Mechanical Ventilation in Older Adults With Dementia: Opportunities to Promote Goal-Concordant Care.

CONTEXT: Recent studies show increasing use of mechanical ventilation among people living with dementia. There are concerns that this trend may not be driven by patient preferences. OBJECTIVES: To better understand decision-making regarding mechanical ventilation in people living with dementia. METHODS: This was an electronic health record-based retrospective cohort study of older adults with dementia (n = 295) hospitalized at one of two teaching hospitals between 2015 and 2019 who were supported with mechanical ventilation (n = 191) or died without mechanical ventilation (n = 104). Multivariable logistic regression was used to examine associations between patient characteristics and mechanical ventilation use. RESULTS: The median age was 78 years (IQR 71-86), 41% were female, 28% resided in a nursing home, and 58% had clinical markers of advanced dementia (dehydration, weight loss, mobility limitations, or pressure ulcers). Among patients supported with mechanical ventilation, 70% were intubated within 24 hours of presentation, including 31% intubated before hospital arrival. Younger age, higher illness acuity, and absence of a treatment-limiting Physician Orders for Life-Sustaining Treatment document were associated with mechanical ventilation use; nursing home residence and clinical markers of advanced dementia were not. Most patients (89%) had a documented goals of care discussion (GOCD) during hospitalization. CONCLUSION: Future efforts to promote goal-concordant care surrounding mechanical ventilation use for people living with dementia should involve identifying barriers to goal-concordant care in pre-hospital settings, assessing the timeliness of in-hospital GOCD, and developing strategies for in-the-moment crisis communication across settings.

Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure.

Rationale: Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care. Objective: To identify risk factors, in particular whether an early goals-of-care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure. Methods: We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ⩾48 h of mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (⩾$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization. Results: Patients in the sample had a median age of 71 (IQR, 62-79) years. Approximately half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. More than half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had a 50% lower risk of a high-cost hospitalization (risk ratio, 0.50; 95% confidence interval, 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with a lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU compared with a medical ICU were associated with a higher likelihood of high-cost hospitalization. Conclusions: Early GOCDs for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.

Palliative Care Consultation and Family-Centered Outcomes in Patients With Unplanned Intensive Care Unit Admissions.

Context: Hospitalized patients who experience unplanned intensive care unit (ICU) admissions face significant challenges, and their family members have unique palliative care needs. Objectives: To identify predictors of palliative care consultation among hospitalized patients with unplanned ICU admissions and to examine the association between palliative care consultation and family outcomes. Methods: We conducted a prospective cohort study of patients with unplanned ICU admissions at two medical centers in Seattle, WA. This study was approved by the institutional review board at the University of Washington (STUDY00008182). Using multivariable logistic regression, we examined associations between patient characteristics and palliative care consultation. Family members completed surveys assessing psychological distress within 90 days of patient discharge. Adjusted ordinal probit or binary logistic regression models were used to identify associations between palliative care consultation and family symptoms of psychological distress. Results: In our cohort (n = 413 patients and 272 family members), palliative care was consulted for 24% of patients during hospitalization (n = 100), with the majority (93%) of these consultations occurring after ICU admission. Factors associated with palliative care consultation after ICU transfer included enrollment site (OR, 2.29; 95% CI: 1.17-4.50), Sequential Organ Failure Assessment score at ICU admission (OR, 1.12; 95% CI: 1.05-1.19), and reason for hospital admission (kidney dysfunction [OR, 7.02; 95% CI: 1.08-45.69]). There was no significant difference in family symptoms of depression or posttraumatic stress based on palliative care consultation status. Conclusions: For patients experiencing unplanned ICU admission, palliative care consultation often happened after transfer and was associated with illness severity, comorbid illness, and hospital site. Patient death was associated with family symptoms of psychological distress.

Long-term health-related quality of life and independence among older survivors of serious injury.

BACKGROUND: Little is known about the recovery experiences of older trauma intensive care unit (TICU) survivors and the relationship between geriatric trauma care and long-term functional ability and health-related quality of life (HRQOL). METHODS: We conducted a prospective cohort study of 218 patients (age, ≥65 years) admitted to a Level 1 regional trauma center TICU before versus after implementation of a geriatric care bundle with protocolized geriatrics consultations (Geri-T). Survivors or their proxies were interviewed approximately 1 year after hospitalization. Outcomes included the Katz Index of Independence in Activities of Daily Living (ADLs), Lawton Instrumental Activities of Daily Living (IADLs), and EQ-5D-5L HRQOL survey. Two investigator-developed questions regarding recovery experiences were included. Differences in outcomes among survivors admitted before versus after Geri-T were analyzed using multivariable linear regression. Responses to questions about recovery experiences were qualitatively assessed using content analysis. RESULTS: We reached 67% (146/218) of hospital survivors or their proxies across both groups; 126 patients were still alive and completed the survey. Mean age was 76 (SD, 8), 36% were female, and 90% were independent with ADLs preinjury. At follow-up, independence with ADLs was 76% and IADLs was 63%. The mean EQ-5D-5L index score was 0.78 (SD, 0.18). Most patients (65%) reported having not returned to preinjury functional status. Neither functional ability or HRQOL differed significantly among patients admitted before versus after Geri-T. Content analysis of open-ended questions revealed themes of activity limitations, persistent pain, and cognitive dysfunction. CONCLUSION: Nearly one-fifth of TICU survivors experienced loss of ADL function 1 year after injury, and most reported having not returned to preinjury functional status. Nonetheless, patient-reported HRQOL was comparable to age-adjusted norms. Geri-T was not associated with differences in HRQOL or functional ability. Survivors reported persistent difficulty with activities beyond those of daily living, pain, and cognition. LEVEL OF EVIDENCE: Prognostic and Epidemiologic, Level III.

Predictors of Documented Goals-of-Care Discussion for Hospitalized Patients With Chronic Illness.

CONTEXT: Goals-of-care discussions are important for patient-centered care among hospitalized patients with serious illness. However, there are little data on the occurrence, predictors, and timing of these discussions. OBJECTIVES: To examine the occurrence, predictors, and timing of electronic health record (EHR)-documented goals-of-care discussions for hospitalized patients. METHODS: This retrospective cohort study used natural language processing (NLP) to examine EHR-documented goals-of-care discussions for adults with chronic life-limiting illness or age ≥80 hospitalized 2015-2019. The primary outcome was NLP-identified documentation of a goals-of-care discussion during the index hospitalization. We used multivariable logistic regression to evaluate associations with baseline characteristics. RESULTS: Of 16,262 consecutive, eligible patients without missing data, 5,918 (36.4%) had a documented goals-of-care discussion during hospitalization; approximately 57% of these discussions occurred within 24 hours of admission. In multivariable analysis, documented goals-of-care discussions were more common for women (OR=1.26, 95%CI 1.18-1.36), older patients (OR=1.04 per year, 95%CI 1.03-1.04), and patients with more comorbidities (OR=1.11 per Deyo-Charlson point, 95%CI 1.10-1.13), cancer (OR=1.88, 95%CI 1.72-2.06), dementia (OR=2.60, 95%CI 2.29-2.94), higher acute illness severity (OR=1.12 per National Early Warning Score point, 95%CI 1.11-1.14), or prior advance care planning documents (OR=1.18, 95%CI 1.08-1.30). Documentation of these discussions was less common for racially or ethnically minoritized patients (OR=0.823, 95%CI 0.75-0.90). CONCLUSION: Among hospitalized patients with serious illness, documented goals-of-care discussions identified by NLP were more common among patients with older age and increased burden of acute or chronic illness, and less common among racially or ethnically minoritized patients. This suggests important disparities in goals-of-care discussions.

Hemoptysis and the Risk for Lung Transplant or Death without Transplant in Individuals with Cystic Fibrosis in the United States.

Rationale: Hemoptysis is a common and important complication in persons with cystic fibrosis (PwCF). Despite this, there is limited literature on the impact of hemoptysis on contemporary cystic fibrosis (CF) outcomes. Objectives: Evaluate whether hemoptysis increases the risk of lung transplant or death without a transplant in PwCF. Methods: We reviewed a dataset of PwCF ages 12 years or older from the CFFPR (CF Foundation Patient Registry) that included 29,587 individuals. We identified hemoptysis as our predictor of interest and categorized PwCF as either no hemoptysis, any hemoptysis (submassive and/or massive), or massive hemoptysis. We subsequently evaluated whether hemoptysis, as defined above, was associated with death without transplant or receipt of lung transplant via logistic regression. We adjusted for age, sex, body mass index, forced expiratory volume in one second (FEV1), number of exacerbations, supplemental oxygen use, CF-related diabetes, and Pseudomonas aeruginosa colonization status. Subgroup analyses were performed in advanced lung disease, defined as PwCF with an FEV1 <40% predicted. Results: PwCF with any form of hemoptysis were more likely to progress to lung transplant or die without transplant than PwCF who did not have hemoptysis (odds ratio [OR], 1.3 [95% confidence interval (CI), 1.1-1.7]). The effect size of these associations was larger when hemoptysis events were classified as "massive" (massive hemoptysis OR, 2.2 [95% CI, 1.2-3.8]) or in PwCF with advanced lung disease (massive hemoptysis in advanced lung disease OR, 3.2 [95% CI 1.3-8.2]). Conclusions: Hemoptysis is associated with an increased risk of lung transplant and death without a transplant in PwCF, especially among those with massive hemoptysis or advanced lung disease. Our results suggest that hemoptysis functions as a useful predictor of serious outcomes in PwCF and may be important to incorporate into risk prediction models and/or transplant decisions in CF.

Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19.

CONTEXT: The COVID-19 pandemic has highlighted variability in intensity of care. We aimed to characterize intensity of care among hospitalized patients with COVID-19. OBJECTIVES: Examine the prevalence and predictors of admission code status, palliative care consultation, comfort-measures-only orders, and cardiopulmonary resuscitation (CPR) among patients hospitalized with COVID-19. METHODS: This cross-sectional study examined data from an international registry of hospitalized patients with COVID-19. A proportional odds model evaluated predictors of more aggressive code status (i.e., Full Code) vs. less (i.e., Do Not Resuscitate, DNR). Among decedents, logistic regression was used to identify predictors of palliative care consultation, comfort measures only, and CPR at time of death. RESULTS: We included 29,923 patients across 179 sites. Among those with admission code status documented, Full Code was selected by 90% (n = 15,273). Adjusting for site, Full Code was more likely for patients who were of Black or Asian race (ORs 1.82, 95% CIs 1.5-2.19; 1.78, 1.15-3.09 respectively, relative to White race), Hispanic ethnicity (OR 1.89, CI 1.35-2.32), and male sex (OR 1.16, CI 1.0-1.33). Of the 4951 decedents, 29% received palliative care consultation, 59% transitioned to comfort measures only, and 29% received CPR, with non-White racial and ethnic groups less likely to receive comfort measures only and more likely to receive CPR. CONCLUSION: In this international cohort of patients with COVID-19, Full Code was the initial code status in the majority, and more likely among patients who were Black or Asian race, Hispanic ethnicity or male. These results provide direction for future studies to improve these disparities in care.

Frailty subtypes and recovery in older survivors of acute respiratory failure: a pilot study.

BACKGROUND: Identifying subtypes of acute respiratory failure survivors may facilitate patient selection for post-intensive care unit (ICU) follow-up clinics and trials. METHODS: We conducted a single-centre prospective cohort study of 185 acute respiratory failure survivors, aged ≥ 65 years. We applied latent class modelling to identify frailty subtypes using frailty phenotype and cognitive impairment measurements made during the week before hospital discharge. We used Fine-Gray competing risks survival regression to test associations between frailty subtypes and recovery, defined as returning to a basic Activities of Daily Living disability count less than or equal to the pre-hospitalisation count within 6 months. We characterised subtypes by pre-ICU frailty (Clinical Frailty Scale score ≥ 5), the post-ICU frailty phenotype, and serum inflammatory cytokines, hormones and exosome proteomics during the week before hospital discharge. RESULTS: We identified five frailty subtypes. The recovery rate decreased 49% across each subtype independent of age, sex, pre-existing disability, comorbidity and Acute Physiology and Chronic Health Evaluation II score (recovery rate ratio: 0.51, 95% CI 0.41 to 0.63). Post-ICU frailty phenotype prevalence increased across subtypes, but pre-ICU frailty prevalence did not. In the subtype with the slowest recovery, all had cognitive impairment. The three subtypes with the slowest recovery had higher interleukin-6 levels (p=0.03) and a higher prevalence of ≥ 2 deficiencies in insulin growth factor-1, dehydroepiandrostersone-sulfate, or free-testosterone (p=0.02). Exosome proteomics revealed impaired innate immunity in subtypes with slower recovery. CONCLUSIONS: Frailty subtypes varied by prehospitalisation frailty and cognitive impairment at hospital discharge. Subtypes with the slowest recovery were similarly characterised by greater systemic inflammation and more anabolic hormone deficiencies at hospital discharge.

Moral distress and burnout in caring for older adults during medical school training.

BACKGROUND: Moral distress is a reason for burnout in healthcare professionals, but the clinical settings in which moral distress is most often experienced by medical students, and whether moral distress is associated with burnout and career choices in medical students is unknown. We assessed moral distress in medical students while caring for older patients, and examined associations with burnout and interest in geriatrics. METHODS: A cross-sectional survey study of second-, third-, and fourth-year medical students at an American medical school. The survey described 12 potentially morally distressing clinical scenarios involving older adult patients. Students reported if they encountered each scenario, and whether they experienced moral distress, graded on a 1-10 scale. We conducted a principal axis factor analysis to assess the dimensionality of the survey scenarios. A composite moral distress score was calculated as the sum of moral distress scores across all 12 scenarios. Burnout was assessed using the Maslach Abbreviated Burnout Inventory, and interest in geriatrics was rated on a 7-point Likert scale. RESULTS: Two-hundred and nine students responded (47%), of whom 90% (188/209) reported moral distress in response to ≥1 scenario with a median (IQR) score of 6 (4-7). Factor analysis suggested a unidimensional factor structure of the 12 survey questions that reliably measured individual distress (Cronbach alpha = 0.78). Those in the highest tertile of composite moral distress scores were more likely to be burnt out (51%) than those in the middle tertile of scores (34%), or lowest tertile of scores (31%) (p = 0.02). There was a trend towards greater interest in geriatrics among those in the higher tertiles of composite moral distress scores (16% lowest tertile, 20% middle tertile, 25% highest tertile, p-for-tend = 0.21). Respondents suggested that moral distress might be mitigated with didactic sessions in inpatient geriatric care, and debriefing sessions with peers and faculty on the inpatient clerkships on medicine, neurology, and surgery, where students most often reported experiencing moral distress. CONCLUSIONS: Moral distress is highly prevalent among medical students while caring for older patients, and associated with burnout. Incorporating geriatrics education and debriefing sessions into inpatient clerkships could alleviate medical student moral distress and burnout.

Randomized controlled trial of REbeL: A peer education program to promote positive body image, healthy eating behavior, and empowerment in teens.

Short-term outcomes associated with participation in REbeL, a peer-led dissonance-based eating disorder prevention program for high school students, were evaluated. Seventy-one students across the three high schools were enrolled in the study (REbeL N = 48; Control N = 23) and were assessed on measures of eating attitudes and behaviors, body image, weight bias, self-esteem, empowerment, and mood at the beginning of the school year; 37 REbeL students and 20 control students completed assessments at the end of the school year. Mixed effects GLM compared groups on outcomes at the end of the academic year. When controlling for baseline scores, students in both REbeL schools, compared to control school students, demonstrated statistically significantly lower scores at post-test on the EDE-Q Global score, the EDE-Q Restraint, Eating Concern, Shape Concern and Weight Concern subscales, and the Body Checking Questionnaire (all ps < .05). This study provides preliminary empirical support for the REbeL program.

Patterns and Predictors of Frailty Transitions in Older Men: The Osteoporotic Fractures in Men Study.

OBJECTIVES: To describe the natural history of frailty transitions in a large cohort of community-dwelling older men and identify predictors associated with progression to or improvement from states of greater frailty. DESIGN: Prospective cohort study. SETTING: Six U.S. sites. PARTICIPANTS: Community-dwelling men aged 65 and older (N = 5,086). MEASUREMENTS: Frailty was measured at baseline and an average of 4.6 years later. Frailty was defined as having three or more of the following components (low lean mass, weakness, self-reported exhaustion, low activity level, and slow walking speed); prefrailty was defined as having one or two components. Separate multivariable logistic regression models were analyzed for progression and improvement in frailty status. RESULTS: Of the 5,086 men, 8% were frail, 46% were prefrail, and 46% were robust at baseline. Between baseline and follow-up, 35% progressed in frailty status or died, 56% had no change in frailty status, and 15% of prefrail or frail participants improved, although only 0.5% improved across two levels, from frail to robust. In multivariable models, factors associated with improvement in frailty status included greater leg power, being married, and good or excellent self-reported health, whereas presence of any instrumental activity of daily living (IADL) limitations, low albumin levels, high interleukin-6 levels, and presence of chronic obstructive pulmonary disease or diabetes mellitus were associated with lower likelihood of improvement in frailty status. CONCLUSION: Improvement in frailty status was possible in this cohort of community-dwelling older men, but improvement from frail to robust was rare. Several predictors were identified as possible targets for intervention, including prevention and management of comorbid medical conditions, prevention of IADL disability, physical exercise, and nutritional and social support.

Refining Low Physical Activity Measurement Improves Frailty Assessment in Advanced Lung Disease and Survivors of Critical Illness.

RATIONALE: The frail phenotype has gained popularity as a clinically relevant measure in adults with advanced lung disease and in critical illness survivors. Because respiratory disease and chronic illness can greatly limit physical activity, the measurement of participation in traditional leisure time activities as a frailty component may lead to substantial misclassification of frailty in pulmonary and critical care patients. OBJECTIVES: To test and validate substituting the Duke Activity Status Index (DASI), a simple 12-item questionnaire, for the Minnesota Leisure Time Physical Activity (MLTA) questionnaire, a detailed questionnaire covering 18 leisure time activities, as the measure of low activity in the Fried frailty phenotype (FFP) instrument. METHODS: In separate multicenter prospective cohort studies of adults with advanced lung disease who were candidates for lung transplant and older survivors of acute respiratory failure, we assessed the FFP using either the MLTA or the DASI. For both the DASI and MLTA, we evaluated content validity by testing floor effects and construct validity through comparisons with conceptually related factors. We tested the predictive validity of substituting the DASI for the MLTA in the FFP assessment using Cox models to estimate associations between the FFP and delisting/death before transplant in those with advanced lung disease and 6-month mortality in older intensive care unit (ICU) survivors. RESULTS: Among 618 adults with advanced lung disease and 130 older ICU survivors, the MLTA had a substantially greater floor effect than the DASI (42% vs. 1%, and 49% vs. 12%, respectively). The DASI correlated more strongly with strength and function measures than did the MLTA in both cohorts. In models adjusting for age, sex, comorbidities, and illness severity, substitution of the DASI for the MLTA led to stronger associations of the FFP with delisting/death in lung transplant candidates (FFP-MLTA hazard ratio [HR], 1.42; 95% confidence interval [CI], 0.55-3.65; FFP-DASI HR, 2.99; 95% CI, 1.03-8.65) and with mortality in older ICU survivors (FFP-MLTA HR, 2.68; 95% CI, 0.62-11.6; FFP-DASI HR, 5.71; 95% CI, 1.34-24.3). CONCLUSIONS: The DASI improves the construct and predictive validity of frailty assessment in adults with advanced lung disease or recent critical illness. This simple questionnaire should replace the more complex MLTA in assessing the frailty phenotype in these populations.

The Frailty Phenotype and Palliative Care Needs of Older Survivors of Critical Illness.

OBJECTIVES: To assess symptoms in older intensive care unit (ICU) survivors and determine whether post-ICU frailty identifies those with the greatest palliative care needs. DESIGN: A prospective cohort study. SETTING: Urban tertiary care hospital and community hospital. PARTICIPANTS: Medical ICU survivors of mechanical ventilation aged 65 and older (N = 125). MEASUREMENTS: Baseline measurements of the Edmonton Symptom Assessment Scale (ESAS), categorized as mild (0-3), moderate (4-6), and severe (7-10), and the frailty phenotype were made during the week before hospital discharge. Functional recovery was defined as a return to a Katz activity of daily living dependency count less than or equal to the prehospitalization dependency count within 3 months. In the last 29 participants recruited, we made additional assessments of fatigue and ESAS both at baseline and 1 month after discharge. RESULTS: Fatigue was the most-prevalent moderate to severe symptom (74%), followed by dyspnea (53%), drowsiness (50%), poor appetite (47%), pain (45%), depression (42%), anxiety (36%), and nausea (17%). At 1-month follow-up, there were no significant differences in the proportions of participants with moderate to severe symptoms. Each increase in baseline ESAS fatigue severity category was associated with 55% lower odds of functional recovery (odds ratio = 0.45, 95% confidence interval = 0.24-0.84), independent of age, sex, comorbidities, and critical illness severity. Frail participants had a higher median baseline total ESAS symptom distress score (34, interquartile range (IQR) 23-44) than nonfrail participants (13, IQR 9-22) (P < .001). CONCLUSION: Older ICU survivors have a high burden of palliative care needs that persist 1 month after discharge. Fatigue is the most-prevalent symptom and may interfere with recovery. Post-ICU frailty may be a useful trigger for palliative care consultation and a treatment target.

Perceptions of Caring for Adolescents With Eating Disorders Hospitalized on a General Pediatric Unit.

PURPOSE: To describe the perceptions of inpatient pediatric hospitalist physicians (HPs), registered nurses (RNs), and care assistants (CAs) at a tertiary pediatric hospital regarding caring for children with eating disorders (EDs) who are hospitalized for medical stabilization. DESIGN AND METHODS: A qualitative descriptive study was conducted using semi-structured individual interviews with aforementioned health care workers (HCWs) to explore their perspectives on caring for children/adolescents with EDs in relation to recent initiatives to transform their care. These initiatives focused on admitting patients to a designated "ED Unit", development of an ED consult team, providing ED education to staff, and development of ED standardized order sets (SOSs). RESULTS: Twenty HCWs representing the three disciplines completed individual interviews. Most participants reported that the system changes led to more consistent care of patients with ED. Content analysis of the interviews revealed the following themes: awkwardness and uncertainties of care, navigating family dynamics, establishing therapeutic boundaries, and finding rewards in ED care. CONCLUSIONS: Education, structure, and support for staff improved care for adolescents with EDs as perceived by HCWs. HCWs found satisfaction in providing care during the medical stabilization process. Study findings were positive for staff and future studies should include perceptions of patients/families to further design a therapeutic environment. PRACTICE IMPLICATIONS: Providing a standardized order set, expert consult team, and ongoing staff training can strengthen the therapeutic hospital environment for adolescents with EDs. Pediatric hospitals can provide excellent care for children with EDs while supporting their staff to provide a therapeutic environment.

Voluntary emotion regulation in anorexia nervosa: A preliminary emotion-modulated startle investigation.

Emotion regulation difficulties are implicated in the development and maintenance of anorexia nervosa (AN). However, research has been limited by an almost exclusive reliance on self-report. This study is the first to use the emotion-modulated startle paradigm (EMSP) to investigate emotional reactivity and voluntary emotion regulation in individuals with AN. Twenty women with AN viewed negative, positive, neutral, and food images and were asked to enhance, suppress, or maintain their emotional responses mid-way through picture presentation. Startle eyeblink magnitudes in response to startle probes administered prior, and subsequent, to regulation instructions indexed emotional reactivity and regulation, respectively. On emotional reactivity trials, startle magnitudes were greater for negative, positive, and food images, compared to neutral images. Participants had difficulty suppressing startle responses to negative and food images, as indicated by non-significant suppress-maintain comparisons. In contrast, startle responses to enhance and suppress cues during presentation of pleasant images were comparable and significantly lower than maintain cues. Findings converge with self-report data to suggest that patients with AN have difficulties with voluntary emotion regulation. The EMSP may be a promising trans-diagnostic method for examining emotion regulation difficulties that underlie risk for eating disorders and other psychiatric conditions.

Quantitative and Qualitative Analysis of the Quality of Life of Individuals With Eating Disorders.

OBJECTIVE: To examine the quality of a broad range of life domains using both quantitative and qualitative methodologies. METHOD: Forty-eight individuals seeking inpatient treatment for an eating disorder (mean age = 29.8 years, female = 100%, white = 96.4%) from 2007 to 2009 completed the Quality of Life Inventory (QOLI) and the Eating Disorder Examination Questionnaire; a medical chart review confirmed diagnosis and treatment history. Patients diagnosed with anorexia nervosa (n = 24) and bulimia nervosa (n = 24) were compared. Body mass index (kg/m(2)), treatment history, number of comorbid psychiatric conditions, and eating disorder severity were used to predict quality of life. Finally, an inductive content analysis was performed on qualitative QOLI responses to contextualize the quantitative findings. RESULTS: Participants with anorexia nervosa, compared to those with bulimia nervosa, reported significantly less satisfaction with the domain of relatives (F 1,46 = 5.35; P = .025); no other significant group differences were found. The only significant predictor of QOLI global score was number of previous treatments (F 1,41 = 8.67; P = .005; R (2) = 0.175). Content analysis of qualitative data yielded complementary findings to the quantitative data; interesting group differences emerged for satisfaction with health with implications for measuring quality of life domains. CONCLUSIONS: Across several life domains, individuals seeking treatment for anorexia nervosa and bulimia nervosa appear to have similar levels of satisfaction, as evidenced by numeric and descriptive responses. Satisfaction with relatives, however, appears to differ between groups and suggests a specific target for intervention among patients in treatment for anorexia nervosa (eg, a family-based intervention such as the Maudsley approach). The use of quantitative and qualitative assessments, such as the QOLI, provides more clinically meaningful, contextualized information about quality of life than traditional self-report assessments alone.

Comparison of obese adults with poor versus good sleep quality during a functional neuroimaging delay discounting task: A pilot study.

This study aimed to determine if obese adults with poor versus good sleep quality demonstrate reduced self-regulatory capacity and different patterns of neural activation when making impulsive monetary choices. Six obese, good quality sleepers (M age=44.7 years, M BMI=38.1 kg/m(2)) were compared to 13 obese, poor quality sleepers (M age=42.6, M BMI=39.2 kg/m(2)) on sleep and eating behavior and brain activation in prefrontal and insular regions while engaging in a delay discounting task during functional magnetic resonance imaging (fMRI). Poor quality sleepers demonstrated significantly lower brain activation in the right inferior frontal gyrus, right middle frontal gyrus, and bilateral insula when making immediate and smaller (impulsive) monetary choices compared to the baseline condition. Behaviorally, poor compared to good quality sleepers reported higher scores in the night eating questionnaire. Obese adults with poor sleep quality demonstrate decreased brain activation in multiple regions that regulate cognitive control and interceptive awareness, possibly reducing self-regulatory capacity when making immediately gratifying decisions.

Depression screening on a maternity unit: a mixed-methods evaluation of nurses' views and implementation strategies.

Postpartum women often suffer clinically significant depressive symptoms, a problem addressed by nurse-delivered screening programs. In the past, success of these identification programs was measured in terms of screening rates; however, merely evaluating the screening rate does little to inform how to implement depression screening in clinical practice. This article describes the experiences of nurses in implementing depression screening on a maternity unit. We evaluate the practice qualitatively, by asking nurses to describe their screening strategies and their views about implementation, as well as quantitatively by assessing their screening rates and the number of women identified. Utilizing a framework of program evaluation, 20 maternity unit nurses completed qualitative assessments investigating their day-to-day experiences with this practice. To include the perspectives of nurses that declined to participate in qualitative assessments, 14 additional maternity unit nurses completed a brief survey assessing their views. We also assessed screening rates, defined as the number of women screened divided by the number eligible for screening. Maternity unit nurses viewed depression screening positively and were able to screen patients in relatively few steps, which they implemented using strategies they had developed themselves. Despite nurses' ongoing concern about finding time to screen, they achieved high screening rates and, with one exception, indicated they would opt to continue voluntarily. Depression screening on the maternity unit is feasible and embraced by attending nurses. The clinical strategies used to implement screening are extensively described and provide a basis for implementation in other settings that serve perinatal women.

Using the Neuroscience of Obesity, Eating Behavior, and Sleep to Inform the Neural Mechanisms of Night Eating Syndrome.

The development and maintenance of night eating syndrome (NES) is likely influenced by physiological, psychological, and social factors. Within the physiological domain, neural mechanisms (e.g., neurotransmitters and specific brain region functioning) remain understudied in contrast to other eating disorders and obesity. The serotonin system has been hypothesized to contribute to NES based on one single photon emission computed tomography (SPECT) study and supportive pharmacologic treatment outcome findings, but additional neural models are plausible. Functional magnetic resonance imaging (fMRI) is a brain imaging tool that is increasingly being used to study obesity, eating behavior, and sleep. Converging data from these literatures using food motivation and decision making fMRI paradigms suggest that the prefrontal and limbic brain systems might also play a role in the development and/or maintenance of NES. We use these data to support a new neural model of NES for future testing and validation.

How specific are the relationships between eating disorder behaviors and perfectionism?

Perfectionism is associated with several mental disorders, including depression, anxiety, and eating disorders. The goal of this study was to test the specificity of the associations between perfectionism facets and eating disorder behaviors, by examining whether neuroticism and conscientiousness mediated or moderated associations between these variables. Participants from a representative community sample (N = 407; 47% female) completed questionnaires assessing perfectionism, neuroticism, conscientiousness, and eating disorder behaviors. Neuroticism partially mediated associations between binge eating, restraint, body dissatisfaction, and maladaptive perfectionism facets. Neuroticism did not mediate associations between restriction and achievement striving perfectionism facets. Conscientiousness did not mediate any associations between perfectionism facets and eating disorder behaviors, yet Doubts about Actions interacted with conscientiousness to predict body dissatisfaction. Results indicate that neuroticism is key for understanding general risk factors that lead to myriad internalizing disorders, whereas maladaptive perfectionism has limited usefulness as a specific risk factor for eating disorder behaviors. Nevertheless, there is a unique association between dietary restraint and achievement striving dimensions of perfectionism that cannot be explained by higher-order personality traits.