Responsive Feeding Practices to Promote Healthy Diets: A Mixed Method Study among Low-Income Caregivers with Toddlers.

Responsive feeding (RF), the reciprocal feeding approach between caregiver and child that promotes child health, is understudied among low-income caregivers. This mixed methods study with low-income caregivers of 12-to-36-month-olds aimed to (1) assess variability in RF and associations with children's dietary intake, and (2) explore caregivers' perceptions of RF. Caregivers (n = 134) completed an online survey with RF questions (n = 25), grouped into environmental (meal environment, caregiver modeling, caregiver beliefs) and child (self-regulation, hunger/satiety cues, food for reward, food acceptance) influences scores. Children's recent food group consumption was loaded onto healthy and less healthy intake scores. In an adjusted multiple linear regression analysis, greater RF scores for environmental and child influences were associated with greater healthy intake scores (p's < 0.01). Greater scores for environmental influences were also associated with lower scores for unhealthy intake (p < 0.01). From focus groups with a separate sample of caregivers (n = 24), thematic analysis uncovered that two themes aligned (trust in child cues, positive strategies to encourage children to eat non-preferred foods) and two misaligned (lack of trust in child cues, use of force/bribery) with RF. Complementary integration of quantitative and qualitative findings can inform future interventions with low-income caregivers, encouraging trust in young children's hunger/satiety cues and positive strategies for food acceptance to improve diet quality.

Negotiating Complexity: Challenges to Implementing Community-Led Nature-Based Solutions in England Pre- and Post-COVID-19.

Nature-based solutions (NbS), including green social prescribing (GSP), are sustainable ways to address health and wellbeing, especially since the COVID-19 pandemic exacerbated the strain on healthcare. NbS require national and local cross-sector coordination across complex, interrelated systems, but little is known about the specific challenges this poses for community-led NbS. We carried out a traditional literature review to establish the context and knowledge base for this study and interviewed 26 stakeholders. These came from environment, health and social care sectors at national and local levels, with local-level stakeholders from Bradford and Walsall: English cities significantly affected by the pandemic, with high levels of deprivation and health inequality. The interviews explored experiences of implementing NbS, both pre- and post-pandemic and the resulting renewed interest in the salutogenic effects of engaging with natural environments. We coded the interview transcriptions using NVivo to identify the challenges existing in the systems within which these stakeholders operate to create and manage NbS. By synthesizing what is known about the challenges from existing literature with findings from the interviews, we developed eight categories of challenges (perception and knowledge, political, financial, access to natural spaces, engagement, institutional and organisational, coordination, GSP referral and services) faced by multiple sectors in implementing community-led NbS in England. Furthermore, this study highlights the new challenges related to the pandemic. Identifying these challenges helps stakeholders in existing complex systems recognise what is needed to support and mainstream NbS in England.

Gender differences in the prevalence of frailty in heart failure: A systematic review and meta-analysis.

OBJECTIVES: This study quantitatively synthesized literature to identify gender differences in the prevalence of frailty in heart failure (HF). BACKGROUND: The intersection of frailty and HF continues to garner interest. Almost half of patients with HF are frail; however, gender differences in frailty in HF are poorly understood. METHODS: We performed a literature search to identify studies that reported prevalence of frailty by gender in HF. Random-effects meta-analysis was used to quantify the relative and absolute risk of frailty in women compared with men with HF, overall, and by Physical and Multidimensional Frailty measures. Meta-regression was performed to examine the influence of study age and functional class on relative risk in HF. RESULTS: Twenty-nine studies involving 8854 adults with HF were included. Overall in HF, women had a 26% higher relative risk of being frail compared with men (95% CI = 1.14-1.38, z = 4.69, p < 0.001, I2 = 76.5%). The overall absolute risk for women compared to men with HF being frail was 10% (95% CI = 0.06-0.15, z = 4.41, p < 0.001). The relative risk of frailty was slightly higher among studies that used Physical measures (relative risk = 1.27, p < 0.001) compared with studies that used Multidimensional measures (relative risk = 1.24, p = 0.024). There were no significant relationships between relative risk and either study age or functional class. CONCLUSIONS: In HF, frailty affects women significantly more than men. Future work should focus on elucidating potential causes of gender differences in frailty in HF.

Patient Perspectives on Telepsychiatry on the Inpatient Psychiatric Unit During the COVID-19 Pandemic.

Hospitals have eliminated many in-person interactions and established new protocols to stem the spread of COVID-19. Inpatient psychiatric units face unique challenges, as patients cannot be isolated in their rooms and are at times unable to practice social distancing measures. Many institutions have experimented with providing some psychiatric services remotely to reduce the number of people physically present on the wards and decrease the risk of disease transmission. This case report presents 2 patient perspectives on receiving psychiatric care via videoconferencing while on the inpatient unit of a large academic tertiary care hospital. One patient identified some benefits to virtual treatment while the second found the experience impersonal; both were satisfied with the overall quality of care they received and were stable 2 weeks after discharge. These cases demonstrate that effective care can be provided remotely even to severely ill psychiatric patients who require hospitalization.

The psychopharmacology of brain vascular disease/poststroke depression.

Poststroke depression (PSD) is a frequent complication and source of suffering among stroke survivors. Assessment of mood, suicidal ideation, and other neuropsychiatric disturbances that can co-occur or share similar features with depression are important aspects of clinical stroke care. Pharmacotherapy is the first-line treatment of PSD, with selective serotonin reuptake inhibitors (SSRIs) being agents of first choice. The evidence for SSRIs, newer generation antidepressants, and tricyclic antidepressants for PSD will be reviewed with consideration of their side effect profiles and use for other neuropsychiatric comorbidities. Additional therapeutic options, such as cognitive enhancing medications, brain stimulation, and psychotherapy can also be considered. Given the prevalence of PSD, preventive pharmacologic strategies may be effective alternatives. Ultimately, the choice of treatment will be determined by the type and severity of medical and psychiatric comorbidities as well as the preferences of the patient.

Hospice Care in Assisted Living Facilities Versus at Home: Results of a Multisite Cohort Study.

OBJECTIVES: To compare residents of assisted living facilities receiving hospice with people receiving hospice care at home. DESIGN: Electronic health record-based retrospective cohort study. SETTING: Nonprofit hospices in the Coalition of Hospices Organized to Investigate Comparative Effectiveness network. PARTICIPANTS: Individuals admitted to hospice between January 1, 2008, and May 15, 2012 (N = 85,581; 7,451 (8.7%) assisted living facility, 78,130 (91.3%) home). MEASUREMENTS: Hospice length of stay, use of opioids for pain, and site of death. RESULTS: The assisted living population was more likely than the home hospice population to have a diagnosis of dementia (23.5% vs 4.7%; odds ratio (OR) = 13.3, 95% confidence interval (CI) = 12.3-14.4; P < .001) and enroll in hospice closer to death (median length of stay 24 vs 29 days). Assisted living residents were less likely to receive opioids for pain (18.1% vs 39.7%; OR = 0.33, 95% CI = 0.29-0.39, P < .001) and less likely to die in an inpatient hospice unit (9.3% vs 16.1%; OR = 0.53, 95% CI = 0.49-0.58, P < .001) or a hospital (1.3% vs 7.6%; OR = 0.16, 95% CI = 0.13-0.19, P < .001). CONCLUSION: Three are several differences between residents of assisted living receiving hospice care and individuals living at home receiving hospice care. A better understanding of these differences could allow hospices to develop guidelines for better coordination of end-of-life care for the assisted living population.

Staying in the game: the 10-step approach to sustaining geriatrics education in hospitalists and subspecialty providers.

Geriatrics as a field has been fortunate to have the support of several philanthropic organizations to advance geriatrics education and training in the past two decades. Awardees of such grants were presented with unparalleled opportunities to develop new and innovative educational initiatives affecting learners at multiple levels and in multiple disciplines and specialties. The lessons learned from the Donald W. Reynolds Foundation initiatives about effect and sustainability are invaluable to the ongoing strategic development of geriatrics nationally. This article highlights successful educational initiatives developed at four institutions with past and current Donald W. Reynolds Foundation funding. Following an ice hockey playbook, this article identifies 10 strategies and initiatives to "stay in the geriatrics game" by training hospitalists and subspecialty providers. The authors' collective experience suggests that geriatrics educational initiatives can not only influence provider education, but also improve the care of older adults in multiple settings.

Implantable cardioverter defibrillator deactivation: a hospice quality improvement initiative.

BACKGROUND: Dying patients whose implantable cardioverter defibrillators (ICDs) continue to deliver shocks may experience significant pain, and the National Quality Forum has endorsed routine deactivation of ICDs when patients near the end of life. The overarching goal of this quality improvement project was to increase rates of ICD deactivation among hospice patients. MEASURES: ICD deactivation rates pre- vs. post-intervention; and clinicians' knowledge and confidence regarding ICD management. INTERVENTION: A multifaceted intervention included clinical tools, education, and standardized documentation templates in the electronic medical record. OUTCOMES: The proportion of patients whose ICD was deactivated increased after the intervention (pre- vs. post-intervention: 39/68, 57% vs. 47/56, 84%; odds ratio 3.88; 95% confidence interval 1.54-10.37; P = 0.001). Clinicians' knowledge and confidence regarding ICD management improved (pre- vs. post-intervention median questionnaire scores: 5 vs. 9 on a scale of 0 to 10; Wilcoxon signed-rank test Z = -5.01; P < 0.001). CONCLUSIONS/LESSONS LEARNED: A multifaceted intervention can increase rates of ICD deactivation among patients near the end of life.

Piloting a medical student observational experience with hospital-based trauma chaplains.

INTRODUCTION: Medical students have typically received relatively modest training in approaches for engaging the concerns of patients and families facing life-threatening situations and terminal illnesses. We propose that medical students would perceive benefits to their communication skills, understanding of the role of the chaplain, and knowledge of emotional and spiritual needs of grieving patients and families after shadowing hospital-based trauma chaplains whose work focuses on emergency department traumas and intensive care units. METHODS: The authors developed a pilot program in which medical students shadowed a trauma chaplain during an on-call shift in an urban level 1 trauma center. Students subsequently completed an evaluative survey of their experience. RESULTS: Of 21 participants, 14 (67%) completed the questionnaire. Students observed an average of 1.50 traumas and 3.57 interactions with patients or families. One-third of the students witnessed a death. More than 90% of respondents agreed or strongly agreed that (1) the program provided them with a greater understanding of how to engage patients and families in difficult conversations; (2) they learned about the chaplain's role in the hospital; and (3) the experience was useful for their medical education, careers, and personal development. About two-thirds (9/14) perceived that they learned how to discuss spirituality with patients and families. All recommended the experience be part of the medical school curriculum. DISCUSSION: Observational experiences with hospital-based trauma chaplains might be an effective nondidactic approach for teaching medical students effective communication with patients and families, collaboration with chaplains, and spirituality in patient care.

Geriatric palliative care: do medical students' narrative reflections after a hospice clinical experience link to geriatric competencies?

Since the Association of American Medical Colleges geriatric competencies were released, educators are striving to incorporate them into medical student curricula. The purpose of this study is to examine medical students' reflections after an interdisciplinary, hospice staff-precepted clinical experience, and whether these reflections relate to the geriatric competencies which focus on palliative care. From July 2010 to June 2011, 155 2nd- and 3rd-year medical students participated in a required, half-day hospice experience, with 120 (77%) submitting narrative reflections for analysis. The narratives were analyzed using the constant comparative method associated with grounded theory, followed by consensus-building in an iterative process, to identify themes. Six themes were identified from the analysis of student narratives: demonstrating a new or expanded knowledge of hospice care (79%, 95/120), developing new insights about self and others (74%, 89/120), changing attitudes toward hospice care (63%, 76/120), linking patient needs with appropriate team members (43%, 52/120), understanding patient goals of care (43%, 51/120), and discussing palliative care as a treatment option (27%, 32/120). The authors conclude that a brief, interdisciplinary, hospice staff-precepted clinical experience is an effective model to inspire medical students to reflect on geriatric palliative care. Students clearly reflected on the geriatric palliative care competencies of symptom assessment and management, and gained insight into the role of the hospice team members and how hospice care can be a positive treatment option. Future educators should think about building on this type of high impact learning experience, and developing items to measure application of knowledge gained.

Pilot test of a three-station palliative care observed structured clinical examination for multidisciplinary trainees.

Developing effective communication and symptom assessment skills is an important component of palliative care training for advance practice nurses (APNs) and other health care providers. The purpose of this project was to develop and pilot test a three-station palliative care Observed Structured Clinical Examination (OSCE) for APN students and physician fellows. Three stations included discussing goals of care, breaking bad news, and assessing delirium. Measures included the Interpersonal Skills Tool, Station Checklists, the OSCE Evaluation Tool, and a focus group to solicit learners' perspectives about the experience. Findings showed that learners evaluated the exercise as appropriate for their level of training and that standardized patients were convincing and provided helpful feedback. Learner self-evaluation means were significantly lower than those of standardized patient or faculty, and faculty raters demonstrated low interrater reliability. Initial evaluation suggests a three-station palliative care OSCE exercise is effective for multidisciplinary learners, although additional refinement is necessary.

Dlx5 and Msx2 regulate mouse anterior neural tube closure through ephrinA5-EphA7.

Homeodomain-containing transcription factors Dlx5 and Msx2 are able to form a heterodimer, and together can regulate embryonic development including skeletogenesis. Dlx5 functions as a transcriptional activator and Msx2 a transcriptional repressor, and they share common target genes. During mouse digit development, the expression domains of Dlx5 and Msx2 overlap at the distal region of the developing terminal phalange, although digit formation and regeneration are not altered in the Dlx5 and Msx2 null mutant embryos. Interestingly, we observed a high rate of defects in neural tube formation in Dlx5 and Msx2 double null mutants. In the absence of both Dlx5 and Msx2, a high occurrence of exencephaly and severe defects in craniofacial morphology are observed. Additionally, Dlx5 and Msx2 expression domain analysis showed overlap of the genes at the apex of the neural folds just prior to neural fold fusion. The expression patterns of ephrinA5 and two isoforms of EphA7 were tested as downstream targets of Dlx5 and Msx2. Results show that EphrinA5 and the truncated isoform of EphA7 are regulated by Dlx5 and Msx2 together, although the full length isoform of EphA7 expression is not altered. Overall, these data show that Dlx5 and Msx2 play a critical role in controlling cranial neural tube morphogenesis by regulating cell adhesion via the ephrinA5 and EphA7 pathway.

Utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: determinants of use and barriers to access.

UNLABELLED: Abstract Background: Cancer causes significant symptom burden and diminished quality of life. Despite the expansion of supportive and palliative care services (SPCS), little is known about rates of utilization and barriers to access to these services among oncology outpatients. METHODS: We performed a cross-sectional survey in three outpatient medical oncology clinics. Patients with a diagnosis of breast, lung, or gastrointestinal (GI) cancer and a Karnofsky score of ≥60 were included. Patients reported their use of SPCS and any perceived barriers. Multivariable logistic regression was used to identify factors associated with SPCS use. RESULTS: Among 313 participants, (50.5%) had not used SPCS since cancer diagnosis. The most common services used were nutrition (26.5%), psychiatric/psychological counseling (29.7%), and physical therapy (15.1%). Pain/palliative care and cancer rehabilitation consultations were used by 8.5% and 4.1% of participants, respectively. In multivariate analysis, graduate education was associated with greater SPCS use (adjusted odds ratio [AOR] 2.14, 95% confidence interval [CI] 1.08-4.26) compared with those with high school or less, whereas having lung cancer was associated with less SPCS use (AOR 0.48, 95% CI 0.24-0.96) when compared with those having breast cancer. The biggest reported barriers to using SPCS were a lack of awareness (22.4%) and lack of physician referral (23%). CONCLUSIONS: Approximately half of these patients had not accessed SPCS since cancer diagnosis and cite lack of awareness and physician nonreferral as barriers. Further research is needed to understand patients' needs and beliefs regarding SPCS, and how to integrate SPCS into conventional treatments to improve cancer care.

End-stage renal disease: symptom management and advance care planning.

The prevalence of end-stage renal disease continues to increase, and dialysis is offered to older and more medically complex patients. Pain is problematic in up to one-half of patients receiving dialysis and may result from renal and nonrenal etiologies. Opioids can be prescribed safely, but the patient's renal function must be considered when selecting a drug and when determining the dosage. Fentanyl and methadone are considered the safest opioids for use in patients with end-stage renal disease. Nonpain symptoms are common and affect quality of life. Phosphate binders, ondansetron, and naltrexone can be helpful for pruritus. Fatigue can be managed with treatment of anemia and optimization of dialysis, but persistent fatigue should prompt screening for depression. Ondansetron, metoclopramide, and haloperidol are effective for uremia-associated nausea. Nondialytic management may be preferable to dialysis initiation in older patients and in those with additional life-limiting illnesses, and may not significantly decrease life expectancy. Delaying dialysis initiation is also an option. Patients with end-stage renal disease should have advance directives, including documentation of situations in which they would no longer want dialysis.

Palliative care for patients with dementia in long-term care.

Seventy percent of people in the United States who have dementia die in the nursing home. This article addresses the following topics on palliative care for patients with dementia in long-term care: (1) transitions of care, (2) infections, other comorbidities, and decisions on hospitalization, (3) prognostication, (4) the evidence for and against tube feeding, (5) discussing goals of care with families/surrogate decision makers, (6) types of palliative care programs, (7) pain assessment and management, and (8) optimizing function and quality of life for residents with advanced dementia.

Chronic obstructive pulmonary disease diagnosis and management in older adults.

Chronic obstructive pulmonary disease (COPD) in older adults is a complex disorder with several unique age-related aspects. Underlying changes in pulmonary lung function and poor sensitivity to bronchoconstriction and hypoxia with advancing age can place older adults at greater risk of mortality or other complications from COPD. The establishment of the Global Initiative for Obstructive Lung Disease criteria, which can be effectively applied to older adults, has more rigorously defined the diagnosis and management of COPD. An important component of this approach is the use of spirometry for disease staging, a procedure that can be performed in most older adults. The management of COPD includes smoking cessation, influenza and pneumococcal vaccinations, and the use of short-and long-acting bronchodilators. Unlike with asthma, corticosteroid inhalers represent a third-line option for COPD. Combination therapy is frequently required. When using various inhaler designs, it is important to note that older adults, especially those with more-severe disease, may have inadequate inspiratory force for some dry-powder inhalers, although many older adults find the dry-powder inhalers easier to use than metered-dose inhalers. Other important treatment options include pulmonary rehabilitation, oxygen therapy, noninvasive positive airway pressure, and depression and osteopenia screening. Clinicians caring for older adults with an acute COPD exacerbation should also guard against prognostic pessimism. Although COPD is associated with significant disability, there is a growing range of treatment options to assist patients.

Advance care planning and hospice enrollment: who really makes the decision to enroll?

PURPOSE: The purpose of this study was to assess patient participation in advance care planning (ACP) and the decision to enroll in hospice. METHODS: One hundred sixty-five family members of patients who died in hospice between January 2004 and September 2004 returned an anonymous survey (165/380; 43% response rate). RESULTS: Forty-nine percent of family members reported that the patient was not involved in the hospice enrollment decision. The majority of respondents (78%) reported one or more people helped make the decision to enroll in hospice. For patients reported as being involved in the decision to enroll in hospice (either independently or in a shared capacity) they were more likely to have cancer (odds ratio [OR] = 2.3, p = 0.02), die at home (OR = 3.3, p = 0.006), have a length of stay in hospice greater than 7 days (OR = 2.1, p = 0.03), and less likely to have dementia (OR = 0.43, p = 0.001). White respondents were more likely to report having ACP discussions with the patient about: feeding tubes (OR = 4.7; p = 0.001), cardiopulmonary resuscitation (CPR; OR = 3.9; p = 0.002), or mechanical ventilation (OR = 2.7; p = 0.02) than non-white respondents. White respondents were more likely than non-white respondents to report that the patient had a written advance directive (OR = 4.2, p = 0.001). DISCUSSION: These data indicate that some patients are not actively involved in the decision to enroll in hospice and that others, often physicians and family members, are making these decisions for the patient collaboratively. These data support the need for early education and interventions that assist patients and families in discussing ACP preferences and the need for greater understanding of how involved patients want to be with the decision to enroll in hospice.