Health Care Team Interventions to Reduce Distress Behaviors in Older Adults: A Systematic Review.

OBJECTIVES: This review examines health care team-focused interventions on managing persistent or recurrent distress behaviors among older adults in long-term residential or inpatient health care settings. METHODS: We searched interventions addressing health care worker (HCW) knowledge and skills related to distress behavior management using Ovid MEDLINE, Elsevier Embase, and Ovid PsycINFO from December 2002 through December 2022. RESULTS: We screened 6,582 articles; 29 randomized trials met inclusion criteria. Three studies on patient-facing HCW interactions (e.g. medication management, diagnosing distress) showed mixed results on agitation; one study found no effect on quality of life. Six HCW-focused studies suggested short-term reduction in distress behaviors. Quality-of-life improvement or decreased antipsychotic use was not evidenced. Among 17 interventions combining HCW-focused and patient-facing activities, 0 showed significant distress reduction, 8 showed significant antipsychotic reduction (OR = 0.79, 95%CI [0.69, 0.91]) and 9 showed quality of life improvements (SMD = 0.71, 95%CI [0.39, 1.04]). One study evaluating HCW, patient-, and environmental-focused intervention activities showed short-term improvement in agitation. CONCLUSIONS AND CLINICAL IMPLICATIONS: Novel health care models combining HCW training and patient management improve patient quality of life, reduce antipsychotic use, and may reduce distress behaviors. Evaluation of intervention's effects on staff burnout and utilization is needed.

Graph-theoretical chirality measure and chirality-property relations for chemical structures with multiscale mirror asymmetries.

Chirality is an essential geometric property unifying small molecules, biological macromolecules, inorganic nanomaterials, biological microparticles, and many other chemical structures. Numerous chirality measures have attempted to quantify this geometric property of mirror asymmetry and to correlate these measures with physical and chemical properties. However, their utility has been widely limited because these correlations have been largely notional. Furthermore, chirality measures also require prohibitively demanding computations, especially for chiral structures comprised of thousands of atoms. Acknowledging the fundamental problems with quantification of mirror asymmetry, including the ambiguity of sign-variable pseudoscalar chirality measures, we revisit this subject because of the significance of quantifying chirality for quantitative biomimetics and describing the chirality of nanoscale materials that display chirality continuum and scale-dependent mirror asymmetry. We apply the concept of torsion within the framework of differential geometry to the graph theoretical representation of chiral molecules and nanostructures to address some of the fundamental problems and practical limitations of other chirality measures. Chiral gold clusters and other chiral structures are used as models to elaborate a graph-theoretical chirality (GTC) measure, demonstrating its applicability to chiral materials with different degrees of chirality at different scales. For specific cases, we show that GTC provides an adequate description of both the sign and magnitude of mirror asymmetry. The direct correlations with macroscopic properties, such as chiroptical spectra, are enhanced by using the hybrid chirality measures combining parameters from discrete mathematics and physics. Taking molecular helices as an example, we established a direct relation between GTC and optical activity, indicating that this chirality measure can be applied to chiral metamaterials and complex chiral constructs.

Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy.

BACKGROUND: Documenting goals of care in the electronic health record is meant to relay patient preferences to other clinicians. Evaluating the content and documentation of nurse and social worker led goals of care conversations can inform future goals of care initiative efforts. METHODS: As part of the ADvancing symptom Alleviation with Palliative Treatment trial, this study analyzed goals of care conversations led by nurses and social workers and documented in the electronic health record. Informed by a goals of care communication guide, we identified five goals of care components: illness understanding, goals and values, end of life planning, surrogate, and advance directives. Forty conversation transcripts underwent content analysis. Through an iterative team process, we defined documentation accuracy as four categories: (1) Complete-comprehensive accurate documentation of the conversation, (2) Incomplete-partial documentation of the conversation, (3) Missing-discussed and not documented, and (4) Incorrect-misrepresented in documentation. We also defined-Not Discussed-for communication guide questions that were not discussed nor documented. A constant comparative approach was used to determine the presence or absence of conversation content in the documentation. RESULTS: All five goals of care components were discussed in 67% (27/40) of conversation transcripts. Compared to the transcripts, surrogate (37/40, 93%) and advance directives (36/40, 90%) were often documented completely. Almost 40% of goals and values (15/40, 38%) and half of end of life planning (19/40, 48%) were incomplete. Illness understanding was missing (13/40, 33%), not discussed (13/40, 33%), or incorrect (2/40, 5%). CONCLUSION: Nurse and social worker led goals of care conversations discussed and documented most components of the goals of care communication guide. Further research may guide how best to determine the relative importance of accuracy, especially in the broad setting of incomplete, missing, and incorrect EHR documentation.

Factors Associated With Hospital Admission in the Last Month: A Retrospective Single Center Analysis.

CONTEXT: Driven by concerns about care quality, patient experience, and national metrics, health systems are increasingly focusing on identifying risk factors for patients who are hospitalized in the last month of life. OBJECTIVE: To evaluate patient factors associated with hospital admission in the last month (30 days). METHODS: We analyzed a retrospective cohort of 8488 patients with a primary care visit in a tertiary health system in the last year of life using a linked electronic health record and decedent dataset. We examined healthcare utilization (primary care, emergency, hospital, intensive care unit encounters) and end-of-life related outcomes (palliative care consultation, do-not-resuscitate orders, advance care planning documentation, hospice at hospital discharge, death in health system). Multivariable logistic regressions identified patient factors associated with admission in the last month. RESULTS: About 2202 (25.9%) patients had a hospital admission in the last month. Among the 1282 (15.1%) who died in a health system facility, most (1103/1282, 86.0%) were admitted to the hospital in the last month. Among patients with a hospital admission and discharged in the last month, 60.9% (686/1126) were discharged on hospice. Compared to those without these diseases, metastatic cancer, liver disease, or heart failure had the highest odds of admission in the last month (adjusted OR 2.36 95%CI 2.05-2.72; 2.28, 95%CI 1.98-2.62; and 2.17 95%CI 1.93-2.45 respectively). CONCLUSIONS: As patients with heart or liver disease or metastatic cancer had the highest odds of admission in the last month, collaborative interventions between primary, palliative, and specialty care may improve quality of care at the end of life.

Trajectories of Physical Resilience Among Older Veterans With Stage 4 CKD.

RATIONALE & OBJECTIVE: Although functional impairment is common among older adults with chronic kidney disease (CKD), functional reserve before an acute health event and physical resilience after the event have not been characterized in this population. The purpose of this study was to identify distinct patterns of physical function before and after an acute health event among older veterans with stage 4 CKD. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: National sample of veterans≥70 years of age with an estimated glomerular filtration rate (eGFR) of<30mL/min/1.73m2 who had an acute care encounter (emergency department visit or hospitalization) during the follow-up period (n = 272). PREDICTORS: Demographic characteristics, eGFR, basic and instrumental activities of daily living (ADL/IADL) difficulty, symptom burden, cognition, depressive symptoms, social support. OUTCOME: Function measured using the life-space mobility assessment obtained by telephone survey before and after an acute care encounter. ANALYTICAL APPROACH: General growth mixture models to identify classes of functional trajectories. Calculation of percentages for demographic characteristics and means for eGFR, ADL/IADL difficulty, symptom burden, cognition, depressive symptoms, and social support by trajectory class. RESULTS: Four trajectory classes were identified and characterized by different levels of life-space mobility before (reserve) and change in life-space mobility after (resilience) an acute care encounter: (1) low reserve, low resilience (n=91), (2) high reserve, high resilience (n=23), (3) moderate reserve, moderate resilience (n=89), and (4) high reserve, low resilience (n=69). Mean levels of ADL/IADL difficulty, symptom burden, cognition, and depressive symptoms, but not demographic characteristics, eGFR, or social support, differed by trajectory class. LIMITATIONS: Veteran cohort was primarily male. CONCLUSIONS: Among older adults with stage 4 CKD, physical function trajectories before and after an acute health event vary. Integrating reserve and resilience into care for this population may be useful for anticipating changes in function and developing tailored treatment plans.

Tapered chiral nanoparticles as broad-spectrum thermally stable antivirals for SARS-CoV-2 variants.

The incessant mutations of viruses, variable immune responses, and likely emergence of new viral threats necessitate multiple approaches to novel antiviral therapeutics. Furthermore, the new antiviral agents should have broad-spectrum activity and be environmentally stable. Here, we show that biocompatible tapered CuS nanoparticles (NPs) efficiently agglutinate coronaviruses with binding affinity dependent on the chirality of surface ligands and particle shape. L-penicillamine-stabilized NPs with left-handed curved apexes display half-maximal inhibitory concentrations (IC50) as low as 0.66 pM (1.4 ng/mL) and 0.57 pM (1.2 ng/mL) for pseudo-type SARS-CoV-2 viruses and wild-type Wuhan-1 SARS-CoV-2 viruses, respectively, which are about 1,100 times lower than those for antibodies (0.73 nM). Benefiting from strong NPs-protein interactions, the same particles are also effective against other strains of coronaviruses, such as HCoV-HKU1, HCoV-OC43, HCoV-NL63, and SARS-CoV-2 Omicron variants with IC50 values below 10 pM (21.8 ng/mL). Considering rapid response to outbreaks, exposure to elevated temperatures causes no change in the antiviral activity of NPs while antibodies are completely deactivated. Testing in mice indicates that the chirality-optimized NPs can serve as thermally stable analogs of antiviral biologics complementing the current spectrum of treatments.

Identifying Strategies for the Use of Gender and Sex Language in Clinical One-Liners.

Purpose: The "one-liner," commonly used in clinical communications, summarizes a patient's identity, presenting condition, medical history, and clinical findings. Imprecise, inconsistent use of gender and sex information in one-liners threatens the provision of affirming care to transgender, nonbinary, gender-expansive, and intersex patients and may exacerbate health care disparities. This study aimed to generate guidance for communicating gender and sex information in one-liners. Methods: This is an explanatory sequential, equal status mixed methods study of transgender, nonbinary, gender-expansive, and intersex people and clinicians caring for this population. Survey participants rated one-liners on a five-point Likert-type scale of appropriateness, considering affirmation and clinical utility, and provided open-ended comments. We conducted two focus groups with survey respondents to explore survey results and performed a thematic analysis of survey comments and focus group transcripts. Results: Survey respondents included 57 clinicians and 80 nonclinicians. One-liners containing patient pronouns were rated most appropriate, and appropriate patient descriptors included self-described gender identity or gender-neutral terms. In scenarios where patient sex information was not pertinent to the chief concern (CC), one-liners containing no sex information were rated most appropriate. Four themes were identified: inclusion of sex information based on relevance to the CC, accurate patient representation, influence of clinical setting, and risk of harm from inaccurate one-liners. Conclusion: This study generated data to support the appropriate use of gender and sex language in one-liners. Clinicians, educators, and trainees may use these findings to compose one-liners that are affirming and clinically useful for patients of diverse gender and sex identities.

Role of Early Psychosis Detection in the Relationship Between Personal Income and Duration of Untreated Psychosis.

OBJECTIVE: Prolonged duration of untreated psychosis (DUP) predicts poor outcomes of first-episode psychosis (FEP) and is often linked to low socioeconomic status (SES). The authors sought to determine whether patients' personal income, used as a proxy for SES, predicts length of DUP and whether personal income influences the effect of an early psychosis detection campaign-called Mindmap-on DUP reduction. METHODS: Data were drawn from a trial that compared the effectiveness of early detection in reducing DUP across the catchment area of an FEP service (N=147 participants) compared with an FEP service with no early detection (N=75 participants). Hierarchical regression was used to determine whether personal income predicted DUP when analyses controlled for effects of age, race, and exposure to early psychosis detection. A group × personal income interaction term was used to assess whether the DUP difference between the early detection and control groups differed by personal income. RESULTS: Lower personal income was significantly associated with younger age, fewer years of education, Black race, and longer DUP. Personal income predicted DUP beyond the effects of age, race, and early psychosis detection. Although Mindmap significantly reduced DUP across all income levels, this effect was smaller for participants reporting lower personal income. CONCLUSIONS: Patients' personal income may be an important indicator of disparity in access to specialty care clinics across a wide range of settings. Early detection efforts should measure and target personal income and other SES indicators to improve access for all individuals who may benefit from FEP services.

Aging induces cell loss and a decline in phagosome processing in the mouse retinal pigment epithelium.

Age-related macular degeneration (AMD) is a leading cause of irreversible vision loss and dysfunction in the retinal pigment epithelium (RPE) with age is known to contribute to disease development. The aim of this study was to investigate how the C57BL/6J mouse RPE changes with age. RPE structure was found to change with age and eccentricity, with cell size increasing, nuclei lost, and tight junctions altered in the peripheral retina. Phagocytosis of photoreceptor outer segments (POS) by the RPE was investigated using gene expression analysis and histology. RNA-Seq transcriptomic gene profiling of the RPE showed a downregulation of genes involved in phagosome processing and histological analysis showed a decline in phagosome-lysosome association in the aged tissue. In addition, failures in the autophagy pathway that modulates intracellular waste degradation were observed in the aged RPE tissue. These findings highlight that RPE cell loss and slowing of POS processing contribute to RPE dysfunction with age and may predispose the aging eye to AMD development.

Provider Interaction With an Electronic Health Record Notification to Identify Eligible Patients for a Cluster Randomized Trial of Advance Care Planning in Primary Care: Secondary Analysis.

BACKGROUND: Advance care planning (ACP) improves patient-provider communication and aligns care to patient values, preferences, and goals. Within a multisite Meta-network Learning and Research Center ACP study, one health system deployed an electronic health record (EHR) notification and algorithm to alert providers about patients potentially appropriate for ACP and the clinical study. OBJECTIVE: The aim of the study is to describe the implementation and usage of an EHR notification for referring patients to an ACP study, evaluate the association of notifications with study referrals and engagement in ACP, and assess provider interactions with and perspectives on the notifications. METHODS: A secondary analysis assessed provider usage and their response to the notification (eg, acknowledge, dismiss, or engage patient in ACP conversation and refer patient to the clinical study). We evaluated all patients identified by the EHR algorithm during the Meta-network Learning and Research Center ACP study. Descriptive statistics compared patients referred to the study to those who were not referred to the study. Health care utilization, hospice referrals, and mortality as well as documentation and billing for ACP and related legal documents are reported. We evaluated associations between notifications with provider actions (ie, referral to study, ACP not documentation, and ACP billing). Provider free-text comments in the notifications were summarized qualitatively. Providers were surveyed on their satisfaction with the notification. RESULTS: Among the 2877 patients identified by the EHR algorithm over 20 months, 17,047 unique notifications were presented to 45 providers in 6 clinics, who then referred 290 (10%) patients. Providers had a median of 269 (IQR 65-552) total notifications, and patients had a median of 4 (IQR 2-8). Patients with more (over 5) notifications were less likely to be referred to the study than those with fewer notifications (57/1092, 5.2% vs 233/1785, 13.1%; P<.001). The most common free-text comment on the notification was lack of time. Providers who referred patients to the study were more likely to document ACP and submit ACP billing codes (P<.001). In the survey, 11 providers would recommend the notification (n=7, 64%); however, the notification impacted clinical workflow (n=9, 82%) and was difficult to navigate (n=6, 55%). CONCLUSIONS: An EHR notification can be implemented to remind providers to both perform ACP conversations and refer patients to a clinical study. There were diminishing returns after the fifth EHR notification where additional notifications did not lead to more trial referrals, ACP documentation, or ACP billing. Creation and optimization of EHR notifications for study referrals and ACP should consider the provider user, their workflow, and alert fatigue to improve implementation and adoption. TRIAL REGISTRATION: ClinicalTrials.gov NCT03577002; https://clinicaltrials.gov/ct2/show/NCT03577002.

The Use of Templates for Documenting Advance Care Planning Conversations: A Descriptive Analysis.

CONTEXT: While professional societies and expert panels have recommended quality indicators related to advance care planning (ACP) documentation, including using structured documentation templates, it is unclear how clinicians document these conversations. OBJECTIVE: To explore how clinicians document ACP, specifically, which components of these conversations are documented. METHODS: A codebook was developed based on existing frameworks for ACP conversations and documentation. ACP documentation from a hospital medicine quality improvement project conducted from November 2019 to April 2021 were included and assessed. Documentation was examined for the presence or absence of each component within the coding schema. Clinician documented ACP using three different note types: template (only template prompts were used), template plus (authors added additional text to the template), and free text only. ACP note components were analyzed by note type and author department. RESULTS: A total of 182 ACP notes were identified and reviewed. The most common note type was template plus (58%), followed by free text (28%) and template (14%). The most frequent components across all note types were: important relationships to patient (92%), and discussion of life-sustaining treatment preferences (87%). There was considerable heterogeneity in the components across note types. The presence of components focused on treatment decisions and legal paperwork differed significantly between note types (P < 0.05). Components on preference for medical information, emotional state, or spiritual support were rarely included across all note types. CONCLUSION: This study provides a preliminary exploration of ACP documentation and found that templates may influence what information is documented after an ACP conversation.

Using Design Thinking to Promote Goals of Care Conversations With Seriously Ill Patients.

BACKGROUND: Goals of care (GOC) conversations can improve serious illness outcomes such as pain and symptom management and patient satisfaction. PROBLEM: However, we recognized that very few Duke Health patients who died had a GOC conversation documented in the designated electronic health record (EHR) tab. Therefore, in 2020, we set a target that all Duke Health patients who died should have had a GOC conversation documented in a designated EHR tab in the last 6 months of life. INTERVENTION: In developing a strategy to promote GOC conversations, we used two interwoven approaches. The first was RE-AIM, a model for designing, reporting and evaluating health behavior research. The second was less of a model than a way of approaching problems, known as "design thinking." OUTCOMES: We employed both of these approaches in a system-wide effort that achieved a 50% prevalence of GOC conversations in the last 6 months of life. KEY MESSAGE: In combination, simple interventions can have a significant impact on behavior change in an academic health system. LESSONS LEARNED: We found that design thinking techniques offered a useful bridge between RE-AIM strategy and clinical.

Videoconferencing of Movement-Based and Psychologically Informed Interventions for Chronic Pain: A Systematic Review and Horizon Scan.

Introduction: With the coronavirus disease 2019 (COVID-19) pandemic, use of telehealth technology increased dramatically. Nonpharmacological approaches to pain management may be well suited for virtual care. Yet, it is not widely understood if this treatment modality is effective when delivered via videoconferencing. This review examines the effectiveness of movement-based and psychologically informed chronic pain management interventions delivered via videoconferencing compared to in-person care. Methods: Searches of MEDLINE® (via Ovid®), Embase (via Elsevier), CINAHL Complete (via EBSCO), and Cochrane Central Register of Controlled Trials (via Ovid) were performed from inception to June 10, 2021. All articles meeting eligibility criteria were included for data abstraction. Results: Eight thousand two hundred fifty-two citations were identified, and after removing duplicates, 4,661 citations remained. One study investigating acceptance and commitment therapy met eligibility criteria. The noninferiority randomized trial found no statistically significant difference in outcomes between delivery modalities. A horizon scan was conducted to assess planned or recent studies. Horizon scan results yielded six protocols in trial databases, one pilot study, and three published protocols for ongoing studies. Discussion: Findings from this study indicate that virtually delivered pain management is a possible substitute for in-person care. Given the paucity of evidence on this topic, further comparative and adequately powered studies that assess the impact of movement-based and psychologically informed pain management delivered via videoconferencing are needed. Conclusions: Research is needed to understand patient preferences of such interventions within a variety of settings. Such evaluations will be needed to guide clinical and operations practice to optimize equitable deployment and access to high-quality health care delivered via videoconferencing.

Internal Medicine Resident Barriers to Advance Care Planning in the Primary Care Continuity Clinic.

Background: While primary care providers regularly engage in Advance Care Planning (ACP) conversations, it is not well known what challenges resident physicians face to achieving this core competency. Objectives: We aimed to assess resident perceptions of barriers and potential interventions to outpatient ACP. Methods: We distributed an electronic survey to Internal Medicine and Medicine-Psychiatry residents at our institution in 2022. Questions addressed outpatient ACP barriers and potential interventions in several domains: structural issues, personal knowledge, and communication skills. We reported results using descriptive statistics and Wilcoxon rank-sum tests, comparing responses by residency year (interns vs upperyears). Likert-scale responses were dichotomized to a "not at all or slightly" vs "moderate or extreme" barrier or helpful intervention. Results: Of 149 residents, 71 completed the survey (48%). Highest scoring barriers were structural, including 1) lack of clinic time (99%), 2) need to prioritize other medical problems (94%), and 3) lack of patient continuity (62%). Highest scoring interventions included the ability to schedule dedicated ACP visits with themselves (96%) or another clinician (82%). Interns were statistically significantly less confident in their ability to conduct ACP, and more likely to report lack of knowledge (i.e., not understanding ACP, patient prognosis, or how to complete paperwork, P < .05). Conclusions: Residents report significant structural barriers to outpatient ACP, including limitations in time, continuity, and competing medical priorities, that may warrant greater program attention to interventions such as clinic schedules and work-flow. Additional trainings may be most beneficial if targeted to the beginning of intern year.

Prevalence and Characteristics of Australians Complementary Medicine Product Use, and Concurrent Use with Prescription and Over-the-Counter Medications-A Cross Sectional Study.

Data about the characteristics and prevalence of complementary medicine (CM) product use by Australians, including concurrent use with prescription and over-the-counter medications, have not been collected in the last five years. A cross-sectional online survey involving a representative sample of the Australian population was administered in 2021-2022. Of the 2351 survey responses included in this study, 49.4% reported use of a CM product over the previous 12-month period. Of these, 50% reported they always or often used CM products on the same day as a prescription medicine. Participants aged 65 and over were five times more likely to use CMs and other medications on the same day compared to 18-24-year-olds. Lower levels of education and having a chronic illness were also predictors of same-day use. The prevalence and characteristics of CM use by participants was similar to data collected five years ago. The study shows that concurrent use of CM products with prescription medications among older and more vulnerable populations is prevalent and this area requires further research to help ensure appropriate and safe use of CM products.

Clinician Perspectives on Managing Chronic Pain After Curative-Intent Cancer Treatment.

PURPOSE: Among cancer survivors who have completed curative-intent treatment, the high prevalence and adverse consequences of chronic pain are well documented. Yet, research on clinicians' experiences with and perspectives on managing chronic pain among cancer survivors is critically lacking. METHODS: We conducted semistructured interviews with 17 clinicians (six oncology, three palliative care, and eight primary care) affiliated with an academic medical center. Interview questions addressed clinicians' experiences with and perspectives on managing chronic pain (with or without opioid therapy) during the transition from active treatment to survivorship. A multidisciplinary team conducted content analysis of interview transcripts to identify and refine themes related to current practices and challenges in managing chronic pain in this context. RESULTS: Overall, clinicians perceived chronic pain to be relatively uncommon among cancer survivors. Identified challenges included a lack of clarity about which clinician (or clinicians) are best positioned to manage chronic pain among cancer survivors, and (relatedly) complexities introduced by long-term opioid management, with many clinicians describing this practice as outside their skill set. Additionally, although most clinicians recognized chronic pain as a biopsychosocial phenomenon, they described challenges with effectively managing psychosocial stressors, including difficulty accessing mental or behavioral health services for cancer survivors. CONCLUSION: Discovered challenges highlight unmet needs related to cancer survivor-clinician communication about chronic pain and the absence of a chronic pain management home for cancer survivors, including those requiring long-term opioid therapy. Research evaluating routine pain monitoring and accessible, tailored models of multimodal pain care in survivorship may help to address these challenges.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Chinese American Patients.

The Chinese American population is one of the fastest-growing communities in the United States, composed of ∼5.4 million people, and represents ∼5.5% of overseas Chinese populations. With an expected exponential population rise, Chinese American patients who experience serious illness or approach end-of-life (EOL) may find their cultural values influencing the medical care they receive. Palliative care clinicians must recognize diverse cultural beliefs and preferences of Chinese American patients and their families. In this study, we provide 10 cultural pearls to guide the provision of palliative and EOL care for Chinese American patients, including discussions of Chinese traditions, communication strategies for Chinese patients and families, advance care planning, and EOL care beliefs.