A Qualitative Analysis of Suicide Notes to Understand Suicidality in Older Adults.

OBJECTIVE: Suicide is a complex multifactorial process influenced by a variety of biological, psychological, and social stressors. Many older adults face a characteristic set of challenges that predispose them to suicidal ideation, suicide-related behavior, and death by suicide. This study explored the subjective experience of suicidality through the analysis of suicide notes from older adults. DESIGN: Qualitative study analyzing written suicide notes. SETTING: Written notes for suicide deaths in Toronto, Canada, between 2003 and 2009 were obtained from the Office of the Chief Coroner for Ontario. PARTICIPANTS: The analysis comprised 29 suicide notes (mean words per note: 221; range: 6-1095) written by individuals 65 years and older (mean ± SD age: 76.2 ± 8.3). MEASUREMENTS: We employed a constructivist grounded theory framework for the analysis, conducted through line-by-line open coding, axial coding, and theorizing of data to establish themes. RESULTS: Suicide notes elucidated the writers' conception of suicide and their emotional responses to stressors. Expressed narratives contributing to suicide centered on burdensomeness or guilt, experiences of mental illness, loneliness or isolation, and poor physical health or disability. Terms related to pain, poor sleep, apology, and inability to go on were recurrent. CONCLUSIONS: Suicide notes enrich our understanding of the thoughts and emotions of those at highest risk of suicide, and they inform potential interventions for reducing suicide risk in older adults.

Development and evaluation of stem cell collection procedure diagrams to support the education and recruitment of committed stem cell donors.

BACKGROUND: Diagrams which allow potential unrelated stem cell donors to visualize the stem cell collection process were hypothesized to support the recruitment and education of committed stem cell donors. STUDY DESIGN AND METHODS: A series of bone marrow and peripheral blood stem cell collection procedure diagrams were developed, featuring young adult male donors of varied ethnic backgrounds. Post-implementation, surveys were conducted to evaluate stakeholder perspective on the diagrams' utility. A quality improvement project was conducted at five stem cell drives from 2017 to 2018 at which recruiters did or did not show the diagrams to potential donors. Following the drives, registrants were invited to complete a survey exploring their experience, knowledge and attitude towards donation. RESULTS: The diagrams were implemented in Canada in 07/2016. Of 293 participating registrants (24·7% non-Caucasian males) recruited at five drives between 2017 and 2018, 76% (n = 197) were shown the diagrams. Participants who were shown the diagrams were significantly more likely to report that the recruiters appeared very knowledgeable (89% vs. 76%, P = 0·019) and to report improved self-reported knowledge of stem cell donation (P = 0·010) compared to participants not shown the diagram. Data are also shown demonstrating that stakeholders in donor recruitment used and valued the diagrams and that use of the diagrams was associated with improved donor recruitment outcomes in Canada. CONCLUSION: This report is the first evaluation of stem cell collection diagrams in the literature. The diagrams are relevant to donor registries, recruitment organizations and transplant centres worldwide, and their use may support efforts to educate and recruit committed, ethnically diverse donors.

A Survey of Nurses' Perspectives on Delirium Screening in Older Adult Medical Inpatients With Limited English Proficiency.

The Confusion Assessment Method (CAM) is commonly used to detect delirium but its utility in patients with limited English proficiency (LEP) is not well-established. In the current study, internal medicine nurses at an acute care hospital in Canada were surveyed on the use of the CAM in older adults with LEP. Nurses' perspectives were explored with a focus on barriers to administration. Fifty participants were enrolled (response rate = 47.6%). Twenty-eight (56%) participants stated they could not confidently and accurately assess delirium in patients with LEP. Twenty-nine (58%) participants believed the CAM is not an effective delirium screening tool in the LEP population. Barriers to screening included: challenges with interpretation services, dependence on family members, and fear that the assessment itself may worsen confusion. Our study is the first to describe specific barriers to administering the CAM in patients with LEP. Strategies are required to address these barriers and optimize delirium screening for patients with LEP. [Journal of Gerontological Nursing, 47(4), 29-34.].

Initiation of Extended-release Depot Buprenorphine in a Patient Subject to a Community Treatment Order for Both Antipsychotic and Opioid Agonist Treatments.

ABSTRACT: Opioid use disorder (OUD) and schizophrenia are commonly comorbid, and patient outcomes are improved when these conditions are managed concurrently. Medication for OUD such as methadone and buprenorphine are treatments for OUD, yet psychosis introduces additional challenges in retaining patients in care. Extended-release depot buprenorphine is an emerging option for the treatment of moderate-to-severe OUD, and it may provide certain benefits in patients with concurrent OUD and psychosis. We present the case of a 32-year-old man with schizophrenia, traumatic brain injury, and OUD with a history of multiple opioid-related overdoses, followed by an assertive community treatment team, and subject to a community treatment order for both his primary psychotic disorder and OUD treatments. We discuss the role of extended-release depot buprenorphine in this unique patient population and the ethical considerations of involuntary treatment of OUD in patients lacking capacity to consent to treatment.

Is Gastric Bypass a Risk Factor for Complicated Alcohol Withdrawal? Case Report and Literature Review.

Alcohol use disorder and gastric bypass surgery are highly comorbid. Alcohol withdrawal syndrome (AWS) is a common and potentially life-threatening event, requiring nuanced and individually tailored management depending on various clinical factors including patient history, alcohol consumption, comorbidities, and timeline of use. Although increasingly common, the literature for managing alcohol withdrawal in the gastric bypass population is quite limited. We present the case of a 45-year-old woman with a past history of Roux-en-Y gastric bypass admitted for alcohol withdrawal at a psychiatric hospital who experienced a complicated withdrawal despite adhering to standard management guidelines. She had been consuming 8 to 12 standard drinks daily, and she was therefore monitored on a Clinical Institute Withdrawal Assessment for Alcohol. She experienced only minimal withdrawal symptoms up to 48 hours following cessation of alcohol consumption. At 70 hours postcessation, she experienced a witnessed tonic-clonic seizure with associated head trauma with internal bleeding, requiring acute medical intervention. This timeline of withdrawal symptoms is atypical, yet perhaps understood in the context of her past medical history which included gastric bypass surgery. We discuss the potential complicating factors inherent in individuals who have received Roux-en-Y gastric bypass in the past with respect to alcohol metabolism. We discuss the similar considerations with respect to altered metabolism of therapeutics commonly used in managing this condition. Lastly, we include a review of the extent literature on this topic and propose possible considerations for managing this unique but increasingly prevalent clinical scenario.

Overlapping mechanisms linking insulin resistance with cognition and neuroprogression in bipolar disorder.

Cognitive impairment is highly prevalent in the progression of both diabetes mellitus and bipolar disorder. The relationship between insulin resistance in diabetes and the risk of developing major neurocognitive disorders such as Alzheimer's disease has been well described. Insulin resistance and the associated metabolic deficiencies lead to biochemical alteration which hasten neurodegeneration and subsequent cognitive impairment. For bipolar disorder, some patients experience a cyclical, yet progressive course of illness. These patients are also more likely to have medical comorbidities such as cardiovascular disease and diabetes, and insulin resistance in particular may precede the neuroprogressive course. Diabetes and bipolar disorder share epidemiological, biochemical, and structural signatures, as well as cognitive impairment within similar domains, suggesting a common mechanism between the two conditions. Here we describe the association between insulin resistance and cognitive changes in bipolar disorder, as well as potential implications for therapeutic modulation of neuroprogression.

Do Interest Groups Cultivate Interest? Trajectories of Geriatric Interest Group Members.

BACKGROUND: Minimal exposure, misconceptions, and lack of interest have historically driven the shortage of health-care providers for older adults. This study aimed to determine how medical students' participation in the National Geriatrics Interest Group (NGIG) and local Geriatrics Interest Groups (GIGs) shapes their career development in the care of older adults. METHODS: An electronic survey consisting of quantitative and qualitative metrics to assess the influence of Interest Groups was distributed to all current and past members of local GIGs at Canadian universities since 2017, as well as current and past executives of the NGIG since 2011. Descriptive statistics and thematic analysis were performed. RESULTS: Thirty-one responses (27.7% response rate) were collected from medical students (13), residents (16), and physicians (2). 79% of resident respondents indicated they will likely have a geriatrics-focused medical practice. 45% of respondents indicated GIG/NGIG involvement facilitated the establishment of strong mentorship. Several themes emerged on how GIG/NGIG promoted interest in geriatrics: faculty mentorship, networking, dispelling stigma, and career advancement. CONCLUSION: The positive associations with the development of geriatrics-focused careers and mentorship compel ongoing support for these organizations as a strategy to increase the number of physicians in geriatrics-related practices.

The Complex Interaction of Mitochondrial Genetics and Mitochondrial Pathways in Psychiatric Disease.

While accounting for only 2% of the body's weight, the brain utilizes up to 20% of the body's total energy. Not surprisingly, metabolic dysfunction and energy supply-and-demand mismatch have been implicated in a variety of neurological and psychiatric disorders. Mitochondria are responsible for providing the brain with most of its energetic demands, and the brain uses glucose as its exclusive energy source. Exploring the role of mitochondrial dysfunction in the etiology of psychiatric disease is a promising avenue to investigate further. Genetic analysis of mitochondrial activity is a cornerstone in understanding disease pathogenesis related to metabolic dysfunction. In concert with neuroimaging and pathological study, genetics provides an important bridge between biochemical findings and clinical correlates in psychiatric disease. Mitochondrial genetics has several unique aspects to its analysis, and corresponding special considerations. Here, we review the components of mitochondrial genetic analysis - nuclear DNA, mitochon-drial DNA, mitochondrial pathways, pseudogenes, nuclear-mitochondrial mismatch, and microRNAs - that could contribute to an observable clinical phenotype. Throughout, we highlight psychiatric diseases that can arise due to dysfunction in these processes, with a focus on schizophrenia and bipolar disorder.

A Comprehensive Analysis of Nuclear-Encoded Mitochondrial Genes in Schizophrenia.

BACKGROUND: The genetic risk factors of schizophrenia (SCZ), a severe psychiatric disorder, are not yet fully understood. Multiple lines of evidence suggest that mitochondrial dysfunction may play a role in SCZ, but comprehensive association studies are lacking. We hypothesized that variants in nuclear-encoded mitochondrial genes influence susceptibility to SCZ. METHODS: We conducted gene-based and gene-set analyses using summary association results from the Psychiatric Genomics Consortium Schizophrenia Phase 2 (PGC-SCZ2) genome-wide association study comprising 35,476 cases and 46,839 control subjects. We applied the MAGMA method to three sets of nuclear-encoded mitochondrial genes: oxidative phosphorylation genes, other nuclear-encoded mitochondrial genes, and genes involved in nucleus-mitochondria crosstalk. Furthermore, we conducted a replication study using the iPSYCH SCZ sample of 2290 cases and 21,621 control subjects. RESULTS: In the PGC-SCZ2 sample, 1186 mitochondrial genes were analyzed, among which 159 had p values < .05 and 19 remained significant after multiple testing correction. A meta-analysis of 818 genes combining the PGC-SCZ2 and iPSYCH samples resulted in 104 nominally significant and nine significant genes, suggesting a polygenic model for the nuclear-encoded mitochondrial genes. Gene-set analysis, however, did not show significant results. In an in silico protein-protein interaction network analysis, 14 mitochondrial genes interacted directly with 158 SCZ risk genes identified in PGC-SCZ2 (permutation p = .02), and aldosterone signaling in epithelial cells and mitochondrial dysfunction pathways appeared to be overrepresented in this network of mitochondrial and SCZ risk genes. CONCLUSIONS: This study provides evidence that specific aspects of mitochondrial function may play a role in SCZ, but we did not observe its broad involvement even using a large sample.

A comprehensive analysis of mitochondrial genes variants and their association with antipsychotic-induced weight gain.

Antipsychotic Induced Weight Gain (AIWG) is a common and severe side effect of many antipsychotic medications. Mitochondria play a vital role for whole-body energy homeostasis and there is increasing evidence that antipsychotics modulate mitochondrial function. This study aimed to examine the role of variants in nuclear-encoded mitochondrial genes and the mitochondrial DNA (mtDNA) in conferring risk for AIWG. We selected 168 European-Caucasian individuals from the CATIE sample based upon meeting criteria of multiple weight measures while taking selected antipsychotics (risperidone, quetiapine or olanzapine). We tested the association of 670 nuclear-encoded mitochondrial genes with weight change (%) using MAGMA software. Thirty of these genes showed nominally significant P-values (<0.05). We were able to replicate the association of three genes, CLPB, PARL, and ACAD10, with weight change (%) in an independent prospectively assessed AIWG sample. We analyzed mtDNA variants in a subset of 74 of these individuals using next-generation sequencing. No common or rare mtDNA variants were found to be significantly associated with weight change (%) in our sample. Additionally, analysis of mitochondrial haplogroups showed no association with weight change (%). In conclusion, our findings suggest nuclear-encoded mitochondrial genes play a role in AIWG. Replication in larger sample is required to validate our initial report of mtDNA variants in AIWG.