Advancing Beyond the Hippocampus to Preserve Cognition for Patients With Brain Metastases: Dosimetric Results From a Phase 2 Trial of Memory-Avoidance Whole Brain Radiation Therapy.

Purpose: Recent advances to preserve neurocognitive function in patients treated for brain metastases include stereotactic radiosurgery, hippocampal avoidance whole brain radiation therapy (WBRT), and memantine administration. The hippocampus, corpus callosum, fornix, and amygdala are key neurocognitive substructures with a low propensity for brain metastases. Herein, we report our preliminary experience using a "memory-avoidance" WBRT (MA-WBRT) approach that spares these substructures for patients with >15 brain metastases. Methods and Materials: Ten consecutive patients treated with MA-WBRT on a phase 2 clinical trial were reviewed. In each patient, the hippocampi, amygdalae, corpus callosum, and fornix were contoured. Patients were not eligible for MA-WBRT if they had metastases in these substructures. A memory-avoidance region was created using a 5-mm volumetric expansion around these substructures. Hotspots were avoided in the hypothalamus and pituitary gland. Coverage of brain metastases was prioritized over memory avoidance dose constraints. Dose constraints for these avoidance structures included a D100% ≤ 9 Gy and D0.03 cm3 ≤ 16 Gy (variation acceptable to 20 Gy). LINAC-based volumetric modulated arc therapy plans were generated for a prescription dose of 30 Gy in 10 fractions. Results: On average, the memory avoidance structure volume was 37.1 cm3 (range, 25.2-44.6 cm3), occupying 2.5% of the entire whole brain target volume. All treatment plans met the D100% dose constraint, and 8 of 10 plans met the D0.03 cm3 constraint, with priority given to tumor coverage for the remaining 2 cases. Target coverage (D98% > 25 Gy) and homogeneity (D2% ≤ 37.5 Gy) were achieved for all plans. Conclusions: Modern volumetric modulated arc therapy techniques allow for sparing of the hippocampus, amygdala, corpus callosum, and fornix with good target coverage and homogeneity. After enrollment is completed, quality of life and cognitive data will be evaluated to assess the efficacy of MA-WBRT to mitigate declines in quality of life and cognition after whole brain radiation.

Parental, caregiving, and family leave during clinical neuropsychology postdoctoral training: Recommendations and guidelines from the Women in Neuropsychology (WIN) committee and Education Advisory Committee (EAC) of the Society for Clinical Neuropsychology (SCN; APA division 40).

Objective: Parental and other caregiving leave is important to postdoctoral fellows, yet there is no field-wide recommendation for leave policies among clinical neuropsychology postdoctoral training programs, which is of particular relevance given the two-year requirement for eligibility for board certification. The aims of this manuscript are to (a) discuss general guidelines and recommendations for leave policies, both informed by prior empirical evidence as well as relevant existing policy guidelines from various academic and healthcare organizations, and (b) use vignettes to provide possible solutions for potential leave scenarios. Method: A critical review of literature on family leave from public policy and political science, industrial-organizational psychology, academic medicine, and psychology was conducted and findings were synthesized. Results and Conclusions: Fellowship training programs are encouraged to adopt a competency-based model that permits flexibility in leave during training without necessarily requiring an extended end date. Programs should adopt clear policies and make this information readily available to trainees and think flexibly about training options that best meet the training needs and goals of each individual. We also encourage neuropsychologists at all levels to engage in advocacy for broader systemic supports of trainees seeking equitable family leave.

Productivity measurement in psychology and neuropsychology: Existing standards and alternative suggestions.

Objective: The Relative Value Unit (RVU) system was initially developed to account for costs associated with clinical services and has since been applied in some settings as a metric for monitoring productivity. That practice has come under fire in the medical literature due to perceived flaws in determination of "work RVU" for different billing codes and negative impacts on healthcare rendered. This issue also affects psychologists, who bill codes associated with highly variable hourly wRVUs. This paper highlights this discrepancy and suggests alternative options for measuring productivity to better equate psychologists' time spent completing various billable clinical activities. Method: A review was performed to identify potential limitations to measuring providers' productivity based on wRVU alone. Available publications focus almost exclusively on physician productivity models. Little information was available relating to wRVU for psychology services, including neuropsychological evaluations, specifically. Conclusions: Measurement of clinician productivity using only wRVU disregards patient outcomes and under-values psychological assessment. Neuropsychologists are particularly affected. Based on the existing literature, we propose alternative approaches that capture productivity equitably among subspecialists and support provision of non-billable services that are also of high value (e.g. education and research).

Diverse experiences and approaches to tele neuropsychology: Commentary and reflections over the past year of COVID-19.

Objectives: In response to the coronavirus disease 2019 (COVID-19) pandemic, neuropsychologists rapidly adopted teleneuropsychology (TeleNP) services to ensure continued clinical care. Prior to COVID-19, TeleNP was not widely used nor was it included in the majority of traditional practice or training models across graduate, internship, and postdoctoral programs. Out of necessity, the pandemic was a catalyst that promoted greater adoption of TeleNP services. In response, neuropsychological guidelines for modified assessments were developed and further empirical studies have been published. Numerous surveys in response to service delivery changes during COVID-19 now exist, but what follows is a commentary based on neuropsychologists' experiences with adapting clinical practice to TeleNP. Methods: Co-authors represent settings across academic medical centers, Veterans Affairs hospitals, and private practices that serve multiculturally diverse pediatric, adult, and geriatric populations in the United States. Results: The perspectives within this commentary aim to highlight the growth of TeleNP and highlight lessons learned from implementation across practice settings. Conclusions: Our goal is to help foster the development of further empirical studies through candid discussion of various TeleNP experiences and approaches. Through this reflective process, TeleNP presents both opportunities and challenges but it ultimately has potential to reduce healthcare disparities and enhance patient care.

A qualitative study of injection and sexual risk behavior among unstably housed people who inject drugs in the context of an HIV outbreak in Northeast Massachusetts, 2018.

BACKGROUND: To investigate the underlying causes of a sudden increase in HIV among people who inject drugs (PWID) and initiate an appropriate response to the outbreak, we engaged in in-depth qualitative interviews with members of the PWID community in Lawrence and Lowell, Massachusetts. METHODS: We interviewed 34 PWID who were currently or recently unstably housed, then transcribed interviews and coded transcripts, grouping codes into categories from which we identified key themes. RESULTS: Participants described a heightened threat of overdose prompting PWID to inject together, increasing opportunities for sharing injection equipment. There were misunderstandings about safe injection practices to prevent HIV transmission and a low threshold for injection-related risk taking. Stigma regarding HIV prevented conversations about HIV status. Less thought was given to sexual risks than injection-related risks for HIV transmission. CONCLUSIONS: We found multiple facilitators of HIV transmission. Additional HIV education and prevention interventions focusing on both injection and sexual risk practices would benefit this population, in addition to structural interventions such as increased access and availability of syringe service programs.

Opioid Use Fueling HIV Transmission in an Urban Setting: An Outbreak of HIV Infection Among People Who Inject Drugs-Massachusetts, 2015-2018.

Objectives. To describe and control an outbreak of HIV infection among people who inject drugs (PWID).Methods. The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors.Results. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses.Conclusions. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response.Public Health Implications. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative.

Monitoring of Neurocognitive Function in the Care of Patients with Brain Tumors.

PURPOSE OF REVIEW: A detailed characterization of the nature of neurocognitive impairment in patients with brain tumors is provided, as well as considerations for clinical practice regarding neuropsychological assessment throughout the disease course. RECENT FINDINGS: Neurocognitive impairment is common in patients with brain tumors and may result from the tumor itself, as a consequence of treatment, including surgery, chemotherapy, and radiation, or in association with supportive care medications (e.g., anticonvulsant and pain medications). Serial surveillance of neurocognitive functioning in this population can facilitate medical decision-making and inform recommendations to improve patient daily functioning and quality of life. Neuropsychological assessment is increasingly recognized as a critical component of the multidisciplinary care of patients with brain tumors and has already had practice-changing effects. Further understanding of genetic risk factors for neurocognitive decline along with the development of novel assessment and intervention strategies may further enhance functioning and general well-being in this patient population.

Resilience, condom use self-efficacy, internalized homophobia, and condomless anal sex among black men who have sex with men, New York City.

BACKGROUND: Black men who have sex with men, who account for less than 1% of the U.S. population, account for approximately 25% of new HIV infections annually. Condomless anal sex contributes to HIV infection among black men who have sex with men. The capacity to recover quickly from difficulties (resilience) may be protective against condomless anal sex, but has been understudied among black men who have sex with men. Psychosocial factors related to resilience, i.e., condom use self-efficacy and internalized homophobia, may also affect condomless anal sex. We assessed the association between resilience, condom use self-efficacy, internalized homophobia and condomless anal sex among black men who have sex with men. METHODS: Data are from a 2010-2011 study examining condomless anal sex (past 60 days) among black men who have sex with men in New York City. Validated scales assessed resilience (theoretical range = 0-100), condom use self-efficacy (theoretical range = 27-135), and internalized homophobia (theoretical range = 9-36). We described continuous variables using median and interquartile range (IQR). Univariable and multivariable Poisson regression models assuming a robust variance estimator were used to compute unadjusted and adjusted prevalence ratios, respectively, and their corresponding 95% confidence intervals (CI). Adjusted prevalence ratios (aPR) examined the association of resilience, condom use self-efficacy, and internalized homophobia with condomless anal sex, while controlling for potential confounders (e.g., having >1 sex partner). RESULTS: The median resilience score within our sample (N = 228) was 75 (IQR = 66-83). Many black men who have sex with men reported condomless anal sex (55.7%) and >1 sex partner (58.8%). Decreased condomless anal sex was associated with increased levels of condom use self-efficacy (aPR: 0.94 per 10-point increase in condom use self-efficacy score; CI: 0.90-0.97; p-value: 0.001). Condomless anal sex was not associated with resilience or internalized homophobia. CONCLUSIONS: Within this sample of black men who have sex with men, condomless anal sex was prevalent. Greater resilience was not protective against condomless anal sex. Interventions that support condom use are warranted for black men who have sex with men.

Executive Functioning at Baseline Prospectively Predicts Depression Treatment Response.

OBJECTIVE: Existing cognitive and clinical predictors of treatment response to date are not of sufficient strength to meaningfully impact treatment decision making and are not readily employed in clinical settings. This study investigated whether clinical and cognitive markers used in a tertiary care clinic could predict response to usual treatment over a period of 4 to 6 months in a sample of 75 depressed adults. METHODS: Patients (N = 384) were sequentially tested in 2 half-day clinics as part of a quality improvement project at an outpatient tertiary care center between August 2003 and September 2007; additional subjects evaluated in the clinic between 2007 and 2009 were also included. Diagnosis was according to DSM-IV-TR criteria and completed by residents and attending faculty. Test scores obtained at intake visits on a computerized neuropsychological screening battery were the Parametric Go/No-Go task and Facial Emotion Perception Task. Treatment outcome was assessed using 9-item Patient Health Questionnaire (PHQ-9) self-ratings at follow-up (n = 75). Usual treatment included psychotropic medication and psychotherapy. Decline in PHQ-9 scores was predicted on the basis of baseline PHQ-9 score and education, with neuropsychological variables entered in the second step. RESULTS: PHQ-9 scores declined by 46% at follow-up (56% responders). Using 2-step multiple regression, baseline PHQ-9 score (P ≤ .05) and education (P ≤ .01) were significant step 1 predictors of percent change in PHQ-9 follow-up scores. In step 2 of the model, faster processing speed with interference resolution (go reaction time) independently explained a significant amount of variance over and above variables in step 1 (12% of variance, P < .01), while other cognitive and affective skills did not. This 2-step model accounted for 28% of the variance in treatment change in PHQ-9 scores. Processing speed with interference resolution also accounted for 12% variance in treatment and follow-up attrition. CONCLUSIONS: Use of executive functioning assessments in clinics may help identify individuals with cognitive weaknesses at risk for not responding to standard treatments.

Shared dimensions of performance and activation dysfunction in cognitive control in females with mood disorders.

Major depressive disorder and bipolar disorder share symptoms that may reflect core mood disorder features. This has led to the pursuit of intermediate phenotypes and a dimensional approach to understand neurobiological disruptions in mood disorders. Executive dysfunction, including cognitive control, may represent a promising intermediate phenotype across major depressive disorder and bipolar disorder. This study examined dimensions of cognitive control in women with major depressive disorder or bipolar disorder in comparison to healthy control subjects using two separate, consecutive experiments. For Experiment 1, participants completed a behavioural cognitive control task (healthy controls = 150, major depressive disorder = 260, bipolar disorder = 202; age range 17-84 years). A sample of those participants (healthy controls = 17, major depressive disorder = 19, and bipolar disorder = 16) completed a similar cognitive control task in an event-related design functional magnetic resonance imaging protocol for Experiment 2. Results for Experiment 1 showed greater impairments on the cognitive control task in patients with mood disorders relative to healthy controls (P < 0.001), with more of those in the mood disorder group falling into the 'impaired' range when using clinical cut-offs (<5th percentile). Experiment 2 revealed only a few areas of shared activation differences in mood disorder greater than healthy controls. Activation analyses using performance as a regressor, irrespective of diagnosis, revealed within and extra-network areas that were more active in poor performers. In summary, performance and activation during cognitive control tasks may represent an intermediate phenotype for mood disorders. However, cognitive control dysfunction is not uniform across women with mood disorders, and activation is linked to performance more so than disease. These findings support subtype and dimensional approaches to understanding risk and expression of mood disorders and are a promising area of inquiry, in line with the Research Domain Criteria initiative of NIMH.

Impulsivity predicts time to reach euthymia in adults with bipolar disorder.

OBJECTIVES: Specific demographic and illness characteristics have been identified as predictors of overall morbidity and treatment course among individuals with bipolar disorder. However, the role of specific cognitive limitations on disease severity and treatment response is unclear. The present study evaluated whether impulsiveness during acute mania was a significant predictor of achieving euthymia within one year following psychiatric hospitalization. METHODS: Participants were 94 adult inpatients (60 manic) with bipolar I disorder. Baseline symptom severity was assessed using the Young Mania Rating Scale and the Montgomery-Åsberg Depression Rating Scale. Impulsivity was measured with the Stop Signal Task, Degraded Stimulus Continuous Performance Task, Delayed Response Task, and Barratt Impulsiveness Scale-11. RESULTS: Individual predictors of time to reach euthymia included fewer depressive symptoms and better impulse control at baseline, later age at illness onset, shorter illness duration, and the absence of comorbid attention-deficit hyperactivity disorder. Self-reported impulsivity was a significant independent predictor of time to euthymia, even after accounting for relevant clinical variables. CONCLUSIONS: Better trait impulse control may be associated with better treatment responsiveness among adults with bipolar disorder.

Behavior regulation and mood predict social functioning among healthy young adults.

Impulsive behavior is thought to lead to both positive and negative psychosocial outcomes. However, little is known about the potential consequences of subclinical expressions of behavior dysregulation on everyday functioning. To examine this relationship, global social functioning was measured in 89 healthy, young adults who also completed the Degraded Stimulus Continuous Performance Test, Color-Word Interference Test, Barratt Impulsiveness Scale, 11th Edition, and Behavior Rating Inventory of Executive Functioning-Adult. Better self-reported executive functioning and mood were significant independent predictors of higher social functioning, even in a sample of healthy adults. The results of this study may serve as a foundation for comparison with clinical populations who demonstrate greater behavior dysregulation and mood instability.