Results of Early Transplantation for Alcohol-Related Cirrhosis: Integrated Addiction Treatment With Low Rate of Relapse.

BACKGROUND & AIMS: In 2018, our team initiated a prospective pilot program to challenge the paradigm of the "6-month rule" of abstinence for patients with alcohol-related liver disease (ALD) requiring transplant. Our pilot involved an in-depth examination of patients' alcohol use, social support, and psychiatric comorbidity, as well as the provision of pre- and post-transplantation addiction treatment. METHODS: Patients with ALD were assessed for inclusion in the pilot by a multidisciplinary team. Relapse prevention therapy was provided directly to all patients deemed to meet the program's inclusion criteria. Random biomarker testing for alcohol was used pre and post transplantation. RESULTS: We received 703 referrals from May 1, 2018 to October 31, 2020. After fulfilling the program's criteria, 101 patients (14%) were listed for transplantation and 44 (6.2%) received transplants. There were no significant differences in survival rates between those receiving transplants through the pilot program compared with a control group with more than 6 months of abstinence (P = .07). Three patients returned to alcohol use during an average post-transplantation follow-up period of 339 days. In a multivariate analysis, younger age and lower Model for End-Stage Liver Disease scores at listing were associated with an increased likelihood of a return to alcohol use (P < .05); length of abstinence was not a predictor. CONCLUSIONS: Our prospective program provided direct monitoring and relapse prevention treatment for patients with ALD and with less than 6 months of abstinence and resulted in a reduction of post-transplantation return to drinking. This pilot study provides a framework for the future of more equitable transplant care.

Senior Residents' Perceived Competence in Evidence-Based Treatments for Major Depressive Disorder.

OBJECTIVE: The current study aims to assess the self-reported competence of graduating psychiatry residents in Canada to provide pharmacotherapy and psychotherapy for major depressive disorder as recommended in national practice guidelines. METHODS: Canadian psychiatry residents who participated in an optional national review course to prepare for licensing were anonymously surveyed regarding their experience and competence in providing treatments recommended by the 2016 Canadian Network for Mood and Anxiety Treatments guidelines. RESULTS: The majority (89%, 130/146) reported competence in ≥ 5 medication monotherapies (e.g., selective serotonin/norepinephrine reuptake inhibitors, bupropion, mirtazapine) and ≥ 3 adjuncts (e.g., mirtazapine, second-generation antipsychotics). While 76% expressed interest in practicing multiple psychotherapeutic modalities, only 47% reported self-assessed competence in delivering multiple modalities. Only 42% reported pharmacological competence (≥ 5 monotherapies, ≥ 3 adjuncts) and competence in ≥ 2 psychotherapies. Only 9% reported competence in offering medication, psychotherapy, and electroconvulsive therapy. Less than two-thirds endorsed sufficient didactic teaching (58%) or supervision in pharmacotherapy (50%) for treatment-resistant depression. CONCLUSIONS: Canadian psychiatry residents report competence in prescribing many first-line medications. However, only a minority report competence in prescribing medications and competence in psychotherapies and/or electroconvulsive therapy. Given known biases in assessments by self-report, real-world competence may be even lower. This study identifies gaps between national practice guidelines and the comfort of the emerging psychiatric workforce in delivering recommended treatments. These gaps in resident competence may lead to under-use of effective treatments for depression. Residency programs should consider how to improve resident competence in providing the full range of evidence-based treatments for depression.

Conversational avoidance during existential interviews with patients with progressive illness.

We examined patterns of avoidance when existential emotional topics were raised during conversations with patients with pulmonary arterial hypertension (PAH), an incurable life-limiting disease. 30 adult outpatients with PAH were recruited for a 20 to 60-minute interview about their illness experience. Qualitative content analysis was used to identify avoidance strategies that patients employed. Participants averaged 58 years in age (SD = 18), 77% were female, and mean length of illness was 6.3 years (SD = 5.3). We found four avoidance strategies: (1) Reversal, when individuals would begin discussing a negative concern and then backtrack to more positive sentiments; (2) Diversion for when patients would sidetrack the conversation to a different and less uncomfortable topic; (3) Diminishment for when a concern is raised and then made to seem unimportant; and (4) Obstruction, when patients refuse to discuss a concern further. Exploration of existential concerns can elicit distress but may be necessary to promote adaptation to progressive illness and to the foreseeable challenges that may affect the sense of life meaning and value. By recognizing when existential concerns may be present but not adequately discussed, clinicians may be better able to assist patients to cope and prepare for the future.

One-Year Outcomes in Caregivers of Critically Ill Patients.

BACKGROUND: Few resources are available to support caregivers of patients who have survived critical illness; consequently, the caregivers' own health may suffer. We studied caregiver and patient characteristics to determine which characteristics were associated with caregivers' health outcomes during the first year after patient discharge from an intensive care unit (ICU). METHODS: We prospectively enrolled 280 caregivers of patients who had received 7 or more days of mechanical ventilation in an ICU. Using hospital data and self-administered questionnaires, we collected information on caregiver and patient characteristics, including caregiver depressive symptoms, psychological well-being, health-related quality of life, sense of control over life, and effect of providing care on other activities. Assessments occurred 7 days and 3, 6, and 12 months after ICU discharge. RESULTS: The caregivers' mean age was 53 years, 70% were women, and 61% were caring for a spouse. A large percentage of caregivers (67% initially and 43% at 1 year) reported high levels of depressive symptoms. Depressive symptoms decreased at least partially with time in 84% of the caregivers but did not in 16%. Variables that were significantly associated with worse mental health outcomes in caregivers were younger age, greater effect of patient care on other activities, less social support, less sense of control over life, and less personal growth. No patient variables were consistently associated with caregiver outcomes over time. CONCLUSIONS: In this study, most caregivers of critically ill patients reported high levels of depressive symptoms, which commonly persisted up to 1 year and did not decrease in some caregivers. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00896220.).

The RECOVER Program: Disability Risk Groups and 1-Year Outcome after 7 or More Days of Mechanical Ventilation.

RATIONALE: Disability risk groups and 1-year outcome after greater than or equal to 7 days of mechanical ventilation (MV) in medical/surgical intensive care unit (ICU) patients are unknown and may inform education, prognostication, rehabilitation, and study design. OBJECTIVES: To stratify patients for post-ICU disability and recovery to 1 year after critical illness. METHODS: We evaluated a multicenter cohort of 391 medical/surgical ICU patients who received greater than or equal to 1 week of MV at 7 days and 3, 6, and 12 months after ICU discharge. Disability risk groups were identified using recursive partitioning modeling. MEASUREMENTS AND MAIN RESULTS: The 7-day post-ICU Functional Independence Measure (FIM) determined the recovery trajectory to 1-year after ICU discharge and was an independent risk factor for 1-year mortality. The 7-day post-ICU FIM was predicted by age and ICU length of stay. By 2 weeks of MV, ICU patients could be stratified into four disability groups characterized by increasing risk for post ICU disability, ICU and post-ICU healthcare use, and disposition. Patients less than 42 years with ICU length of stay less than 2 weeks had the best function and fewest deaths at 1 year compared with patients greater than 66 years with ICU length of stay greater than 2 weeks who sustained the worst disability and 40% 1-year mortality. Depressive symptoms (17%) and post-traumatic stress disorder (18%) persisted at 1 year. CONCLUSIONS: ICU survivors of greater than or equal to 1 week of MV may be stratified into four disability groups based on age and ICU length of stay. These groups determine 1-year recovery and healthcare use and are independent of admitting diagnosis and illness severity. Clinical trial registered with www.clinicaltrials.gov (NCT 00896220).

Time to Consultation-Liaison Psychiatry Service Referral as a Predictor of Length of Stay.

OBJECTIVES: The aim of this study was to determine the relationship between the time to referral (TTR) to psychiatric consultation and the length of stay (LOS) after adjusting for medical comorbity. METHODS: Using a naturalistic study design, we collected and analyzed inpatient consultation-liaison psychiatry service data over a 12-month period from 2 Canadian hospital sites. Data collected included demographic characteristics, referral characteristics, Charlson Comorbidity Index to measure medical comorbidity severity, psychiatric diagnoses, type of psychiatric intervention, and time variables, namely TTR and LOS. We modeled the relationship LOS and TTR after adjusting for Charlson Index using a 3-component finite mixture of exponential regression models. RESULTS: A total of 814 patients were included. The median LOS was 12 days (interquartile range : 4-28 days). Median TTR was 3 days (interquartile range: 1,9), and median Charlson Index was 5 (interquartile range 3,6). Bivariate analysis indicated a strong positive correlation among LOS and TTR (Spearman correlation: 0.77, p < 0.0001) and Charlson Index(Spearman correlation: 0.34, p < 0.0001), respectively. After controlling for Charlson Index, we observe that TTR was significantly associated with LOS in each of the 3 components of the mixture of exponential regression models. Persons with longer TTR have longer expected LOS. Graphical summaries suggest that the mixture of exponential regression model provides a good fit to these LOS response data. CONCLUSIONS: Patients with longer TTR had significantly longer LOS. The association between TTR and LOS holds after controlling for severity of medical comorbidity. Our results support the role of integrated and proactive consultation-liaison psychiatry programs aimed at reducing TTR to improve LOS outcomes.

Determining the need for team-based training in delirium management: A needs assessment of surgical healthcare professionals.

The high incidence of delirium in surgical units is a serious quality concern, given its impact on morbidity and mortality. While successful delirium management depends upon interdisciplinary care, training needs for surgical teams have not been studied. A needs assessment of surgical units was conducted to determine perceived comfort in managing delirium, and interprofessional training needs for team-based care. We administered a survey to 106 General Surgery healthcare professionals (69% response rate) with a focus on attitudes towards delirium and team management. Although most respondents identified delirium as important to patient outcomes, only 61% of healthcare professionals indicated that a team-based approach was always observed in practice. Less than half had a clear understanding of their role in delirium care, while just over half observed team communication of delirium care plans during handover. This is the first observation of clear gaps in perceived team performance in a General Surgery setting.

Lost in Transition: Examining Transitions in Psychotherapy Training.

OBJECTIVE: Disruptions are inevitable during psychiatry residency training and can affect resident learning and patient care. This exploratory study examined the nature and impact of transitions in psychotherapy training. METHODS: PGY2-5 residents (45/150; 30% response rate) and psychotherapy supervisors (46/247; 18.6% response rate) were surveyed about transitional events during residency training in psychotherapy. RESULTS: Supervisors and residents ranked the frequency of occurrence of transitional events and their impact very similarly, as well as the "feed forward" items when transitioning to a new supervisor. Residents feeling confused or overwhelmed with the balancing of learning differing models with differing levels of comfort or knowledge was ranked as the issue that occurred most frequently by both supervisors and residents. CONCLUSIONS: This study highlights issues that arise at transitions during psychotherapy training in psychiatry residency. Strategies for managing these periods are discussed, with a focus on resident learning and improved continuity of patient care.

A framework for understanding international medical graduate challenges during transition into fellowship programs.

BACKGROUND: Previous studies have highlighted unique needs of international medical graduates (IMG) during their transition into medical training programs; however, limited data exist on IMG needs specific to fellowship training. PURPOSES: We conducted the following mixed-method study to determine IMG fellow training needs during the transition into fellowship training programs in psychiatry and surgery. METHODS: The authors conducted a mixed-methods study consisting of an online survey of IMG fellows and their supervisors in psychiatry or surgery fellowship training programs and individual interviews of IMG fellows. The survey assessed (a) fellows' and supervisors' perceptions on IMG challenges in clinical communication, health systems, and education domains and (b) past orientation initiatives. In the second phase of the study, IMG fellows were interviewed during the latter half of their fellowship training, and perceptions regarding orientation and adaptation to fellowship in Canada were assessed. Survey data were analyzed using descriptive and Mann-Whitney U statistics. Qualitative interviews were analyzed using grounded theory methodology. RESULTS: The survey response rate was 76% (35/46) and 69% (35/51) for IMG fellows and supervisors, respectively. Fellows reported the greatest difficulty with adapting to the hospital system, medical documentation, and balancing one's professional and personal life. Supervisors believed that fellows had the greatest difficulty with managing language and slang in Canada, the healthcare system, and an interprofessional team. In Phase 2, fellows generated themes of disorientation, disconnection, interprofessional team challenges, a need for IMG fellow resources, and a benefit from training in a multicultural setting. CONCLUSIONS: Our study results highlight the need for IMG specific orientation resources for fellows and supervisors. Maslow's Hierarchy of Needs may be a useful framework for understanding IMG training needs.

Interprofessional education for delirium care: a systematic review.

Recent delirium prevention and treatment guidelines recommend the use of an interprofessional team trained and competent in delirium care. We conducted a systematic review to identify the evidence for the value of interprofessional delirium education programs on learning outcomes. We searched several databases and the grey literature. Studies describing an education intervention, involving two or more healthcare professions and reporting on at least one learning outcome as classified by Kirkpatrick's evaluation framework were included in this review. Ten out of 633 abstracts reviewed met the study inclusion criteria. Several studies reported on more than one learning outcome. Two studies focused on learner reactions to interprofessional delirium education; three studies focused on learning outcomes (e.g. delirium knowledge); six studies focused on learner behavior in practice; and six studies reported on learning results (e.g. patient outcomes), mainly changes in delirium rates post-intervention. Studies reporting changes in patient outcomes following the delirium education intervention used an interprofessional practice (IPP) intervention in combination with interprofessional education (IPE). Our review of the limited evidence suggests that IPE programs may influence team and patient outcomes in delirium care. More systematic studies of the effectiveness of interprofessional delirium education interventions are needed.

(Dis)orientation of international medical graduates: an approach to foster teaching, learning, and collaboration (TLC).

OBJECTIVE: The Teaching for Learning and Collaboration (TLC) Program is a teaching-skills program focusing on methods to improve student learning. This program was adopted to address the professional and personal challenges faced by International Medical Graduates (IMGs) completing a fellowship in psychosomatic medicine. METHOD: The authors conducted a literature review on the educational challenges encountered by IMGs. Based on this review, an adapted TLC Program was piloted on four IMG fellows who completed a psychosomatic medicine fellowship between 2008 and 2011. RESULTS: Teachers using the adapted TLC Program reported the following as being significant in the IMG training process: a safe educational environment; having an extended period of time for assessment and fellow adjustment; and more direct, rather than "diplomatic," feedback. CONCLUSIONS: Although piloted in a psychosomatic medicine fellowship, the TLC program is intended to be generalizable to other medical training settings. Further evaluation of the effectiveness of this approach for IMGs is required.

Interpersonal processes in palliative care: an attachment perspective on the patient-clinician relationship.

The progression of advanced disease often brings enormous adaptational challenges related to a loss of the capacity to be self-sufficient and to a heightened need for support from others. The increasing need to rely on others at the end of life may reactivate relational problems and may trigger threatening feelings of vulnerability and dependency. Clinicians may find it difficult to identify and respond appropriately to the specific relational needs of individuals receiving end-of-life care. Attachment theory is a developmentally-based approach to understanding the formation and maintenance of relationships relevant to felt security. Although attachment theory has been widely applied to parent-child relationships and to relationships of individuals with chronic medical conditions to their medical caregivers, it has not previously been applied to the understanding of clinician-patient relationships in the palliative care setting. This paper provides an overview of this theory and demonstrates its application and relevance to palliative care.

Respiratory muscle weakness and anorexia nervosa.

BACKGROUND: Nutritional recovery in anorexia nervosa (AN) is associated with improved exercise tolerance. METHOD: We describe the investigation of a male with AN. Despite nutritional recovery, he complained of impaired exercise tolerance. RESULTS: Respiratory muscle weakness was demonstrated as the cause of the impaired exercise tolerance. DISCUSSION: Weakness of the muscles of respiration results from prolonged malnutrition. The diaphragmatic muscle may be slower to recover than other muscles. This can cause impaired exercise tolerance due to shortness of breath on exertion, despite nutritional recovery.