients. Barriers to ACP tool use included insufficient structures and resources in healthcare, death-avoidance culture and inadequate patient and family member engagement. Recommendations for tool use included clarification of roles and processes, training, mandates and monitoring, leadership support, greater reflection of diversity in tools and methods for public engagement. This paper illuminates factors to consider when implementing ACP tools in healthcare.
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http://dx.doi.org/10.12927/hcq.2021.26463DOI Listing
April 2021

Effects of a Brief Mindfulness-Based Attentional Intervention on Threat-Related Perceptual Decision-Making.

Mindfulness (N Y) 2021 Apr 2;12(4):959-969. Epub 2021 Jan 2.

Department of Psychology, Stony Brook University, Stony Brook, NY.

Objectives: Threat-related cues and contexts facilitate perceptual decision-making, yet it is unclear whether this threat-driven tuning of perceptual decision-making is modifiable by top-down attentional control. Since state and dispositional mindfulness are linked to improved attentional control, we examined whether these factors assist the use of prior knowledge to detect threatening stimuli.

Methods: Participants were randomly assigned to a brief mindfulness-based intervention (N=32) or a physics lecture audio recording (N=31) and then asked to perform a task in which they used threatening and neutral cues to discriminate between threatening and neutral faces.

Results: Results showed that threatening cues led to faster and more sensitive perceptual decision-making, specifically for threatening faces. Furthermore, higher levels of dispositional mindfulness were associated with improved ability to use cues to discriminate between threatening and neutral stimuli in the group that underwent a brief mindfulness induction but not in the control group.

Conclusions: Our findings highlight how top-down attention-related dispositions and strategies can influence our ability to detect threats in our environment.
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http://dx.doi.org/10.1007/s12671-020-01562-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011681PMC
April 2021

Caring ahead: Mixed methods development of a questionnaire to measure caregiver preparedness for end-of-life with dementia.

Palliat Med 2021 04 23;35(4):768-784. Epub 2021 Feb 23.

Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, ON, Canada.

Background: Family caregivers of persons with dementia often feel unprepared for end-of-life and preparedness predicts caregiver outcomes in bereavement. Existing questionnaires assessing preparedness have limitations. A multi-dimensional questionnaire assessing family caregiver preparedness for the end-of-life of persons with dementia is needed to identify caregivers at risk for negative outcomes in bereavement and evaluate the quality of strategies within a palliative approach.

Aim: To develop a multi-dimensional questionnaire titled 'Caring Ahead' to assess feelings of preparedness for end-of-life in family caregivers of persons with dementia.

Design: A mixed methods, sequential design employed semi-structured interviews, a Delphi-survey and pilot-testing of the questionnaire, June 2018 to July 2019.

Setting/population: Participants included five current and 16 bereaved family caregivers of persons with symptoms advanced dementia from long-term care homes in Ontario, Canada; and 12 professional experts from clinical and academic settings in Canada, Europe, United States.

Results: Interviews generated three core concepts and 114 indicators of preparedness sampling cognitive, affective and behavioural traits in four domains (i.e., medical, psychosocial, spiritual, practical). Indicators were translated and reduced to a pool of 73 potential questionnaire items. 30-items were selected to create the 'Caring Ahead' preparedness questionnaire through a Delphi-survey. Items were revised through a pilot-test with cognitive interviewing.

Conclusions: Family caregivers' feelings of preparedness for end-of-life need to be assessed and the quality of strategies within a palliative approach evaluated. Future psychometric testing of the Caring Ahead questionnaire will evaluate evidence for validity and reliability.
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http://dx.doi.org/10.1177/0269216321994732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022086PMC
April 2021

Treatment of Patients with Prediabetes in a Primary Care Setting 2011-2018: an Observational Study.

J Gen Intern Med 2021 04 15;36(4):923-929. Epub 2021 Jan 15.

Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.

Background: Over one third of American adults are at high risk for developing diabetes, which can be delayed or prevented using interventions such as medical nutrition therapy (MNT) or metformin. Physicians' self-reported rates of prediabetes treatment are improving, but patterns of actual referral, prescription, and MNT visits are unknown.

Objective: To characterize treatment of prediabetes in primary care.

Design: We conducted a retrospective cohort study using electronic health record data. We described patterns of treatment and used multivariable logistic regression to evaluate the association of patient factors and PCP-specific treatment rate with patient treatment.

Patients: We included overweight or obese outpatients who had a first prediabetes-range hemoglobin A1c (HbA1c) during 2011-2018 and had primary care provider (PCP) follow-up within a year.

Main Measures: We collected patient characteristics and the following treatments: metformin prescription; referral to MNT, diabetes education, endocrinology, or bariatric medicine; and MNT visit. We did not capture within-visit physician counseling.

Key Results: Of 16,713 outpatients with prediabetes, 20.4% received treatment, including metformin prescriptions (7.8%) and MNT referrals (11.3%), but only 7.4% of referred patients completed a MNT visit. The strongest predictor of treatment was the patient's PCP's treatment rate. Some PCPs never treated prediabetes, but two treated more than half of their patients; 62% had no patients complete a MNT visit. Being younger or female and having higher body mass index or HbA1c were also positively associated with treatment. Compared to white patients, black patients were more likely to receive MNT referral and less likely to receive metformin.

Conclusions: Almost 80% of patients with new prediabetes never received treatment, and those who did receive referrals had very poor visit completion. Treatment rates appear to reflect provider rather than patient preferences.
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http://dx.doi.org/10.1007/s11606-020-06354-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041989PMC
April 2021

Clinical Trials in Metastatic Uveal Melanoma: Current Status.

Ocul Oncol Pathol 2020 Dec 10;6(6):381-387. Epub 2020 Sep 10.

Department of Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Background: Uveal melanoma is a rare subtype of melanoma. Prognosis and survival rates for patients with metastatic uveal melanoma remain poor. No current FDA-approved standard of care therapy is available for patients with metastatic uveal melanoma. Thus, clinical trials are essential for the development of new therapies and to provide patients hope for improved survival and outcomes.

Summary: In this article, we review clinical trials identified on the database https://clinicaltrials.gov that are open and enrolling patients with metastatic uveal melanoma as of November 26, 2019. This search produced 17 active trials involving liver-directed therapy, CNS-directed therapy, and systemic therapy with immunotherapy, targeted therapy, or oncolytic virus therapy. Here, we discuss liver and CNS-directed therapy as well as systemic targeted therapy and oncolytic virus therapy. Immunotherapy clinical trials are discussed in a companion review article by Dr. Marlana Orloff.

Key Messages: Various novel therapeutic targets and immunomodulatory approaches are on the horizon for patients with metastatic uveal melanoma and may yield incremental therapeutic benefit. Selecting a clinical trial must be individualized and made jointly with the patient and his/her oncologist.
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http://dx.doi.org/10.1159/000508383DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772871PMC
December 2020

Incidence of thromboembolism in patients with melanoma on immune checkpoint inhibitor therapy and its adverse association with survival.

J Immunother Cancer 2021 Jan;9(1)

Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA

Background: Thromboembolism (TE) in cancer significantly contributes to morbidity and mortality. Little is known about the incidence of arterial TE (ATE) and venous TE (VTE) in patients with melanoma on immune checkpoint inhibitor (ICI) therapy.

Methods: We conducted a retrospective cohort study of patients with melanoma receiving ICI from July 2015 through December 2017 at the Cleveland Clinic. TE, including VTE events of deep venous thrombosis, pulmonary embolism, visceral vein thrombosis, and ATE events of myocardial infarction, stroke, peripheral arterial embolism, or transient ischemic attack after ICI initiation were identified. Overall survival (OS) from ICI initiation was estimated by Kaplan-Meier and Cox hazard models; associations between TE, ICI regimen, and clinical risk factors were evaluated using log-rank test.

Results: The study population comprised 228 patients with median age of 65 years (23-91 years), 67% male, and median follow-up of 27.3 months. Pembrolizumab was most commonly used (38.7%), followed by combination of ipilimumab plus nivolumab (29.4%), ipilimumab (20%), and nivolumab (12.3%). Most had stage IV disease (81.1%) and 11% had brain metastases (BM) at treatment initiation. Fifty-one TE events occurred in 47 patients (20.6%), including 37 (16.2%) VTE and 14 (6.1%) ATE. Cumulative incidence of TE after ICI initiation was 9.3% (95% CI: 6.0% to 13.6%) at 6 months, and 16.0% (95% CI: 11.6% to 21.2%) at 12 months. The 6-month and 12-month VTE cumulative incidence rates were higher with combination ICI than single agent (16.7% vs 5.0% and 21.3% vs 9.5%, respectively; p=0.02). Risk factors significantly associated with VTE in multivariate analysis included combination ICI (HR 2.70; 95% CI: 1.28 to 5.70; p=0.009), Khorana Score ≥1 (HR 2.24; 95% CI: 1.06 to 4.74; p=0.03), history of coronary artery disease (HR 2.71; 95% CI: 1.16 to 6.29); p=0.02), and anticoagulation at treatment start (HR 4.14; 95% CI: 1.60 to 10.7; p=0.003). Of patients without BM, OS was worse in patients with TE compared with those without (2-year OS 50.8% vs 71.3%; HR 2.27; 95% CI: 1.36 to 3.79; p=0.002), when adjusted for age and stage.

Conclusions: ICI is associated with a high incidence of TE in patients with melanoma, with higher rates with combination therapy; TE is associated with substantial worsening of survival. Further studies are needed to identify pathophysiology, biomarkers, and preventive approaches.
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http://dx.doi.org/10.1136/jitc-2020-001719DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805375PMC
January 2021

Advance Care Planning among Older Gay Men Living with HIV in Montreal, Canada: Challenges to and about Future Care.

J Homosex 2021 Jan 12:1-17. Epub 2021 Jan 12.

Department of Gerontology, Simon Fraser University, Vancouver, British Columbia, Canada.

This qualitative study employed a cross sectional focus group design to explore how older gay men living with HIV, experience, perceive, and engage with advance care planning (ACP). Seven gay men 50+, residing in Montreal, Canada, participated in a focus group that was audio-recorded, transcribed, and thematically analyzed. Findings suggested that social isolation, preoccupations with day-to-day living, and managing disclosures related to sexual orientation and HIV status created barriers to these men's capacities to about let alone about future care. These findings challenge current conceptualizations of ACP, which position reflection as an individual process that precedes allocating a decision-maker and communicating care preferences. Analyses further revealed that relational connections helped create a space where ACP could occur for participants. Hence, improving the uptake of ACP amongst older gay men with HIV may require interventions that embed such discussions into broader programs aimed at building support and community.
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http://dx.doi.org/10.1080/00918369.2020.1855029DOI Listing
January 2021

"A Crazy Roller Coaster at the End": A Qualitative Study of Death Preparedness With Caregivers of Persons With Dementia.

SAGE Open Nurs 2020 Jan-Dec;6:2377960820949111. Epub 2020 Aug 25.

School of Nursing, Faculty of Health Sciences, McMaster University.

Introduction: Caregivers of persons with dementia experience challenges that can make preparing for end-of-life particularly difficult. Feeling prepared for death is associated with caregiver well-being in bereavement and is promoted by strategies supporting a palliative approach. Further conceptualization of caregiver preparedness for death of persons with dementia is needed to guide the practice of healthcare providers and to inform development of a preparedness questionnaire.

Objectives: We aimed to: 1) explore the end-of-life experiences of caregivers of persons with dementia to understand factors perceived as influencing preparedness; and 2) identify the core concepts (i.e., components), barriers and facilitators of preparedness for death.

Methods: This study used an interpretive descriptive design. Semi-structured interviews were conducted with sixteen bereaved caregivers of persons with dementia, recruited from long-term care homes in Ontario. Data was analyzed through reflexive thematic analysis.

Findings: Four themes were interpreted including: 'A crazy rollercoaster at the end' which described the journey of caregivers at end-of-life. The journey provided context for the development of core concepts (i.e., components) of preparedness represented by three themes: 'A sense of control, 'Doing right' and 'Coming to terms'.

Conclusion: The study findings serve to expand the conceptualization of preparedness and can guide improvements to practice in long-term care. Core concepts, facilitators and influential factors of preparedness will provide the conceptual basis and content to develop the Caring Ahead: Preparing for End-of-Life with Dementia questionnaire.
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http://dx.doi.org/10.1177/2377960820949111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774442PMC
August 2020

Engaging persons with dementia in advance care planning: Challenges and opportunities.

Dementia (London) 2020 Dec 8:1471301220973059. Epub 2020 Dec 8.

Special Care Counselling, 91424Vanier College, Montreal, Quebec, Canada.

This study reports findings from a series of focus groups with persons with dementia and family caregivers intended to explore: (1) perceptions of and experiences with advance care planning (ACP); (2) concerns related to future care including, but not limited to, end-of-life care; and (3) practices that may support positive engagement with ACP. A total of 18 participants including 10 persons with dementia and eight family caregivers participated in five focus groups held in two urban cities in Canada. All focus group deliberations were audio recorded, transcribed verbatim, and analyzed in five stages using a semantic thematic approach. All participants expressed some form of engagement in ACP, but understandings were limited and divergence was expressed regarding the timing of more expansive conversations about future care. Although some persons with dementia were ready to engage in future care discussions, most preferred focusing on the present and suggested their families did not require direction. This placed families in the complex dilemma of protecting their loved ones while compromising their own needs for dialogue. Although individually focused models of ACP engagement hold promise for those persons with dementia ready to engage in future planning, our findings suggest that early engagement of families in the reflective process may go a long way in supporting ACP activation. Our findings further suggest that persons with dementia who do not have close family/friends may require extensive ACP encouragement and support from service providers.
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http://dx.doi.org/10.1177/1471301220973059DOI Listing
December 2020

Exploration of the acceptability and usability of advance care planning tools in long term care homes.

BMC Palliat Care 2020 Nov 26;19(1):179. Epub 2020 Nov 26.

University of Toronto Faculty of Medicine, Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.

Objectives: Despite known benefits, advance care planning (ACP) is rarely a component of usual practice in long-term care (LTC). A series of tools and workbooks have been developed to support ACP uptake amongst the generable population. Yet, their potential for improving ACP uptake in LTC has yet to be examined. This study explored if available ACP tools are acceptable for use in LTC by (a) eliciting staff views on the content and format that would support ACP tool usability in LTC (b) examining if publicly available ACP tools include content identified as relevant by LTC home staff. Ultimately this study aimed to identify the potential for existing ACP tools to improve ACP engagement in LTC.

Methods: A combination of focus group deliberations with LTC home staff (N = 32) and content analysis of publicly available ACP tools (N = 32) were used to meet the study aims.

Results: Focus group deliberations suggested that publicly available ACP tools may be acceptable for use in LTC if the tools include psychosocial elements and paper-based versions exist. Content analysis of available paper-based tools revealed that only a handful of ACP tools (32/611, 5%) include psychosocial content, with most encouraging psychosocially-oriented reflections (30/32, 84%), and far fewer providing direction around other elements of ACP such as communicating psychosocial preferences (14/32, 44%) or transforming preferences into a documented plan (7/32, 22%).

Conclusions: ACP tools that include psychosocial content may improve ACP uptake in LTC because they elicit future care issues considered pertinent and can be supported by a range of clinical and non-clinical staff. To increase usability and engagement ACP tools may require infusion of scenarios pertinent to frail older persons, and a better balance between psychosocial content that elicits reflections and psychosocial content that supports communication.
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http://dx.doi.org/10.1186/s12904-020-00689-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7756921PMC
November 2020

Do Trajectories of Sensation Seeking Vary by Sex and Child Maltreatment Subtypes?

J Interpers Violence 2020 Aug 12:886260520943722. Epub 2020 Aug 12.

Columbia University, New York City, NY, USA.

Child maltreatment and elevated sensation seeking are associated with a wide range of negative outcomes. Longitudinal data from a study of Puerto Ricans living in two sociocultural contexts were used to determine whether child maltreatment subtypes, sex, or sociocultural context relate to trajectories of sensation seeking. Participants were 2,489 individuals from the Boricua Youth Study (48.5% girls) living in New York and in Puerto Rico (PR; 5-15 years old at Wave 1). Subtypes of child maltreatment were measured using child report on the Parent-Child Conflict Tactics Scale and the Sexual Victimization Scale at Wave 1. The association between child maltreatment subtypes, sex, sociocultural context, and previously established sensation-seeking trajectories across three waves of data collection was probed using multinomial logistic regression. Girls, but not boys, who experienced neglect (adjusted odds ratio; AOR; 95% confidence interval [95% CI] = 5.33 [1.35, 21.03]), or physical abuse (AOR [95% CI] = 3.66 [1.07, 12.54]), were more likely to have an elevated sensation-seeking trajectory than a normative trajectory. For boys, none of the maltreatment subtypes were linked to the elevated sensation-seeking class. Girls exposed to verbal abuse (AOR [95% CI] = 0.33 [0.15, 0.75]) and boys exposed to physical abuse (AOR [95% CI] = 0.39 [0.16, 0.97]) were less likely to belong to the low sensation-seeking class. No significant interactions between sociocultural context (i.e., PR vs. New York) and maltreatment subtype on the development of sensation seeking were found. This research suggests sensation-seeking levels vary by experiences of childhood maltreatment, and that sex moderates the relationship between child maltreatment experiences and sensation seeking, with an association between some maltreatment subtypes and elevated sensation-seeking trajectories found in girls, but not boys. These results underline the importance of considering sex when examining how child maltreatment relates to outcomes.
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http://dx.doi.org/10.1177/0886260520943722DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878577PMC
August 2020

Barriers and facilitators to optimal supportive end-of-life palliative care in long-term care facilities: a qualitative descriptive study of community-based and specialist palliative care physicians' experiences, perceptions and perspectives.

BMJ Open 2020 08 5;10(8):e037466. Epub 2020 Aug 5.

Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

Objective: The COVID-19 pandemic has highlighted ongoing challenges to optimal supportive end-of-life care for adults living in long-term care (LTC) facilities. A supportive end-of-life care approach emphasises family involvement, optimal symptom control, multidisciplinary team collaboration and death and bereavement support services for residents and families. Community-based and palliative care specialist physicians who visit residents in LTC facilities play an important role in supportive end-of-life care. Yet, perspectives, experiences and perceptions of these physicians remain unknown. The objective of this study was to explore barriers and facilitators to optimal supportive end-of-life palliative care in LTC through the experiences and perceptions of community-based and palliative specialist physicians who visit LTC facilities.

Design: Qualitative study using semi-structured interviews, basic qualitative description and directed content analysis using the COM-B (capability, opportunity, motivation - behaviour) theoretical framework.

Setting: Residential long-term care.

Participants: 23 physicians who visit LTC facilities from across Alberta, Canada, including both in urban and rural settings of whom 18 were community-based physicians and 5 were specialist palliative care physicians.

Results: Motivation barriers include families' lack of frailty knowledge, unrealistic expectations and emotional reactions to grief and uncertainty. Capability barriers include lack of symptom assessment tools, as well as palliative care knowledge, training and mentorship. Physical and social design barriers include lack of dedicated spaces for death and bereavement, inadequate staff, and mental health and spiritual services of insufficient scope for the population.

Conclusion: Findings reveal that validating families' concerns, having appropriate symptom assessment tools, providing mentorship in palliative care and adapting the physical and social environment to support dying and grieving with dignity facilitates supportive, end-of-life care within LTC.
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http://dx.doi.org/10.1136/bmjopen-2020-037466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409966PMC
August 2020

A pilot evaluation of the Strengthening a Palliative Approach in Long-Term Care (SPA-LTC) program.

BMC Palliat Care 2020 Jul 13;19(1):107. Epub 2020 Jul 13.

Division of General Internal and Hospitalist Medicine, Credit Valley Hospital, Trillium Health Partners, 2200 Eglinton Ave W, Mississauga, ON, Canada.

Background: Despite increased annual mortality in long-term care (LTC) homes, research has shown that care of dying residents and their families is currently suboptimal in these settings. The purpose of this study was to evaluate resident and family outcomes associated with the Strengthening a Palliative Approach in LTC (SPA-LTC) program, developed to help encourage meaningful end of life discussions and planning.

Methods: The study employs a mixed method design in four LTC homes across Southern Ontario. Data were collected from residents and families of the LTC homes through chart reviews, interviews, and focus groups. Interviews with family who attended a Palliative Care Conference included both closed-ended and open-ended questions.

Results: In total, 39 residents/families agreed to participate in the study. Positive intervention outcomes included a reduction in the proportion of emergency department use at end of life and hospital deaths for those participating in SPA-LTC, improved support for families, and increased family involvement in the care of residents. For families who attended a Palliative Care Conference, both quantitative and qualitative findings revealed that families benefited from attending them. Residents stated that they appreciated learning about a palliative approach to care and being informed about their current status.

Conclusions: The benefits of SPA-LTC for residents and families justify its continued use within LTC. Study results also suggest that certain enhancements of the program could further promote future integration of best practices within a palliative approach to care within the LTC context. However, the generalizability of these results across LTC homes in different regions and countries is limited given the small sample size.
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http://dx.doi.org/10.1186/s12904-020-00599-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358198PMC
July 2020

The relationship between caregivers' perceptions of end-of-life care in long-term care and a good resident death.

Palliat Support Care 2020 12;18(6):683-690

School of Social Work, McGill University, Montréal, QC, Canada.

Objective: Quality end-of-life (EOL) care is critical for dying residents and their family/friend caregivers. While best practices to support resident comfort at EOL in long-term care (LTC) homes are emerging, research rarely explores if and how the type of care received at EOL may contribute to caregivers' perceptions of a good death. To address this gap, this study explored how care practices at EOL contributed to caregivers' perceptions of a good resident death.

Method: This study used a retrospective cross-sectional survey design. Seventy-eight participants whose relative or friend died in one of five LTC homes in Canada completed self-administered questionnaires on their perceptions of EOL care and perceptions of a good resident death.

Results: Overall, caregivers reported positive experiences with EOL care and perceived residents to have died a good death. However, communication regarding what to expect in the final days of life and attention to spiritual issues were often missing components of care. Further, when explored alongside direct resident care, family support, and rooming conditions, staff communication was the only aspect of EOL care significantly associated with caregivers' perceptions of a good resident death.

Significance Of Results: The findings of this study suggest that the critical role staff in LTC play in supporting caregivers' perceptions of a good resident death. By keeping caregivers informed about expectations at the very end of life, staff can enhance caregivers' perceptions of a good resident death. Further, by addressing spiritual issues staff may improve caregivers' perceptions that residents were at peace when they died.
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http://dx.doi.org/10.1017/S1478951520000292DOI Listing
December 2020

Utilization and impact of immunotherapy in stage IV melanoma using the National Cancer Database.

Melanoma Res 2020 08;30(4):376-385

Department of Dermatology and Plastic Surgery.

To evaluate factors affecting the utilization of immunotherapy and to stratify results based on the approval of ipilimumab in 2011 and PD-1 inhibitors in 2014, an analysis of available data from the National Cancer Database (NCDB) was performed. Stage IV melanoma patients were identified. Effects of immunotherapy on overall survival (OS) were assessed using Kaplan-Meier curves and Cox proportional hazards model. A total of 19 233 patients were analyzed and 1998 received immunotherapy. Between 2011 and 2013, and in 2014, 18.6 and 28.9% of patients received immunotherapy, respectively. Patients who received immunotherapy from 2011 to 2013 had a 33% (95% CI, 30-35%) 3-year OS compared to 23% (95% CI, 21-24%). In 2014, 3-year OS was 37% (95% CI, 32-43%) for those who received immunotherapy compared to 22% (95% CI, 18-26%) for those who did not (P < 0.0001). This is the first analysis of a large cancer database for melanoma patients with stratification based on utilization and availability of immunotherapy. Immunotherapy increased yearly and improved OS. With combination immunotherapy now more widely employed, it is expected these results will continue to improve. This is the first analysis of a large cancer database for melanoma patients with stratification based on utilization and availability of immunotherapy demonstrating that immunotherapy increased yearly and improved OS.
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http://dx.doi.org/10.1097/CMR.0000000000000672DOI Listing
August 2020

RNA expression and risk of venous thromboembolism in lung cancer.

Res Pract Thromb Haemost 2020 Jan 27;4(1):117-123. Epub 2019 Dec 27.

Department of Hematology/Oncology Cleveland Clinic Foundation Taussig Cancer Institute Cleveland Ohio.

Background: The propensity to develop venous thromboembolism (VTE) on the basis of individual tumor biological features remains unknown.

Objectives: We conducted a whole transcriptome RNA sequencing strategy, focusing on a single cancer type (lung cancer), to identify biomarkers of cancer-associated VTE.

Methods: Twelve propensity-matched patients, 6 each with or without VTE, were identified from a prospective institutional review board-approved registry at the Cleveland Clinic with available tissue from surgical excision of a primary lung mass between 2010 and 2015. Patients were propensity matched based on age, sex, race, history of prior cancer, date of cancer diagnosis, stage, histology, number of lines of chemotherapy, and length of follow-up. RNA sequencing was performed on tumor tissue, and gene set enrichment analysis (GSEA) was performed on differentially expressed genes.

Results: We identified 1037 genes with differential expression. In patients with VTE, 869 genes were overexpressed and 168 were underexpressed compared to patients without VTE. Of these, 276 overexpressed and 35 underexpressed were significantly different ( < 0.05). GSEA revealed upregulation of genes in complement, inflammation, and KRAS signaling pathways in tumors from patients with VTE.

Conclusions: These differentially expressed genes and associated pathways provide biologic insights into cancer-associated VTE and may provide insignts to develop new risk stratification schemes, prevention, or treatment strategies.
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http://dx.doi.org/10.1002/rth2.12284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971308PMC
January 2020

Supporting Older Homeless Persons' Positive Relocations to Long-Term Care: Service Provider Views.

Gerontologist 2020 08;60(6):1149-1158

Factor-Inwentash Faculty of Social Work, University of Toronto and Baycrest Hospital, Ontario, Canada.

Background And Objectives: This study sought to explore the challenges and opportunities associated with supporting older homeless persons' relocations to long-term care (LTC) from the perspective of service providers. It aims to inform how to improve relocation processes for this vulnerable and growing subpopulation of older persons.

Research Design And Methods: This cross-sectional qualitative study employed semistructured face-to-face interviews with service providers from two Health and Social Service Centres in Montreal, Quebec. All interviews were audio-recorded, transcribed verbatim, and thematically analyzed in five stages.

Results: A total of eight service providers reported on their experiences supporting over 40 relocations of older homeless persons (50+) in the last year. According to participants, older homeless persons' trajectories into LTC typically included a series of neglected medical issues followed by hospitalization and eventual relocation to LTC. Systemic barriers such as limited-time for proper planning, insufficient housing options for persons with minor functional limitations, disregard for preferred geographic location, multiple moves, and staff prejudices worked together to expedite premature relocation and challenge relocation processes.

Discussion And Implications: Older homeless persons appear to be at heightened risk of premature and challenging relocation processes. Expanding housing stock for persons with functional limitations, strengthening intersectoral collaborations, providing education and training to staff, and ensuring flexibility around rules and regulations in receiving LTC homes would both improve access to aging in place for this marginalized group of older persons and ensure conditions are in place to support positive relocations to LTC for those who require it.
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http://dx.doi.org/10.1093/geront/gnz171DOI Listing
August 2020

A Stakeholder Analysis of the Strengthening a Palliative Approach in Long-Term Care Model.

Nurs Leadersh (Tor Ont) 2019 Sep;32(3):27-39

Professor of Nursing Aged Care (Dementia), Faculty of Health, University of Technology Sydney, Ultimo, NSW.

Objective: The purpose of this study was to conduct a stakeholder analysis of the strengthening a palliative approach to long-term care (SPA-LTC) model and refine it based on feedback from long-term care (LTC) residents and their families, staff, researchers and decision makers.

Methods: We used a mixed-methods design to conduct a stakeholder analysis of the SPA-LTC model that consisted of two sequential components: qualitative focus groups with LTC staff followed by a quantitative survey with key stakeholders.

Results: Twenty-one LTC staff provided feedback about the SPA-LTC model after residents relocated to LTC, during advanced illness and at end of life and in the period of grief and bereavement. This feedback helped to guide revisions of the model. According to the survey results, the SPA-LTC model was well received by 35 stakeholders, but its feasibility was questioned.

Conclusion: The Canadian SPA-LTC model is evidence based and endorsed by LTC staff and stakeholders. Efforts are needed to determine the feasibility of implementing the model to ensure that residents' needs are made a priority while in LTC.
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http://dx.doi.org/10.12927/cjnl.2019.25974DOI Listing
September 2019

Palliative Care Models in Long-Term Care: A Scoping Review.

Nurs Leadersh (Tor Ont) 2019 Sep;32(3):8-26

Professor of Nursing Aged Care (Dementia), Faculty of Health, University of Technology Sydney Ultimo, NSW.

Objective: The goal of this scoping review was to identify existing palliative models in long-term care (LTC) homes and differentiate between the key components of each in terms of training/capacity-building strategies; resident, family and staff support; and advance care planning (ACP) and goals-of-care discussions.

Methods: We conducted a scoping review based on established methods to summarize the international literature on palliative models and programs for LTC. We analyzed the data using tabular summaries and content analysis.

Results: We extracted data from 46 articles related to palliative programs, training/capacity building, family support, ACP and goals of care. Study results highlighted that three key components are needed in a palliative program in LTC: (1) training and capacity building; (2) support for residents, family and staff; and (3) ACP, goals-of-care discussion and informed consent.

Conclusion: This scoping review provided important information about key components to be included in a palliative program in LTC. Future work is needed to develop a model that suits the unique characteristics in the Canadian context.
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http://dx.doi.org/10.12927/cjnl.2019.25975DOI Listing
September 2019

Managing Genitourinary Syndrome of Menopause in Breast Cancer Survivors Receiving Endocrine Therapy.

J Oncol Pract 2019 07;15(7):363-370

1 Cleveland Clinic Foundation, Cleveland, OH.

Patients with breast cancer receiving antiestrogen therapy, specifically aromatase inhibitors, often suffer from vaginal dryness, itching, irritation, dyspareunia, and dysuria, collectively known as genitourinary syndrome of menopause (GSM). GSM can decrease quality of life and is undertreated by oncologists because of fear of cancer recurrence, specifically when considering treatment with vaginal estrogen therapy because of unknown levels of systemic absorption of estradiol. In this article, we review the available literature for treatment of GSM in patients with breast cancer and survivors, including nonhormonal, vaginal hormonal, and systemic hormonal therapy options. First-line treatment includes nonhormonal therapy with vaginal moisturizers, lubricants, and gels. Although initial studies showed significant improvement in symptoms, the US Food and Drug Administration recently issued a warning against CO laser therapy for treatment of GSM until additional studies are conducted. In severe or refractory GSM, after discussing risks and benefits of vaginal hormonal therapy, the low-dose 10-μg estradiol-releasing intravaginal tablet or lower-dose 4 μg estrogen vaginal insert and intravaginal dehydroepiandrosterone (prasterone) are options for treatment, because studies show minimal elevation in serum estradiol levels and significant improvement in symptoms. The decision to offer vaginal estrogen therapy must be individualized and made jointly with the patient and her oncologist.
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http://dx.doi.org/10.1200/JOP.18.00710DOI Listing
July 2019

The role of imagery in threat-related perceptual decision making.

Emotion 2020 Dec 13;20(8):1495-1501. Epub 2019 Jun 13.

Department of Psychology.

Visual perception is heavily influenced by "top-down" factors, including goals, expectations, and prior knowledge about the environmental context. Recent research has demonstrated the beneficial role threat-related cues play in perceptual decision making; however, the psychological processes contributing to this differential effect remain unclear. Since visual imagery helps to create perceptual representations or "templates" based on prior knowledge (e.g., cues), the present study examines the role vividness of visual imagery plays in enhanced perceptual decision making following threatening cues. In a perceptual decision-making task, participants used threat-related and neutral cues to detect perceptually degraded fearful and neutral faces presented at predetermined perceptual thresholds. Participants' vividness of imagery was measured by the Vividness of Visual Imagery Questionnaire-2 (VVIQ-2). Our results replicated prior work demonstrating that threat cues improve accuracy, perceptual sensitivity, and speed of perceptual decision making compared to neutral cues. Furthermore, better performance following threat and neutral cues was associated with higher VVIQ-2 scores. Importantly, more precise and rapid perceptual decision making following threatening cues was associated with greater VVIQ-2 scores, even after controlling for performance related to neutral cues. This association may be because greater imagery ability allows one to conjure more vivid threat-related templates, which facilitate subsequent perception. While the detection of threatening stimuli is well studied in the literature, our findings elucidate how threatening cues occurring prior to the stimulus aid in subsequent perception. Overall, these findings highlight the necessity of considering top-down threat-related factors in visual perceptual decision making. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/emo0000610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908763PMC
December 2020

Caregiver preparedness for death in dementia: an evaluation of existing tools.

Aging Ment Health 2020 10 30;24(10):1671-1680. Epub 2019 May 30.

McMaster University, Faculty of Health Sciences, School of Nursing, Hamilton, Ontario, Canada.

Death preparedness amongst family caregivers (CG) is a valuable and measurable concept. Preparedness predicts CG outcomes in bereavement and is modifiable through a palliative approach which includes advance care planning (ACP) interventions. Improving death preparedness is important for CGs of persons with dementia (PwD) whom are more likely to develop negative outcomes in bereavement, and experience less than adequate palliative care. However, the adequacy of existing tools to measure death preparedness in CGs of PwD is unknown, which limits intervention design and prospective evaluation of ACP effectiveness. We conducted a review and evaluation of existing tools measuring the attribute domains and traits of CG death preparedness. Literature was searched for articles describing caregiving at end of life (EOL). Measurement tools were extracted, screened for inclusion criteria, and data extracted regarding: conceptual basis, population of development, and psychometrics. Tool content was compared to preparedness domains/traits to assess congruency and evaluate the adequacy of tools as measures of death preparedness for CGs of PwD. Authors extracted 569 tools from articles, retaining seven tools for evaluation. The majority of tools, n = 5 (70%) did not sample all preparedness domains/traits. Few tools had items specific to EOL; only one tool had a specific item questioning CG preparedness for death, and only one tool had items specific to dementia. Limitations in existing tools suggest they are not adequate measures of death preparedness for CGs of PwD. Consequently, the authors are currently developing a questionnaire to be titled, 'Caring Ahead' for this purpose.
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http://dx.doi.org/10.1080/13607863.2019.1622074DOI Listing
October 2020

Perspectives and experiences of compassion in long-term care facilities within Canada: a qualitative study of patients, family members and health care providers.

BMC Geriatr 2019 05 6;19(1):128. Epub 2019 May 6.

Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.

Introduction: This paper details a subset of the findings from a participatory action research project exploring a palliative intervention in long-term care sites across Canada. The findings presented in this paper relate to understanding compassion within the context of a palliative approach to long-term care.

Methods: Findings presented are drawn from qualitative interviews and focus groups with residents, family members, healthcare providers, and managers from 4 long-term care sites across 4 provinces in Canada. In total, there were 117 individuals (20 residents, 16 family members, 72 healthcare providers, and 9 managers) who participated in one of 19 focus groups. Data was analyzed by multiple members of the research team in accordance with thematic analysis. Individual concepts were organized into themes across the different focus groups and the results were used to build a conceptual understanding of compassion within Long Term Care .

Findings: Two themes, each comprised of 5 sub-themes, emerged from the data. The first theme 'Conceptualizing Compassion in Long-Term Care generated a multidimensional understanding of compassion that was congruent with previous theoretical models. 'Organizational Compassion: resources and staffing', the second major theme, focused on the operationalization of compassion within the practice setting and organizational culture. Organizational Compassion subthemes focused on how compassion could support staff to enact care for the residents, the families, one another, and at times, recognizing their pain and supporting it through grief and mourning.

Conclusions: Results suggest that compassion is an essential part of care and relationships within long-term care, though it is shaped by personal and professional relational aspects of care and bound by organizational and systemic issues. Findings suggest that compassion may be an under-recognised, but essential element in meeting the promise of person-centred care within long-term care environments.
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http://dx.doi.org/10.1186/s12877-019-1135-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503362PMC
May 2019

Editorial: Neural Correlates of Sluggish Cognitive Tempo: Biological Evidence of a Distinct Clinical Entity?

J Am Acad Child Adolesc Psychiatry 2019 02 4;58(2):164-166. Epub 2018 Dec 4.

New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY.

Attention-deficit/hyperactivity disorder (ADHD) is a heterogeneous disorder encompassing a wide array of clinical presentations, levels of impairment, etiologies, and neurobiological correlates. Despite this well-known heterogeneity, most research into the pathophysiology of ADHD has relied on comparisons between typically developing youth and those with the disorder (or perhaps further stratifying by DSM-defined ADHD subtypes). Although informative, this approach assumes a level of pathophysiologic homogeneity that belies the large and growing body of literature underscoring diverse neurobiological and neuropsychological profiles subsumed under the umbrella of this complex syndrome. For example, deficits in executive functions are characteristic of ADHD, yet meta-analysis suggests that these deficits are neither necessary nor sufficient to define all cases and that substantial overlaps in levels of executive functioning exist between children with ADHD and their typically developing peers. Likewise, neuroimaging research points to distinct neural circuits underlying different clinical presentations of ADHD, suggesting that, within the diagnosis of ADHD, the neural circuits that are most salient to the disorder can differ from one child to the next. Refining our understanding of ADHD subtypes not only on the basis of symptoms, but also by incorporating neurobiology, physiology, and neurocognitive profiles, could help propel the field toward greater specificity in diagnosis and treatment.
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http://dx.doi.org/10.1016/j.jaac.2018.08.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453133PMC
February 2019

An Analysis of Documents Guiding Palliative Care in Five Canadian Provinces.

Can J Aging 2019 09 24;38(3):281-295. Epub 2019 Jan 24.

McMaster University, Hamilton,Ontario.

ABSTRACTThe purpose of this study was to analyse the consistency and extent of palliative content across high-level guiding documents related to the care of persons residing in Canadian long-term care homes. A systematic search was conducted examining documents at the national level and across five provinces (Alberta, Ontario, Saskatchewan, Manitoba, and Quebec). Twenty-five documents were selected based on inclusion criteria from 273 documents identified in the systematic search. The majority of these documents were created nationally (48%) or in Ontario (28%). Documents varied in palliative topics discussed, and long-term care was discussed minimally. A minimal number of palliative care guiding documents were found. Long-term care specific documents were absent, and all documents lacked consistency on palliative topics. It is imperative that palliative principles are present and consistent in high-level documents in order to improve the quality of life and care for long-term care residents across Canada.
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http://dx.doi.org/10.1017/S0714980818000594DOI Listing
September 2019

Resting-state connectivity within and across neural circuits in anorexia nervosa.

Brain Behav 2019 01 27;9(1):e01205. Epub 2018 Dec 27.

Department of Psychiatry, Columbia University Irving Medical Center, New York, New York.

Introduction: Obsessional thoughts and ritualized eating behaviors are characteristic of Anorexia Nervosa (AN), leading to the common suggestion that the illness shares neurobiology with obsessive-compulsive disorder (OCD). Resting-state functional connectivity MRI (rs-fcMRI) is a measure of functional neural architecture. This longitudinal study examined functional connectivity in AN within the limbic cortico-striato-thalamo-cortical (CSTC) loop, as well as in the salience network, the default mode network, and the executive control network (components of the triple network model of psychopathology).

Methods: Resting-state functional connectivity MRI scans were collected in unmedicated female inpatients with AN (n = 25) and healthy controls (HC; n = 24). Individuals with AN were scanned before and after weight restoration and followed for one month after hospital discharge. HC were scanned twice over the same timeframe.

Results: Using a seed-based correlation approach, individuals with AN had increased connectivity within the limbic CSTC loop when underweight, only. There was no significant association between limbic CSTC connectivity and obsessive-compulsive symptoms or prognosis. Exploratory analyses of functional network connectivity within the triple network model showed reduced connectivity between the salience network and left executive control network among AN relative to HC. These abnormalities persisted following weight restoration.

Conclusions: The CSTC findings suggest that the neural underpinnings of obsessive-compulsive symptoms may differ from those of OCD. The inter-network abnormalities warrant examination in relation to illness-specific behaviors, namely abnormal eating behavior. This longitudinal study highlights the complexity of the neural underpinnings of AN.
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http://dx.doi.org/10.1002/brb3.1205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373651PMC
January 2019

Condition-Specific Pamphlets to Improve End-of-life Communication in Long-term Care: Staff Perceptions on Usability and Use.

J Am Med Dir Assoc 2019 03 21;20(3):262-267. Epub 2018 Dec 21.

Creative Arts Therapies Department, Concordia University, Canada.

Objectives: This article reports findings on the usability and staff use of 5 condition- specific pamphlets of high prevalence in long-term care (LTC): dementia, heart failure, chronic obstructive pulmonary disease, renal failure, and frailty. The pamphlets were created in response to residents', families', and staff's recommendations for activating early reflections and communication about end-of-life care.

Design: A mixed-method (qualitative and quantitative) survey design was used. Step 1 collected survey data on the usability of the pamphlets. Step 2 collected survey data on pamphlet use.

Settings And Participants: Two nurses with specialized palliative care training, 2 resident/family representatives, 10 condition-specific specialists, and 33 LTC palliative leads reviewed the pamphlets for usability prior to distribution. A total of 178 LTC home staff in 4 participating LTC homes reported on pamphlet use.

Measures: Specialists and resident/family representatives were asked to provide open comments and LTC home palliative leads were asked to complete a survey on the accuracy, readability, and relevance of the pamphlets. After 6 months of distribution, all staff in participating LTC homes were asked to complete a survey on pamphlet use, usefulness, and comfort with distribution.

Results: The pamphlets were reportedly accurate, relevant, and easy to understand. Following 6 months of availability, most staff in LTC had read the pamphlets, found the information useful, and planned to share them. However, half of the staff questioned their role in pamphlet distribution and most had not distributed them. Regulated staff (ie, staff affiliated with a regulated profession) expressed more comfort sharing the pamphlets than care aides and support staff.

Conclusions/implications: Condition-specific pamphlets appear to hold promise in providing residents and families with relevant information that may activate early reflections and conversations about end-of-life care. However, structured implementation strategies, training, and discussions are required to improve staff comfort with distribution and explore roles in distribution and follow-up.
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http://dx.doi.org/10.1016/j.jamda.2018.11.009DOI Listing
March 2019