Patient experiences switching from in-clinic to self-administration of injectable contraception in two Western US states.

OBJECTIVE: We describe the experiences and preferences of women who switched from clinic-administered intramuscular depot medroxyprogesterone acetate (DMPA-IM) to self-administered subcutaneous DMPA (DMPA-SC) in the context of the COVID-19 pandemic. METHODS: We conducted interviews with women in California and Washington about their experiences with self-administered DMPA-SC. We interviewed women after their first or second self-administered DMPA-SC injection and conducted follow-up interviews after their third or fourth injection. We performed both thematic and descriptive content analyses. RESULTS: We completed 29 interviews with 15 women. Most participants (n = 10) were between the ages of 20 and 39 and the majority (n = 12) used DMPA primarily for contraception. Most (n = 13) described self-administered DMPA-SC as "very easy" or "somewhat easy" to use and reported greater convenience, decreased pain, fewer logistical and financial challenges, increased privacy, and improved comfort with injection compared to DMPA-IM. Participants identified difficulties obtaining DMPA-SC from pharmacies and safe needle disposal as barriers. Most (n = 13) would recommend DMPA-SC to a friend and desired to continue self-administration beyond the COVID-19 pandemic. Participants recommended counseling all patients about this option alongside other contraceptive methods, and offering clinician supervision, if desired. CONCLUSION: Women who switched from in-clinic DMPA-IM to self-administered DMPA-SC during the COVID-19 pandemic preferred the latter and intended to continue self-administration. Self-administration of DMPA-SC should be routinely offered and easily accessible to patients.

The Role of Digital Technologies in Facilitating Psychosocial Resilience to Sudden Social Isolation Among Older Adults: Lessons Learned from the COVID-19 Pandemic.

This study investigated how older adults adopted new technologies in response to sudden social isolation caused by the COVID-19 pandemic and how this adoption was related to their long-term psychosocial well-being. The study involved a 6-month longitudinal survey of 151 older adults and two phone-based focus groups, which informed a semi-structured interview guide and purposive sampling of diverse community-dwelling older adults. We then conducted twenty qualitative interviews and thematic analysis and mapped themes to 6-month quantitative trajectories of psychosocial health. Three themes emerged: first, most participants adopted multiple technologies to maintain social connection and psychosocial well-being. Second, participants felt left behind by certain technologies due to complicated systems or ageist societal norms. Third, pandemic-related community resources promoted technology independence among isolated older adults and those wanting to avoid "burdening" family. Results challenge ageist stereotypes and provide a framework for encouraging access and comfort with multiple technologies to adapt to sudden health crises or disruptive events.

Are empathic processes mechanisms of pregnancy's protective effect on smoking? Identification of a novel target for preventive intervention.

BACKGROUND: Spontaneous cessation and reduction in smoking by pregnant women suggest that concern about others, or empathy, could be a malleable target for intervention. We examined various empathy-related processes in relations to reported and biochemically assessed smoking during pregnancy. METHODS: Participants were 154 pregnant women (M = 12.4 weeks gestation, SD = 4.6) who were smoking cigarettes immediately prior to pregnancy recognition (85 had quit and 69 were still smoking at enrollment). Empathy-related processes were measured with performance-based paradigms (affect sharing, empathic concern, and theory of mind) and a speech sample (expressed emotion). Smoking was assessed with timeline follow back interviews and urine cotinine assays. Using zero-inflated Poisson regression models, we tested direct and interactive effects of empathy-related processes with respect to biologically verified smoking cessation (zero portion); and mean cigarettes/day smoked after pregnancy recognition among persistent smokers (count portion). RESULTS: Affect sharing was inversely related to post-recognition cigarettes/day (B(SE) = -0.17(0.07), 95%C.I. -0.30,-0.04, p = .011) and moderated the relationship between pre-recognition smoking and post-recognition smoking consistent with a buffering effect (B(SE) = -.17(0.05); 95%C.I. - 0.28,-0.06; p = .002). Other empathy related processes showed neither direct nor interactive effects on smoking outcomes. CONCLUSIONS: Further research is recommended to clarify the role of empathy in pregnancy smoking.

Lithium Pharmacokinetics in the Perinatal Patient With Bipolar Disorder.

The pharmacokinetics of lithium, the gold standard for the treatment of bipolar disorder, are well described in nonpregnant patients. Because lithium is commonly prescribed to women of childbearing age, more data are essential to characterize lithium pharmacokinetics during the perinatal period. Lithium is primarily eliminated by the kidney. As a result, shifts in lithium elimination clearance parallel pregnancy-related changes in glomerular filtration rate. Lithium's narrow therapeutic window increases the risk for therapeutic failure and toxicity when lithium elimination clearance is altered. To characterize the pharmacokinetics of lithium in pregnancy and postpartum, 3 women treated with lithium for bipolar disorder completed serial blood sampling protocols during each trimester of pregnancy and at least once postpartum. The trajectory of lithium elimination clearance, creatinine clearance, and serum lithium concentrations were determined. Manic, depressive, and anxiety symptoms were also assessed at each study visit. Compared to the nonpregnant state, lithium elimination clearance increased an average of 63.5% by the third trimester. Lithium elimination clearance was inversely related to changes in serum lithium concentration. Mood symptoms worsened with declines in serum lithium concentration. Lithium elimination clearance returned to baseline at 4 to 9 weeks postpartum. To maintain lithium effectiveness during pregnancy and prevent toxicity postpartum, lithium therapeutic drug monitoring and dose adjustments are warranted.

Perinatal use of lurasidone for the treatment of bipolar disorder.

Atypical antipsychotics are commonly prescribed for the treatment of severe mental illnesses during pregnancy. Evidence regarding the impact of physiologic changes during pregnancy on the concentration of atypical antipsychotics is limited, specifically in the case of lurasidone. Data to guide dosing in pregnancy that maximizes efficacy and minimizes adverse effects are lacking. This case report presents perinatal changes in the concentration of lurasidone and the implications for Bipolar Disorder (BD) illness course in a primiparous woman. Monitoring of lurasidone serum concentrations and recurrence of BD symptoms after the second trimester of pregnancy until the third postpartum month was completed. Lurasidone serum concentrations ranged from 0 to 4.7 ng/mL during pregnancy and increased to 10-12 ng/mL postpartum. The subject presented with worsening anxiety and depressive symptoms during the second trimester of pregnancy which resulted in a 40 mg daily dose increase during the second half of her pregnancy. Despite the decrease in lurasidone to the preconception dose post-delivery, the concentrations were higher postpartum compared to pregnancy. The decrease in lurasidone serum concentrations during pregnancy may increase the risk of worsening BD symptoms and suggests the need for determination of whether therapeutic monitoring and dose titration during pregnancy decreases illness exacerbation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Social Isolation and Loneliness Among San Francisco Bay Area Older Adults During the COVID-19 Shelter-in-Place Orders.

BACKGROUND/OBJECTIVES: Physical distancing during the COVID-19 pandemic may have unintended, detrimental effects on social isolation and loneliness among older adults. Our objectives were to investigate (1) experiences of social isolation and loneliness during shelter-in-place orders, and (2) unmet health needs related to changes in social interactions. DESIGN: Mixed-methods longitudinal phone-based survey administered every 2 weeks. SETTING: Two community sites and an academic geriatrics outpatient clinical practice. PARTICIPANTS: A total of 151 community-dwelling older adults. MEASUREMENTS: We measured social isolation using a six-item modified Duke Social Support Index, social interaction subscale, that included assessments of video-based and Internet-based socializing. Measures of loneliness included self-reported worsened loneliness due to the COVID-19 pandemic and loneliness severity based on the three-item University of California, Los Angeles (UCLA) Loneliness Scale. Participants were invited to share open-ended comments about their social experiences. RESULTS: Participants were on average aged 75 years (standard deviation = 10), 50% had hearing or vision impairment, 64% lived alone, and 26% had difficulty bathing. Participants reported social isolation in 40% of interviews, 76% reported minimal video-based socializing, and 42% minimal Internet-based socializing. Socially isolated participants reported difficulty finding help with functional needs including bathing (20% vs 55%; P = .04). More than half (54%) of the participants reported worsened loneliness due to COVID-19 that was associated with worsened depression (62% vs 9%; P < .001) and anxiety (57% vs 9%; P < .001). Rates of loneliness improved on average by time since shelter-in-place orders (4-6 weeks: 46% vs 13-15 weeks: 27%; P = .009), however, loneliness persisted or worsened for a subgroup of participants. Open-ended responses revealed challenges faced by the subgroup experiencing persistent loneliness including poor emotional coping and discomfort with new technologies. CONCLUSION: Many older adults are adjusting to COVID-19 restrictions since the start of shelter-in-place orders. Additional steps are critically needed to address the psychological suffering and unmet medical needs of those with persistent loneliness or barriers to technology-based social interaction.

An implementation project to expand access to self-administered depot medroxyprogesterone acetate (DMPA).

OBJECTIVE: To describe the implementation and results of a proactive patient outreach project to offer self-administered, depot medroxyprogesterone (DMPA) subcutaneous (SC) to interested patients at a California safety-net clinic following expanded state Medicaid coverage. STUDY DESIGN: We contacted non-pregnant patients at an urban, safety-net hospital-based primary care clinic who had been prescribed DMPA intramuscular (IM) in the past year to gauge interest in self-administered DMPA-SC. Interested patients received a prescription for DMPA-SC and a telehealth appointment with a clinic provider to learn self-injection. We recorded patient interest in DMPA-SC, completed appointments, and completed first injections. We conducted initial outreach in May, 2020 and recorded appointment attendance and completed injections through August, 2020. RESULTS: Of 90 eligible patients (age 17-54), we successfully contacted and discussed DMPA-SC with 70 (78%). Twenty-six (37%) patients expressed interest in DMPA-SC and scheduled telehealth appointments to learn to self-administer the medication. Fifteen (58%) of those interested (21% of the total) successfully self-injected DMPA-SC. Of the 44 (63%) patients not interested in DMPA-SC, the three most common reasons were fear of self-injection (n = 23 [52%]), wanting to stop DMPA (n = 11 [25%]), and satisfaction with DMPA-IM (n = 6 [14%]). CONCLUSION: There is interest in and successful initiation of self-administered DMPA-SC among patients at an urban safety net hospital-based primary care clinic who have used DMPA-IM in the last year. IMPLICATIONS: Our data provide evidence for the interest and successful first injection rate after offering self-administered DMPA-SC to patients on DMPA-IM. Expanding coverage of self-administered DMPA-SC could increase patient-centeredness and accessibility of contraception as well as reduce patient anxiety around COVID-19 transmission without losing contraceptive access.

Risk-Benefit assessment of infant exposure to lithium through breast milk: a systematic review of the literature.

The continuation of lithium while breastfeeding is a controversial topic, and clinical recommendations vary. A systematic review was completed of available data on lithium and breastfeeding to determine the degree of lithium exposure through breast milk and assess the potential risk to the infant. Databases, including PubMed MEDLINE, Embase, PsycINFO, Web of Science, Scopus, and Cochrane CENTRAL Register of Controlled Trials databases, were searched for articles on lithium and breastfeeding from the start dates of the databases through December 2018. Articles were included if the report included at least one maternal serum/plasma and/or breast milk lithium concentration and one infant serum/plasma lithium concentration. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Twelve articles, all case reports, were selected for inclusion out of 441 articles that were found and 230 that were reviewed from the search. Data are limited on the safety of lithium continuation while breastfeeding. Among the adverse effects reported, it is difficult to differentiate poor outcomes from factors affecting infant health, concomitant medications, and gestational lithium exposure. Recommendations on whether to continue lithium while breastfeeding must be personalized to the individual woman and her infant.

Obstetric patients' perspectives on functional magnetic neuroimaging research in pregnant women.

Magnetic resonance neuroimaging (MRI) studies of healthy pregnant women could identify key mechanisms of spontaneous health behavior changes observed in expectant mothers as novel intervention targets, but are currently unprecedented. As balancing potential benefits of research with unknown risks, including participant perceptions of risk, is foundational to ethical conduct, we surveyed a convenience obstetric sample to understand pregnant women's perspectives on this issue. Respondents were 76 pregnant women (modal age of 30-39 years; 64% multiparous) presenting for obstetric care from April to June 2016 at privately and publicly funded clinics at an urban academic medical center in the Midwestern USA. Following a written description about functional magnetic resonance neuroimaging (fMRI) and its known and unknown risks, women were queried on their willingness to participate in a hypothetical study involving fMRI during pregnancy, and specific concerns about doing so, if hesitant or unwilling. Willingness to participate was "yes" (28.4%, n = 21), "maybe" (28.4%, n = 21), and "no" (43.2%, n = 32). Among those responding "maybe" or "no" (n = 53, 73.6%), 11 women (20.7%) articulated concern about the fetus. Other concerns expressed were time commitment (n = 11, 20.7%) and discomfort being in an MRI machine (n = 4; 7.5%). Pregnant women may be open to participating in research involving MRI provided concerns about fetal health, time, and personal comfort are addressed.

Comparison of the TOFscan and the TOF-Watch SX during Recovery of Neuromuscular Function.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Quantitative neuromuscular monitoring is required to ensure neuromuscular function has recovered completely at the time of tracheal extubation. The TOFscan (Drager Technologies, Canada) is a new three-dimensional acceleromyography device that measures movement of the thumb in multiple planes. The aim of this observational investigation was to assess the agreement between nonnormalized and normalized train-of-four values obtained with the TOF-Watch SX (Organon, Ireland) and those obtained with the TOFscan during recovery from neuromuscular blockade. METHODS: Twenty-five patients were administered rocuronium, and spontaneous recovery of neuromuscular blockade was allowed to occur. The TOFscan and TOF-Watch SX devices were applied to opposite arms. A preload was applied to the TOF-Watch SX, and calibration was performed before rocuronium administration. Both devices were activated, and train-of-four values were obtained every 15 s. Modified Bland-Altman analyses were conducted to compare train-of-four ratios measured with the TOFscan to those measured with the TOF-Watch SX (when train-of-four thresholds of 0.2 to 1.0 were achieved). RESULTS: Bias and 95% limits of agreement between the TOF-Watch SX and the TOFscan at nonnormalized train-of-four ratios between 0.2 and 1.0 were 0.021 and -0.100 to 0.141, respectively. When train-of-four measures with the TOF-Watch SX were normalized, bias and 95% limits of agreement between the TOF-Watch SX and the TOFscan at ratios between 0.2 and 1.0 were 0.015 and -0.097 to 0.126, respectively. CONCLUSIONS: Good agreement between the TOF-Watch SX with calibration and preload application and the uncalibrated TOFscan was observed throughout all stages of neuromuscular recovery.

Explicating the role of empathic processes in substance use disorders: A conceptual framework and research agenda.

ISSUES: Elucidating the role of empathic processes in developmental pathways to substance use disorders could have important implications for prevention. APPROACH: We searched the biomedical and social sciences literature to determine what is known about empathy and psychopathological manifestations of severe lack of empathy in the initiation, development and maintenance of psychoactive substance use. Thirty-seven empirical studies were identified and formally reviewed. KEY FINDINGS: Adults with alcohol and stimulant use disorders exhibited detectable impairments in both cognitive and affective empathy, measured behaviourally, neuroanatomically and by self-report, relative to controls. There were no developmental studies specifically designed to test the role of empathy in substance use pathways, but several studies that included measures of empathy suggest that empathy may be protective. Studies on severe empathic deficits were mixed regarding a unique role of empathy in substance use trajectories, independent of interpersonal style, impulsivity and social deviance. Implications and Conclusions. In the context of findings and methodological limitations of this review, we recommend more rigorous examination of empathy across the spectrum of substance use behaviour. Future work should utilise the following: (i) prospective assessment of empathic capacity in substance abusers during and following treatment; (ii) large, developmentally based prospective designs beginning prior to substance initiation incorporating multiple measures of empathy; (iii) assessment of the moderating role of gender, race and ethnicity; and (iv) prospective study of empathy in children at elevated risk for substance use disorders. [Massey SH, Newmark RL, Wakschlag LS. Explicating the role of empathic processes in substance use disorders: A conceptual framework and research agenda.

Neostigmine Administration after Spontaneous Recovery to a Train-of-Four Ratio of 0.9 to 1.0: A Randomized Controlled Trial of the Effect on Neuromuscular and Clinical Recovery.

BACKGROUND: When a muscle relaxant is administered to facilitate intubation, the benefits of anticholinesterase reversal must be balanced with potential risks. The aim of this double-blinded, randomized noninferiority trial was to evaluate the effect of neostigmine administration on neuromuscular function when given to patients after spontaneous recovery to a train-of-four ratio of 0.9 or greater. METHODS: A total of 120 patients presenting for surgery requiring intubation were given a small dose of rocuronium. At the conclusion of surgery, 90 patients achieving a train-of-four ratio of 0.9 or greater were randomized to receive either neostigmine 40 µg/kg or saline (control). Train-of-four ratios were measured from the time of reversal until postanesthesia care unit admission. Patients were monitored for postextubation adverse respiratory events and assessed for muscle strength. RESULTS: Ninety patients achieved a train-of-four ratio of 0.9 or greater at the time of reversal. Mean train-of-four ratios in the control and neostigmine groups before reversal (1.02 vs. 1.03), 5 min postreversal (1.05 vs. 1.07), and at postanesthesia care unit admission (1.06 vs. 1.08) did not differ. The mean difference and corresponding 95% CI of the latter were -0.018 and -0.046 to 0.010. The incidences of postoperative hypoxemic events and episodes of airway obstruction were similar for the groups. The number of patients with postoperative signs and symptoms of muscle weakness did not differ between groups (except for double vision: 13 in the control group and 2 in the neostigmine group; P = 0.001). CONCLUSIONS: Administration of neostigmine at neuromuscular recovery was not associated with clinical evidence of anticholinesterase-induced muscle weakness. VISUAL ABSTRACT: An online visual overview is available for this article.(Figure is included in full-text article.).

Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery: A Randomized, Double-blinded, Controlled Trial.

BACKGROUND: Patients undergoing spinal fusion surgery often experience severe pain during the first three postoperative days. The aim of this parallel-group randomized trial was to assess the effect of the long-duration opioid methadone on postoperative analgesic requirements, pain scores, and patient satisfaction after complex spine surgery. METHODS: One hundred twenty patients were randomized to receive either methadone 0.2 mg/kg at the start of surgery or hydromorphone 2 mg at surgical closure. Anesthetic care was standardized, and clinicians were blinded to group assignment. The primary outcome was intravenous hydromorphone consumption on postoperative day 1. Pain scores and satisfaction with pain management were measured at postanesthesia care unit admission, 1 and 2 h postadmission, and on the mornings and afternoons of postoperative days 1 to 3. RESULTS: One hundred fifteen patients were included in the analysis. Median hydromorphone use was reduced in the methadone group not only on postoperative day 1 (4.56 vs. 9.90 mg) but also on postoperative days 2 (0.60 vs. 3.15 mg) and 3 (0 vs. 0.4 mg; all P< 0.001). Pain scores at rest, with movement, and with coughing were less in the methadone group at 21 of 27 assessments (all P = 0.001 to < 0.0001). Overall satisfaction with pain management was higher in the methadone group than in the hydromorphone group until the morning of postoperative day 3 (all P = 0.001 to < 0.0001). CONCLUSIONS: Intraoperative methadone administration reduced postoperative opioid requirements, decreased pain scores, and improved patient satisfaction with pain management.

Perspectives from Patients and Healthcare Providers on the Practice of Maternal Placentophagy.

PURPOSE: Placentophagy (maternal consumption of the placenta) has become increasingly prevalent in the past decade among women seeking to promote health and healing during the postpartum period. The purpose of this study was to assess patient and provider familiarity with and attitudes toward placentophagy, as well as patients' willingness to try placentophagy. METHODS: Two cross-sectional surveys with questions regarding placentophagy practice were distributed to healthcare providers and patients. The provider survey was distributed via email listservers to international perinatal professional organizations and to obstetrics and gynecology, nurse midwifery, family medicine, and psychiatry departments at three urban hospitals. Patient surveys were administered in person at an urban hospital in Chicago, Illinois. RESULTS: Approximately two thirds (66%; n = 100) of patients and most (89%; n = 161) of providers were familiar with placentophagy. Patients with a history of a self-reported mental health disorder were more likely to be willing to consider placentophagy and to believe that healthcare providers should discuss it with their patients. CONCLUSIONS: Most providers and patients have heard of placentophagy but are unsure of its benefits and/or risks. Further research examining the potential therapeutic efficacy and/or risks of placentophagy is needed.