Use of an electronic wellness instrument in the integrated health and social care of older adults: a group concept mapping study.

BACKGROUND: Health system fragmentation directly contributes to poor health and social outcomes for older adults with multiple chronic conditions and their care partners. Older adults often require support from primary care, multiple specialists, home care, community support services, and other health-care sectors and communication between these providers is unstructured and not standardized. Integrated and interprofessional team-based models of care are a recommended strategy to improve health service delivery to older adults with complex needs. Standardized assessment instruments deployed on digital platforms are considered a necessary component of integrated care. The aim of this study was to develop strategies to leverage an electronic wellness instrument, interRAI Check Up Self Report, to support integrated health and social care for older adults and their care partners in a community in Southern Ontario, Canada. METHODS: Group concept mapping, a participatory mixed-methods approach, was conducted. Participants included older adults, care partners, and representatives from: home care, community support services, specialized geriatric services, primary care, and health informatics. In a series of virtual meetings, participants generated ideas to implement the interRAI Check Up and rated the relative importance of these ideas. Hierarchical cluster analysis was used to map the ideas into clusters of similar statements. Participants reviewed the map to co-create an action plan. RESULTS: Forty-one participants contributed to a cluster map of ten action areas (e.g., engagement of older adults and care partners, instrument's ease of use, accessibility of the assessment process, person-centred process, training and education for providers, provider coordination, health information integration, health system decision support and quality improvement, and privacy and confidentiality). The health system decision support cluster was rated as the lowest relative importance and the health information integration was cluster rated as the highest relative importance. CONCLUSIONS: Many person-, provider-, and system-level factors need to be considered when implementing and using an electronic wellness instrument across health- and social-care providers. These factors are highly relevant to the integration of other standardized instruments into interprofessional team care to ensure a compassionate care approach as technology is introduced.

The geriatric certificate program: collaborative partnerships for building capacity for a competent workforce.

Many practicing health care providers find themselves ill-prepared to meet the complex care needs of older adults. The Geriatric Certificate Program (GCP) represents a collaborative partnership leveraging existing educational courses, with new courses developed to fill existing education gaps, aimed at improving quality of care for older adults. This paper describes the GCP and examines its impact on knowledge, skills, clinical practice, as well as confidence, comfort, and competence in providing geriatric care. Upon program completion, all graduates (N = 146; 100%) completed an online evaluation survey. The majority of graduates reported (5-point scale: 1 = much less now; 5 = much more now) being more confident (88%), comfortable (83%), and competent (89%) to provide optimal geriatric care than prior to the program. The GCP provides a significant opportunity for health care providers to build their capacity for the care of older adults. Key lessons learned in implementing the GCP and suggestions for further development are discussed.

IFN Regulatory Factor 3 Balances Th1 and T Follicular Helper Immunity during Nonlethal Blood-Stage Plasmodium Infection.

Differentiation of CD4+ Th cells is critical for immunity to malaria. Several innate immune signaling pathways have been implicated in the detection of blood-stage Plasmodium parasites, yet their influence over Th cell immunity remains unclear. In this study, we used Plasmodium-reactive TCR transgenic CD4+ T cells, termed PbTII cells, during nonlethal P. chabaudi chabaudi AS and P. yoelii 17XNL infection in mice, to examine Th cell development in vivo. We found no role for caspase1/11, stimulator of IFN genes, or mitochondrial antiviral-signaling protein, and only modest roles for MyD88 and TRIF-dependent signaling in controlling PbTII cell expansion. In contrast, IFN regulatory factor 3 (IRF3) was important for supporting PbTII expansion, promoting Th1 over T follicular helper (Tfh) differentiation, and controlling parasites during the first week of infection. IRF3 was not required for early priming by conventional dendritic cells, but was essential for promoting CXCL9 and MHC class II expression by inflammatory monocytes that supported PbTII responses in the spleen. Thereafter, IRF3-deficiency boosted Tfh responses, germinal center B cell and memory B cell development, parasite-specific Ab production, and resolution of infection. We also noted a B cell-intrinsic role for IRF3 in regulating humoral immune responses. Thus, we revealed roles for IRF3 in balancing Th1- and Tfh-dependent immunity during nonlethal infection with blood-stage Plasmodium parasites.

RNA-Seq analysis of chikungunya virus infection and identification of granzyme A as a major promoter of arthritic inflammation.

Chikungunya virus (CHIKV) is an arthritogenic alphavirus causing epidemics of acute and chronic arthritic disease. Herein we describe a comprehensive RNA-Seq analysis of feet and lymph nodes at peak viraemia (day 2 post infection), acute arthritis (day 7) and chronic disease (day 30) in the CHIKV adult wild-type mouse model. Genes previously shown to be up-regulated in CHIKV patients were also up-regulated in the mouse model. CHIKV sequence information was also obtained with up to ≈8% of the reads mapping to the viral genome; however, no adaptive viral genome changes were apparent. Although day 2, 7 and 30 represent distinct stages of infection and disease, there was a pronounced overlap in up-regulated host genes and pathways. Type I interferon response genes (IRGs) represented up to ≈50% of up-regulated genes, even after loss of type I interferon induction on days 7 and 30. Bioinformatic analyses suggested a number of interferon response factors were primarily responsible for maintaining type I IRG induction. A group of genes prominent in the RNA-Seq analysis and hitherto unexplored in viral arthropathies were granzymes A, B and K. Granzyme A-/- and to a lesser extent granzyme K-/-, but not granzyme B-/-, mice showed a pronounced reduction in foot swelling and arthritis, with analysis of granzyme A-/- mice showing no reductions in viral loads but reduced NK and T cell infiltrates post CHIKV infection. Treatment with Serpinb6b, a granzyme A inhibitor, also reduced arthritic inflammation in wild-type mice. In non-human primates circulating granzyme A levels were elevated after CHIKV infection, with the increase correlating with viral load. Elevated granzyme A levels were also seen in a small cohort of human CHIKV patients. Taken together these results suggest granzyme A is an important driver of arthritic inflammation and a potential target for therapy. TRIAL REGISTRATION: ClinicalTrials.gov NCT00281294.

Improving the seniors' transition from hospital to the community: a case for intensive geriatric service workers.

BACKGROUND: Limited continuity of care, poor communication between healthcare providers, and ineffective self-management are barriers to recovery as seniors transition back to the community following an Emergency Department (ED) visit or hospitalization. The intensive geriatric service worker (IGSW) role is a new service developed in southern Ontario, Canada to address gaps for seniors transitioning home from acute care to prevent rehospitalization and premature institutionalization through the provision of intensive support and follow-up to ensure adherence to care plans, facilitate communication with care providers, and promote self-management. This study describes the IGSW role and provides preliminary evidence of its impact on clients, caregivers and the broader health system. METHODS: This mixed methods evaluation included a chart audit of all clients served, tracking of the achievement of goals for IGSW involvement, and interviews with clients and caregivers and other key informants. RESULTS: During the study period, 632 clients were served. Rates of goal achievement ranged from 25%-87% and in cases where achieved, the extent of IGSW involvement mostly exceeded recommendations. IGSWs were credited with improving adherence with treatment recommendations, increasing awareness and use of community services, and improving self-management, which potentially reduced ED visits and hospitalizations and delayed institutionalization. CONCLUSIONS: The IGSW role has the potential to improve supports for seniors and facilitate more appropriate use of health system resources, and represents a promising mechanism for improving the integration and coordination of care across health sectors.

Interferon response factors 3 and 7 protect against Chikungunya virus hemorrhagic fever and shock.

Chikungunya virus (CHIKV) infections can produce severe disease and mortality. Here we show that CHIKV infection of adult mice deficient in interferon response factors 3 and 7 (IRF3/7(-/-)) is lethal. Mortality was associated with undetectable levels of alpha/beta interferon (IFN-α/ß) in serum, ∼50- and ∼10-fold increases in levels of IFN-γ and tumor necrosis factor (TNF), respectively, increased virus replication, edema, vasculitis, hemorrhage, fever followed by hypothermia, oliguria, thrombocytopenia, and raised hematocrits. These features are consistent with hemorrhagic shock and were also evident in infected IFN-α/ß receptor-deficient mice. In situ hybridization suggested CHIKV infection of endothelium, fibroblasts, skeletal muscle, mononuclear cells, chondrocytes, and keratinocytes in IRF3/7(-/-) mice; all but the latter two stained positive in wild-type mice. Vaccination protected IRF3/7(-/-) mice, suggesting that defective antibody responses were not responsible for mortality. IPS-1- and TRIF-dependent pathways were primarily responsible for IFN-α/ß induction, with IRF7 being upregulated >100-fold in infected wild-type mice. These studies suggest that inadequate IFN-α/ß responses following virus infection can be sufficient to induce hemorrhagic fever and shock, a finding with implications for understanding severe CHIKV disease and dengue hemorrhagic fever/dengue shock syndrome.

Developing an integrated system of care for frail seniors.

A consultation process was undertaken with healthcare providers in the Waterloo Wellington region of southern Ontario to assess current system strengths, challenges and gaps in providing care to frail seniors. The findings were used to implement strategies for improving system integration.

Breastfeeding Experiences of Autistic Women.

PURPOSE: The purpose of this study was to explore the experiences of autistic women who breastfed. STUDY DESIGN AND METHODS: We used a qualitative phenomenology design and a thematic analysis method. Semistructured interviews were conducted using a purposive sample from social media support groups for autistic adults. The interview involved one overarching question about their breastfeeding experience. RESULTS: Twenty-three autistic women who breastfed their infant(s) participated in our study. Three main themes were identified including intense sensory perception, focused determination, and one size doesn't fit all. Three subthemes helped to describe intense sensory perception: overstimulated, overtouched, and overwhelmed. CLINICAL IMPLICATIONS: Autistic adults can have social interaction and expressive communication differences. Nurses can promote positive communication and provide appropriate care through supportive action. These findings offer a guide for nurses to better understand the experiences of autistic breastfeeding women.

An Advanced Pharmacy Practice Experience in Leadership Development.

Objective. To describe the development and implementation of an advanced pharmacy practice experience (APPE) in leadership.Methods. A leadership APPE was created and continuously improved over five years from being mostly content-oriented to being more of an experiential offering by identifying and implementing rich, practical leadership experiences. Activities included PhotoVoice, Power of Full Engagement, What's Your Passion?, Transformational Leadership, Speech Acts, a Mindfulness Retreat, PeoplePack Dynamics, and a rowing experience at an Olympic training facility. After five years of developing and refining the APPE, faculty coordinators sought student feedback on the APPE beyond using a standardized APPE evaluation form students complete at the end of each rotation.Results. The majority of students agreed with all of the evaluation items. Items with the highest mean agreement included: content from previous didactic leadership courses were reinforced in the rotation; relevance of the rotation to one's career; rotation objectives facilitated learning; and a variety of teaching methods helped in applying knowledge to future practice. Analysis of comments regarding the leadership APPE identified three main themes: gratitude, development, and more connection.Conclusion. An elective APPE with the primary purpose of leadership training and development can be created and incorporated into the Doctor of Pharmacy curriculum. This leadership APPE can serve as an example for other institutions interested in implementing a similar experience.

Using Social Media for Breastfeeding Support.

OBJECTIVE: To explore the variables that lead to sustained, exclusive breastfeeding to 6 months for breastfeeding women of the millennial generation who follow social media breastfeeding support groups (SMBSGs). DESIGN: Repeated-measures, longitudinal, mixed-methods design. SETTING: Online across 21 countries. PARTICIPANTS: Convenience sample of exclusively breastfeeding millennial women (N = 241) who followed at least one of 17 SMBSGs. MEASUREMENTS: Participants completed the following: a demographic questionnaire; the Perceived Work Demand Scale; the Perceived Family Demand Scale; the Perceived Health-Related Social Support From Facebook Friends Measure; and the Breastfeeding Confidence, Knowledge, and Attitudes Measure. RESULTS: Using structural equation modeling, I examined relationships among personal factors; competing situational demands; social support; and confidence in, knowledge of, attitude toward, and sustainability of breastfeeding. Age, education, and competing work and family demands were all predictive of social support. Breastfeeding social support had a direct effect on participants' breastfeeding confidence, knowledge, and attitudes (F = 4.96, R2 = .07, p < .002). Furthermore, within SMBSGs, exclusive breastfeeding to 6 months was reported to be three times (66%) greater than the U.S. national average (22%). CONCLUSION: Interventions aimed at providing women with resources to gain breastfeeding social support, such as SMBSGs, may be vehicles to improve women's confidence, knowledge, and attitudes and, therefore, increase the potential for exclusive breastfeeding to 6 months.

Questionnaire with Acupuncturists to Investigate the Relationship Between the Governor Vessel and Dementia.

The prevalence of elderly dementia and work-related back neck pain is high, and so is the associated cost. Is dementia, which can take 20-30 years to develop, linked to musculoskeletal problems earlier in life? Classic Chinese Medicine Governor Vessel (GV) theory has in fact detailed a correlation, but its acceptance appears to be influenced and even limited by some inconsistences in the literature. This study involved a nationwide online questionnaire of 381 practicing acupuncturists to investigate GV's usage and impact on brain function. The survey covers areas of the acupuncturist's experience, perception of GV usage, related symptoms, needling concerns and correlations with brain function. 39 completed questionnaires were returned, of which 38 were GV users, and nearly three quarters of respondents accepted that GV influences brain function. Only two respondents rejected this influence, but here several inconsistencies were found. The associations with GV were predominately found to be with the spine, kidney, and brain. Indications from practitioners suggested numerous forms of clinical usage of GV, predominately on spinal, cognitive and qi-blood movement issues. GV influence on the brain was accepted by most respondents with only a few expressing uncertainty. Further worldwide, larger population, in-depth studies and trials are needed to fully establish and expand upon these findings.

Results of the ACCEL trial: Dosimetry in accelerated partial breast irradiation.

PURPOSE: To report the achieved dosimetry in the ACCEL trial and compare the results to reported dosimetry from the major accelerated partial breast irradiation (APBI) phase III trials. METHODS: The ACCEL trial was a single arm, phase II, prospective cohort study. A five-field, inverse-planned, IMRT strategy was employed using a class solution technique to increase planning consistency including high dose conformity and low normal tissue dose to the ipsilateral breast. RESULTS: Between 2016 and 2019, 283 patients were treated with 27 Gy in five fractions in consecutive days. The average PTV conformity index was 1.1. For the ipsilateral breast, the median (range) volume receiving 95% and 50% of the prescription dose was 9.7% (3.2-22.4) and 30.3% (11.1-54.6), respectively. Compared to major APBI phase III trial constraints, this reduction in irradiated volume at the 95% and 50% isodose levels represents a reduction of 209 cm3 and 265 cm3, respectively. CONCLUSION: The IMRT planning strategy employed in the ACCEL trial demonstrated consistent and superior dosimetry by comparison to conventionally used 3D CRT techniques. Future APBI trials should update dosimetric constraints.

Official incidents of domestic violence: types, injury, and associations with nonofficial couple aggression.

Official police reports of intimate partner violence (IPV) were examined in a community sample of young, at-risk couples to determine the degree of mutuality and the relation between IPV arrests and aggression toward a partner (self-reported, partner reported, and observed). Arrests were predominantly of the men. Men were more likely to initiate physical contact, use physical force, and inflict injuries than women, although few injuries required medical attention. In the context of nonofficial aggression toward a partner, overall, women had higher levels of physical and psychological aggression compared to men, and levels of severe physical aggression did not differ by gender. Couples with an IPV arrest were more aggressive toward each other than couples with no IPV arrests; however, nonofficial levels of aggression were not higher for men than for women among couples experiencing an IPV incident.

A narrative study of the experiences of student nurses who have participated in the Hearing Voices that are Distressing simulation.

The aim of this study was to provide nursing students with an experiential learning opportunity which simulated living with the challenge of voice hearing. The purpose was to access understanding and insights of nursing students who completed "Hearing Voices that are Distressing: A Training Experience and Simulation for Students" (Deegan, 1996). Using a narrative research design and a convenience sample of 27 nursing students, participants were asked to respond in written format to three open ended prompts immediately following their participation in the simulation. Data generated was subjected to a thematic content analysis using a manual cut and paste approach to inductively find meanings and insights elicited from the respondents' actual words. Affirmed in this study was the use of this teaching tool to assist the students in their understanding of the challenges posed by voice hearing.

One-Year Cosmesis and Fibrosis From ACCEL: Accelerated Partial Breast Irradiation (APBI) Using 27 Gy in 5 Daily Fractions.

PURPOSE: To report 1-year cosmesis and toxicity outcomes of a prospective, phase II trial of accelerated partial breast irradiation using intensity-modulated radiation therapy (RT) to deliver 27 Gy in 5 daily fractions. METHODS AND MATERIALS: Node-negative breast cancer patients after breast conserving surgery with clear excision margins, with physician-assessed excellent or good baseline cosmesis were invited to participate in a prospective clinical trial to receive 27 Gy in 5 daily fractions to the expanded primary site. Clinical photographs and European Organisation for Research and Treatment of Cancer cosmetic score were collected at baseline prior to RT and 1-year after radiation therapy. A protocol-specified, interim analysis was scheduled when 50 patients had completed 1-year follow-up. A panel of 6 physicians provided a consensus global cosmetic score (termed panel-assessed score) based on clinical photographs at baseline and 1-year. Fibrosis and telangiectasia were prospectively assessed by clinical research staff at clinic visits. RESULTS: At the interim analysis, 55 patients had baseline and 1-year post-RT images available. Most patients had either an improvement (53%) or no change (40%) in cosmesis from baseline to 1-year. Among 49 patients with excellent or good panel-assessed score at baseline, only 2 (4%) patients had a fair score at 1-year post-RT, indicating cosmetic deterioration. No patients had evidence of telangiectasia or grade 2 or higher fibrosis. There were no recurrences. CONCLUSIONS: APBI using 27 Gy in 5 daily fractions achieved acceptable 1-year cosmesis and no grade 2 fibrosis. A preplanned stopping rule of 5% grade 2+ fibrosis was not observed. The trial will continue to the planned target accrual of 274 patients.

Amelioration of sexual fantasies to sexual abuse cues in an adult survivor of childhood sexual abuse: a case study.

Although sexual dysfunction of childhood sexual abuse survivors has received considerable attention, other sexual difficulties experienced by survivors of CSA, such as sexual fantasies to cues of sexual abuse, have received less attention. In this A-B design case study, a young adult female survivor of childhood sexual abuse presented for treatment at a Midwest rape crisis center. After successful treatment of post-traumatic stress disorder, she complained of unwanted sexual fantasies to sexual abuse cues and concomitant guilt and shame. Following baseline data collection, treatment consisted of self-applied aversion therapy to unwanted sexual arousal to sexual abuse cues. Decrease in sexual arousal to these cues was concurrent with the introduction of treatment. A concomitant decrease in guilt and shame occurred while self-ratings of control increased.

Emotional intelligence scores among three cohorts of pharmacy students before and after completing the University of Oklahoma College of Pharmacy's Leadership Degree Option Program.

BACKGROUND AND PURPOSE: Report change in Emotional Intelligence Appraisal scores among three cohorts of student pharmacists before and after completing the Leadership Degree Option (LDO) Program within the University of Oklahoma College of Pharmacy. EDUCATIONAL ACTIVITY AND SETTING: The first three cohorts of student pharmacists who elected to enroll in the College's LDO completed the self-administered Emotional Intelligence Appraisal, Me Edition, at the start of the LDO program and again three years later at the end of the program. Paired samples t-test compared differences between mean pre- and post-scores stratified by gender. FINDINGS: A total of 36 students from Cohorts 1, 2, and 3 completed and voluntarily reported their scores of the Emotional Intelligence Appraisal. There was a statistically significant increase in mean overall Emotional Intelligence Appraisal score between the start and end of the LDO (pre = 76.39, post = 81.03, p < 0.0001). Statistical significance remained when stratified by gender. There also were statistically significant differences on various sub-domain scores. DISCUSSIONS AND CONCLUSIONS: We observed a before and after increase in Emotional Intelligence Appraisal scores among three cohorts of pharmacy students who completed a three-year LDO Program in parallel with completing the Doctor of Pharmacy Degree Program. Emotional recognizance and management in oneself and others has potential to build leadership capacity that can be applied in the health-care delivery setting.

A novel use of photovoice methodology in a leadership APPE and pharmacy leadership elective.

BACKGROUND AND PURPOSE: The purpose of this article is to describe and assess the effectiveness of an innovative teaching approach in an advanced pharmacy practice experience (APPE) and leadership elective. EDUCATIONAL ACTIVITY AND SETTING: Three cohorts of students [(2014: n = 14), (2015: n = 17), (2016: n = 19)] were introduced to the photovoice (PV) method in their leadership APPE. PV required students to take, present, and discuss photographs within their cohorts. PV was used as a teaching method with the intention that the process would compel students to be involved in leadership development throughout experiential rotations, participate in discussions related to leadership development, and engage in creative activity. Group discussions from the class of 2014 were recorded and transcribed. Students from all cohorts were asked to participate in an electronic survey containing items based on PV learning objectives. All students were asked to participate in semi-structured interviews about PV. FINDINGS AND DISCUSSION: The inductive coding method was used to identify themes from discussion transcripts. Analysis of themes revealed 51.5% of the PV photographs related to emotional intelligence. Development of others and strong teams were themes represented in 44.3% of photographs. Survey data indicated all respondents agreed PV was a valuable method to describe learning in leadership. Interview coding revealed themes related to emotional intelligence and development of teams. SUMMARY: The PV method was an effective teaching tool in a leadership APPE and elective course. PV is a teaching method to be utilized in a variety of experiential learning environments to better enhance the professional development of pharmacy students.

The right stuff for early intervention in psychosis: time, attitude, place, intensity, treatment, & cost.

This article shares information about an exciting new approach in psychiatry. During the past 12 years, the authors have worked with young people experiencing their first episode of psychosis. It is clear that intervention at the earliest stages of psychotic illness allows clinicians to make a significant difference in the lives of young people and their families. This article summarizes current intervention strategies, which are considered best practice guidelines for early treatment.