Mental Health Support and Screening for Mood Disorders for Caregivers in the Neonatal Intensive Care Unit: Is the Call to Arms being Answered?

OBJECTIVE: Perinatal mood and anxiety disorders (PMADs) affect many NICU parents and are a significant risk factor for maternal suicide. Lack of screening and treatment interferes with infant development and bonding, compounding risks in fragile infants. We aim to describe PMAD screening in level IV NICUs across the Children's Hospitals Neonatal Consortium (CHNC) and to determine the relationship between standardized screening and mental health professionals (MHPs) presence. STUDY DESIGN: We surveyed experts at 44 CHNC NICUs about PMADs screening practices and presence of NICU-specific MHPs. Kruskal Wallis test was used to examine relationships. RESULTS: Of 44 centers, 34 (77%) responded. 14 centers (41%) perform screening with validated tools. 13 (38%) centers have NICU-dedicated psychologists. Formally-screening centers tend to have higher cumulative MHPs (p=0.089) than informally screening centers. Repeat screening practices were highly variable with no difference in the number of cumulative MHPs. CONCLUSION: Screening practices for PMADs vary across CHNC centers; less than half have additional MHPs beyond social workers. Creating a sustainable model to detect PMADs likely requires more MHPs in NICUs.

Addressing caregiver mental health in the neonatal ICU.

PURPOSE OF REVIEW: The neonatal ICU (NICU) setting is a unique opportunity to not only detect major changes in caregiver mental health through universal perinatal mood and anxiety disorder (PMAD) screening but also intervene with specialized support. We review evidence for addressing caregiver mental health in the NICU, explore current guidelines and models for integrated behavioural health programmes, and describe challenges specific to NICUs, particularly in standalone paediatric hospitals. RECENT FINDINGS: Parents of infants admitted to the NICU are at an increased risk for developing PMADs at rates well above the general postpartum community. Select NICUs within the United States and internationally have recognized the importance of having an embedded psychologist to address caregiver PMADs. However, organizational structures within paediatric healthcare systems are not equipped to manage the logistical, ethical, legal and practical needs of comprehensive caregiver mental health programmes. SUMMARY: To properly address caregiver mental health in NICU settings, clinical and administrative teams must work together to ensure seamless service provision. Systems that facilitate the development of unique parent medical records at the onset of paediatric care are likely to significantly reduce potential liability risks and solve several challenges related to caregiver-focused mental health support in the NICU. VIDEO ABSTRACT: http://links.lww.com/MOP/A70.

Patterns and Predictors of Mortality After Waitlist Dropout of Patients With Hepatocellular Carcinoma Awaiting Liver Transplantation.

BACKGROUND: There is a lack of information about survival after dropout from the liver transplant waiting list. Therefore, we aimed to assess the overall survival, and risk factors for death, after waiting list dropout due to hepatocellular carcinoma (HCC) progression. METHODS: We assessed patients who dropped out of the liver transplant waiting list between 2000 and 2016 in a single, large academic North American center. Patients were divided into 3 groups according to the types of HCC progression: locally advanced disease (LAD), extrahepatic disease (EHD), and macrovascular invasion (MVI). The primary outcome was overall survival. Survival was assessed by the Kaplan-Meier method. Predictors of death after dropout were assessed by multivariable Cox regression. RESULTS: During the study period, 172 patients dropped out due to HCC progression. Of those, 37 (21.5%), 74 (43%), and 61 (35.5%) dropped out due to LAD, EHD, and MVI, respectively. Median survival according to cause of dropout (LAD, EHD, or MVI) was 1.0, 4.4, or 3.3 months, respectively (P = 0.01). Model for End-stage Liver Disease (MELD) score (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.01-1.08), alcoholic liver disease (HR, 1.66; 95% CI, 1.02-2.71), and α-fetoprotein >1000 ng/mL (HR, 1.86; 95% CI, 1.22-2.84) were predictors of mortality after dropout. Dropout due to EHD (HR, 0.61; 95% CI, 0.38-0.98) and undergoing treatment after dropout were protective factors (HR, 0.32; 95% CI, 0.21-0.48) for death. CONCLUSIONS: Patient prognosis after dropout is dismal. However, a subgroup of patients may have longer survival. The present study identifies the patterns of waitlist dropout in patients with HCC and provides evidence for the effectiveness of treatment strategies offered to HCC patients after dropout.

Liver Transplantation for NASH-Related Hepatocellular Carcinoma Versus Non-NASH Etiologies of Hepatocellular Carcinoma.

BACKGROUND: Liver transplant (LT) for nonalcoholic steatohepatitis (NASH) related hepatocellular carcinoma (HCC) is not well characterized in the literature. The aim of the study was to examine characteristics and outcomes of patients who had LT for NASH-HCC (NASH) versus HCC from other liver diseases (non-NASH). METHODS: Using a 2-center retrospective design, all patients from 2004 to 2014 that received LT for HCC were analyzed. Subgroup analysis stratified patients according to Milan criteria. RESULTS: Nine hundred twenty-nine patients were transplanted for HCC. Sixty (6.5%) of 929 had HCC in the context of NASH. There were no significant differences between groups for pretransplant or explant tumor characteristics. The actuarial 1-, 3- and 5-year overall survival was 98%, 96%, and 80% in NASH versus 95%, 84%, and 78% in non-NASH (P = 0.1). No differences in tumor recurrence were observed in patients within and beyond Milan in the NASH group. Multivariate Cox regression demonstrated NASH status to be a protective factor for recurrence among patients with tumors beyond Milan (hazard ratio, 0.21; 95% confidence interval, 0.05-0.86; P = 0.029). CONCLUSION: After LT, outcomes are similar between NASH and non-NASH etiologies for HCC. The hypothesis that patients with more advanced HCC tumors in the context of NASH may have more favorable outcomes after LT has been generated, but requires further study.

Palliative care and active disease management are synergistic in modern surgical oncology.

Palliative care has long been described in medical literature but only recently is being discussed in the surgical domain. Mounting evidence suggests that early integration of palliative care improves patient outcomes and this is especially true of oncology patients. Thus, the pendulum is swinging toward recognizing that palliative care and active disease management are not mutually exclusive but rather synergistic in modern surgical oncology. Here we use a patient vignette to demonstrate the new challenges and possibilities in modern surgical oncology, we then discuss the historic perspective of palliative care and describe how the paradigm is shifting. Finally, we introduce a model that may be beneficial in conceptualizing this new way of thinking about and integrating palliative care into surgical oncology.

Factors affecting family satisfaction with inpatient end-of-life care.

BACKGROUND: Little data exists addressing satisfaction with end-of-life care among hospitalized patients, as they and their family members are systematically excluded from routine satisfaction surveys. It is imperative that we closely examine patient and institution factors associated with quality end-of-life care and determine high-priority target areas for quality improvement. METHODS: Between September 1, 2010 and January 1, 2012 the Canadian Health care Evaluation Project (CANHELP) Bereavement Questionnaire was mailed to the next-of-kin of recently deceased inpatients to seek factors associated with satisfaction with end-of-life care. The primary outcome was the global rating of satisfaction. Secondary outcomes included rates of actual versus preferred location of death, associations between demographic factors and global satisfaction, and identification of targets for quality improvement. RESULTS: Response rate was 33% among 275 valid addresses. Overall, 67.4% of respondents were very or completely satisfied with the overall quality of care their relative received. However, 71.4% of respondents who thought their relative did not die in their preferred location favoured an out-of-hospital location of death. A common location of death was the intensive care unit (45.7%); however, this was not the preferred location of death for 47.6% of such patients. Multivariate Poisson regression analysis showed respondents who believed their relative died in their preferred location were 1.7 times more likely to be satisfied with the end-of-life care that was provided (p = 0.001). Items identified as high-priority targets for improvement included: relationships with, and characteristics of health care professionals; illness management; communication; and end-of-life decision-making. INTERPRETATION: Nearly three-quarters of recently deceased inpatients would have preferred an out-of-hospital death. Intensive care units were a common, but not preferred, location of in-hospital deaths. Family satisfaction with end-of-life care was strongly associated with their relative dying in their preferred location. Improved communication regarding end-of-life care preferences should be a high-priority quality improvement target.

Interpreting principal components in biomechanics: representative extremes and single component reconstruction.

Principal component analysis is a powerful tool in biomechanics for reducing complex multivariate datasets to a subset of important parameters. However, interpreting the biomechanical meaning of these parameters can be a subjective process. Biomechanical interpretations that are based on visual inspection of extreme 5th and 95th percentile waveforms may be confounded when extreme waveforms express more than one biomechanical feature. This study compares interpretation of principal components using representative extremes with a recently developed method, called single component reconstruction, which provides an uncontaminated visualization of each individual biomechanical feature. Example datasets from knee joint moments, lateral gastrocnemius EMG, and lumbar spine kinematics are used to demonstrate that the representative extremes method and single component reconstruction can yield equivalent interpretations of principal components. However, single component reconstruction interpretation cannot be contaminated by other components, which may enhance the use and understanding of principal component analysis within the biomechanics community.

Interjoint coordination and the personal lift-assist device.

It has been suggested that interjoint coordination may serve to reduce joint stress and muscular demand and to maintain balance during dynamic lifting tasks, thus having implications for safe lifting practices. Before recommending the use of an on-body ergonomic aid, the Personal Lift-Assist Device (PLAD), it is important to determine any effects this device may have on interjoint coordination. Principal component analyses were applied to relative phase angle waveforms, defining the hip-knee and lumbar spine-hip coordination of 15 males and 15 females during a repetitive lifting task. When wearing the PLAD, users lifted with more synchronous hip-knee and lumbar spine-hip coordination patterns (P < .01). Furthermore, increases in load caused less synchronized interjoint coordination at both the hip-knee and lumbar spine-hip during the up and down phases of the lift (P < .01) for all conditions. No significant main effects of sex or significant interactions were observed on any of the outcome variables.

Local dynamic stability of trunk movements during the repetitive lifting of loads.

The local dynamic stability of trunk movements was assessed during repetitive lifting using nonlinear Lyapunov analyses. The goal was to assess how varying the load-in-hands affects the neuromuscular control of lumbar spinal stability. Thirty healthy participants (15M, 15F) performed repetitive lifting at 10 cycles per minute for three minutes under two load conditions: zero load and 10% of each participant's maximum back strength. Short- and long-term maximum finite-time Lyapunov exponents (λ(max-s) and λ(max-l)), describing responses to infinitesimally small perturbations, were calculated from the measured trunk kinematics to estimate the local dynamic stability of the system. Kinematic variability was also assessed using mean standard deviations (MeanSD) across cycles. The results of a mixed-design repeated-measures ANOVA showed that increasing the load lifted significantly reduced λ(max-s) (µ(0%-LOAD)=0.379, µ(10%-LOAD)=0.335, p<.001), but not λ(max-l) (µ(0%-LOAD)=0.46E-03, µ(10%-LOAD)=2.41E-03, p=.055) or MeanSD (µ(0%-LOAD)=2.57, µ(10%-LOAD)=2.89, p=.164). There were no between-subject effects of sex, or significant interactions (α<.05). The present findings indicated improved dynamic spinal stability when lifting the heavier load; meaning that as muscular and moment demands increased, so too did participants' abilities to respond to local perturbations. These results support the notion of greater spinal instability during movement with low loads due to decreased muscular demand and trunk stiffness, and should aid in understanding how lifting various loads contributes to occupational low back pain.

Local dynamic stability of the lifting kinematic chain.

While a stable trunk and centre of mass (CoM) trajectory are required during lifting, it is unclear how stability is controlled. Thirty healthy participants (15M, 15F) performed repetitive, symmetric lifting at 10 cycles per minute for 3 min with a load-in-hands equivalent to 10% of their maximum back strength. Short- and long-term maximum finite-time Lyapunov exponents (λ(max-s) and λ(max-l)), describing responses to small (local) perturbations, estimated the local dynamic stability of the foot, shank, thigh, pelvis, lower back, and upper back segments. Instability (λ(max-s)) significantly increased when moving up the kinematic chain (p<0.001). Therefore, to maintain trunk equilibrium and accurately regulate CoM trajectory during lifting, stability of the distal (fixed) lower limb segments is prioritized. This is contrary to previous results observed during gait, indicating that trunk control via kinematic chain stability is accomplished differently for walking and lifting.

The personal lift-assist device and lifting technique: a principal component analysis.

The personal lift-assist device (PLAD) is a non-motorised, on-body device that acts as an external force generator using the concept of stored elastic energy. In this study, the effect of the PLAD on the lifting kinematics of male and female lifters was investigated using principal component analysis. Joint kinematic data of 15 males and 15 females were collected using an opto-electronic system during a freestyle, symmetrical-lifting protocol with and without wearing the PLAD. Of the 31 Principal Components (PCs) retained in the models, eight scores were significantly different between the PLAD and no-PLAD conditions. There were no main effects for gender and no significant interactions. Results indicated that the PLAD similarly affected the lifting kinematics of males and females; demonstrating significantly less lumbar and thoracic flexion and significantly greater hip and ankle flexion when wearing the PLAD. These findings add to the body of work that suggest the PLAD may be a safe and effective ergonomic aid. STATEMENT OF RELEVANCE: The PLAD is an ergonomic aid that has been shown to be effective at reducing low back demands during manual materials handling tasks. This body of work establishes that the PLAD encourages safe lifting practices without adversely affecting lifting technique.

Does the personal lift-assist device affect the local dynamic stability of the spine during lifting?

The personal lift-assist device (PLAD) is an on-body ergonomic aid that reduces low back physical demands through the restorative moment of an external spring element, which possesses a mechanical advantage over the erector spinae. Although the PLAD has proven effective at reducing low back muscular demand, spinal moments, and localized muscular fatigue during laboratory and industrial tasks, the effects of the device on the neuromuscular control of spinal stability during lifting have yet to be assessed. Thirty healthy subjects (15M, 15F) performed repetitive lifting for three minutes, at a rate of 10 lifts per minute, with and without the PLAD. Maximum finite-time Lyapunov exponents, representing short-term (λ(max-s)) and long-term (λ(max-l)) divergence were calculated from the measured trunk kinematics to estimate the local dynamic stability of the lumbar spine. Using a mixed-design repeated-measures ANOVA, it was determined that wearing the PLAD did not significantly change λ(max-s) (µ(NP)=0.335, µ(P)=0.321, p=0.225), but did significantly reduce λ(max-l) (µ(NP)=0.0024, µ(P)=-0.0011, p=0.014, η(2)=0.197). There were no between-subject effects of sex, or significant interactions (p>0.720). The present results indicated that λ(max-s) was not statistically different between the device conditions, but that the PLAD significantly reduced λ(max-l) to a negative (stable) value. This shows that subjects' neuromuscular systems were able to respond to local perturbations more effectively when wearing the device, reflecting a more stable control of spinal movements. These findings are important when recommending the PLAD for long-term industrial or clinical use.