Catch the moment: The power of turning mistakes into 'precious' learning opportunities.

We developed a series of small group workshops that aim to facilitate communication during very challenging ethically sensitive scenarios within a Neonatal-Perinatal Medicine (NPM) postgraduate curriculum at the University of Ottawa. These workshops are called Scenario-Oriented Learning in Ethics (SOLE). This educational intervention aims to focus attention on the learner's needs and to help them recognize, define, and view each communicative or behavioural mistake as an occasion to achieve a personal-defined learning goal in a controlled environment free of judgement. The goal of this commentary is to describe the importance of timely interruptions during the scenarios allowing mini concurrent-guided debriefing-feedback by focusing upon trainees' communication mistakes, utilizing them as valuable learning opportunities.

The role of shame and self-compassion in psychotherapy for narcissistic personality disorder: An exploratory study.

This process-outcome study aims at exploring the role of shame, self-compassion, and specific therapeutic interventions in psychotherapy for patients with narcissistic personality disorder (NPD). This exploratory study included a total of N = 17 patients with NPD undergoing long-term clarification-oriented psychotherapy. Their mean age was 39 years, and 10 were male. On average, treatments were 64 sessions long (range between 45 and 99). Sessions 25 and 36 were rated using the Classification of Affective Meaning States and the Process-Content-Relationship Scale. Outcome was assessed using the Symptom Check List-90 and Beck Depression Inventory-II. Between Sessions 25 and 36, a small decrease in the frequency of shame was found (d = .30). In Session 36, the presence of self-compassion was linked with a set of specific therapist interventions (process-guidance and treatment of behaviour-underlying assumptions; 51% of variance explained and adjusted). This study points to the possible central role of shame in the therapeutic process of patients with NPD. Hypothetically, one way of resolving shame is, for the patient, to access underlying self-compassion.

Education in the Waiting Room: Description of a Pediatric Emergency Department Educational Initiative.

OBJECTIVE: The aim of this study was to understand parents' awareness of and reactions to a slide presentation based waiting-room educational initiative. METHODS: This was a prospective observational study at a Canadian tertiary-care pediatric emergency department (ED) with an annual census of 68,000 visits. An anonymous parental survey was developed de novo, and parents were asked to complete the survey during their low-acuity ED visit over a 2-week study period. Descriptive statistics were used to describe responses and themes. RESULTS: Parents completed 520 surveys (733 approached, 70.9% response rate). Eighty-three percent of respondents had previously sought care in the ED. Most parents (68.9%) were aware of the slide presentation, but only 33.7% were able to watch it in its entirety (20 minutes' duration). Of those who watched the whole presentation, 62.9% understood that lower-acuity cases are assessed in the ambulatory zone of the ED, and sicker children are assessed in the acute zone (89.4%), 79.9% felt the presentation helped them to understand how the ambulatory zone functions, and 83.2% appreciated the current wait-time information. General questions about common health concerns were answered correctly in 58.3% (fever), 56.0% (gastroenteritis), 50.5% (abdominal pain/constipation), 35.7% (earache), and 17.0% (head injury). CONCLUSIONS: The majority of parents were aware of this waiting-room educational initiative, but there was variable uptake of information. Parents watching the entire presentation appreciated the information provided, especially wait-time information, and felt it improved their experience. Knowledge of common health conditions was low; novel methods of knowledge transfer must be utilized and evaluated.

Integrating Engagement and Improvement Work in a Pediatric Hospital.

Although geared towards a common goal - improved patient-centred care - quality improvement strategies and patient engagement-focused approaches are often developed and conducted in silos. The lack of integration may lead, on the one hand, to the uptake of patient suggestions that do not always take into consideration implications for the delivery of quality care and, on the other hand, to inadequate understanding of patient views required to create optimal services. The Children's Hospital of Eastern Ontario (CHEO)'s action plans to address gaps in patient engagement and quality improvement, two of its priority areas, were initially carried out in isolation of each other. While implementing a key patient engagement initiative using an experience-based co-design approach, Lean process improvement tools were used to plan and implement projects to improve patient, family and staff experiences of care. Preliminary assessments of this project revealed that the integration of these two approaches is feasible and that it was well received by both staff and families. There is important synergy to be found between patient engagement and quality improvement that needs to be leveraged by organizational structures and processes to fulfill the commitments inherent in both fields.

But We're Not Like the People on TV: A Qualitative Examination of How Media Messages are Perceived by Pregnant and Parenting Youth.

OBJECTIVES: The media has long been established as influential in the formation of youth attitudes. It remains unknown, however, whether popular media depictions of teenage pregnancy and motherhood shape the meanings pregnant and parenting youth (PPY) construct. This study explored PPY's perceptions of media messages portraying PPY. METHODS: Five focus groups were conducted at three urban centres that service pregnant youth and young parents. Convenience sample of 26 participants was recruited across sites. Focus groups were audio recorded, transcribed verbatim and analyzed thematically. RESULTS: Participants were a mean age of 18.7 years. Participants felt that the storylines in television reality programs featuring PPY were highly incongruent with their lived experiences and that these representations glamorized teenage pregnancy while failing to capture other realities, such as financial hardship. Further, it was felt that such representations informed public opinion and created a double standard for teen parents. Participants felt that healthcare providers were not immune to media messaging; some participants reported withdrawing socially and others delayed accessing health services because of what they perceived as negative media-fuelled public views. CONCLUSION: This study highlights the need for heightened awareness of the influence of popular media on the portrayal of PPY. Acknowledging and challenging stereotypes of teen pregnancy, as well as initiating dialogue with youth about the impact media has on their lives should be encouraged as a means of facilitating ongoing engagement with health care services.

Focus on emotion as a catalyst of memory updating during reconsolidation.

We share the idea of Lane et al. that successful psychotherapy exerts its effects through memory reconsolidation. To support it, we add further evidence that a behavioral interference may trigger memory update during reconsolidation. Furthermore, we propose that - in addition to replacing maladaptive emotions - new emotions experienced in the therapeutic process catalyze reconsolidation of the updated memory structure.

Teaching ethics in neonatal and perinatal medicine: What is happening in Canada?

Ethically challenging clinical situations are frequently encountered in neonatal and perinatal medicine (NPM), resulting in a complex environment for trainees and a need for ethics training during NPM residency. In the present study, the authors conducted a brief environmental scan to investigate the ethics teaching strategies in Canadian NPM programs. Ten of 13 (77%) accredited Canadian NPM residency programs participated in a survey investigating teaching strategies, content and assessment mechanisms. Although informal ethics teaching was more frequently reported, there was significant variability among programs in terms of content and logistics, with the most common topics being 'The medical decision making process: Ethical considerations' and 'Review of bioethics principles' (88.9% each); lectures by staff or visiting staff was the most commonly reported formal strategy (100%); and evaluation was primarily considered to be part of their overall trainee rotation (89%). This variability indicates the need for agreement and standardization among program directors regarding these aspects, and warrants further investigation.

On affronte souvent des situations cliniques difficiles sur le plan éthique en médecine néonatale et périnatale (MNP), qui se traduisent par un milieu complexe pour les stagiaires et par la nécessité de donner une formation en éthique pendant la résidence en MNP. Dans la présente étude, les auteurs ont mené un bref examen du milieu pour examiner les stratégies d'enseignement de l'éthique au sein des programmes de MNP canadiens. Dix des 13 programmes de résidence canadiens agréés en MNP (77 %) ont participé à un sondage sur les stratégies d'enseignement, le contenu et les mécanismes d'évaluation. Même si l'enseignement informel de l'éthique était signalé davantage, on constatait une importante variabilité entre les programmes en matière de contenu et de logistique, les sujets les plus fréquents étant « Le processus de prise de décision médicale : des considérations éthiques ¼ et « Examen des principes bioéthiques ¼ (88,9 % chacun), les conférences données par le personnel ou du personnel en visite étaient la stratégie officielle la plus courante (100 %) et l'évaluation était principalement considérée comme un élément de la rotation globale des stagiaires (89 %). Cette variabilité démontre que les directeurs de programmes doivent s'entendre et standardiser ces aspects de l'éthique, et elle justifie des examens plus approfondis.

Controlling conflict from interfering long-term memory representations.

Remembering is more than an activation of a memory trace. As retrieval cues are often not uniquely related to one specific memory, cognitive control should come into play to guide selective memory retrieval by focusing on relevant while ignoring irrelevant information. Here, we investigated, by means of EEG and fMRI, how the memory system deals with retrieval interference arising when retrieval cues are associated with two material types (faces and spatial positions), but only one is task-relevant. The topography of slow EEG potentials and the fMRI BOLD signal in posterior storage areas indicated that in such situations not only the relevant but also the irrelevant material becomes activated. This results in retrieval interference that triggers control processes mediated by the medial and lateral PFC, which are presumably involved in biasing target representations by boosting the task-relevant material. Moreover, memory-based conflict was found to be dissociable from response conflict that arises when the relevant and irrelevant materials imply different responses. The two types of conflict show different activations in the medial frontal cortex, supporting the claim of domain-specific prefrontal control systems.

Deficient processing of alcohol cues in the addicted brain: Evidence from event-related potential microstates.

OBJECTIVE: Patients with alcohol use disorder (AUD) show altered brain responses to alcohol cues as compared to healthy controls. Event-related potential (ERP) studies mostly focus on the P3, which is usually diminished in AUD patients. The few studies that have investigated earlier components have yielded inconsistent results. The present study aimed at identifying the onset of impaired alcohol cue processing in AUD patients, as well as the association between neurophysiological processing and subjective craving. METHODS: A sample of 15 inpatients with AUD and 15 healthy controls completed a cue reactivity task with alcohol-related, neutral, and scrambled pictures. Multichannel-EEG was recorded from 70 scalp electrodes, and ERP microstates were analyzed. RESULTS: Patients displayed impaired neurophysiological processing, as indexed by a weaker P3 and a weaker, insensitive P1. The blunted P1 was associated with higher subjective craving. CONCLUSIONS: Impaired alcohol cue processing in AUD emerges early, at the stage of sensory processing. Such deficient initial processing seems crucial to understanding cue reactivity processes in the brain and in the subjective experience of craving. SIGNIFICANCE: The results highlight the importance of investigating early ERP components preceding the P3, and contribute to the debate on the onset of information-processing dysfunction in the addicted brain.

Neurophysiological traces of interpersonal pain: How emotional autobiographical memories affect event-related potentials.

The automatic, involuntary reactivation of disturbing emotional memories, for example, of interpersonal pain, causes psychological discomfort and is central to many psychopathologies. This study aimed at elucidating the automatic brain processes underlying emotional autobiographical memories by investigating the neurophysiological dynamics within the first second after memory reactivation. Pictures of different individualized familiar faces served as cues for different specific emotional autobiographical memories, for example, for memories of interpersonal pain and grievances or for memories of appreciation in interpersonal relationships. Nineteen subjects participated in a passive face-viewing task while multichannel electroencephalogram was recorded. Analyses of event-related potentials demonstrated that emotional memories elicited an early posterior negativity and a stronger late positive potential, which tended to be particularly enhanced for painful memories. Source estimations attributed this stronger activation to networks including the posterior cingulate and ventrolateral prefrontal cortices. The findings suggest that the reactivation of emotional autobiographical memories involves privileged automatic attention at perceptual processing stages, and an enhanced recruitment of neural network activity at a postperceptual stage sensitive to emotional-motivational processing. (PsycINFO Database Record

Treat Me But Don't Judge Me: A Qualitative Examination of Health Care Experiences of Pregnant and Parenting Youth.

STUDY OBJECTIVE: To share pregnant and parenting youth's experiences with health care to inform recommendations for promoting youth-friendly medical encounters. DESIGN: This exploratory study used a qualitative descriptive approach. SETTING: Three urban centers that service pregnant youth and young parents in a large Canadian city. PARTICIPANTS: A convenience sample of 26 participants (mean age of 18.7 years) was recruited across sites. INTERVENTIONS: Five focus groups were conducted. MAIN OUTCOME MEASURES: Focus groups were audio recorded, transcribed verbatim, and analyzed thematically. Analysis involved the independent, open coding of data by 2 qualitative researchers to identify and compare emerging themes. RESULTS: Three major themes emerged regarding their experiences with health care providers: characteristics of negative health care encounters, the emergence of contemporary stereotypes during these encounters, and characteristics of positive health care encounters. Negative encounters often resulted from perceived judgmental attitudes of providers and were shown to contribute to a general sense of mistrust and fear. Positive health care encounters tended to feature mutual respect, support, open dialogue, and nonjudgmental attitudes. CONCLUSION: Pregnant and parenting youth in our study have experienced many negative health care encounters that have contributed to disengagement and mistrust of the health care system. To engage this high-risk population in health care, practitioners are encouraged to consider their own biases when servicing this population and work toward fostering positive, nonjudgmental interactions, and supportive environments.

Development of stimulus material for research in alcohol use disorders.

The availability of appropriate stimulus material is a key concern for an experimental approach to research on alcohol use disorders (AUDs). A large number of such stimuli are necessary to evoke relevant alcohol-related associations. We report the development of a large stimulus database consisting of 457 pictures of alcoholic beverages and 398 pictures of neutral objects. These stimuli were rated by 18 inpatients hospitalized due to severe AUD and 18 healthy controls along four dimensions: arousal, valence, alcohol-relatedness, and craving. Physical parameters of the pictures were assessed. After outlier removal, 831 stimuli that were characterized as either alcohol-related or neutral were retained in the final stimulus pool. Alcohol-related pictures (versus neutral pictures) evoked higher arousal, more craving and were judged to have higher alcohol-relatedness and a more negative valence. Group comparisons indicated that in patients, neutral pictures evoked more craving and had higher alcohol-relatedness than they did in controls. Physical parameters such as visual complexity, luminance, and color were extracted from these pictures, and extreme values were normalized to minimize mean differences between alcoholic and neutral stimuli. The pictures met the qualitative requirements for (neurophysiological) research. A data file containing rating values and physical parameters will be provided upon request.

Leaving Distress Behind: A Randomized Controlled Study on Change in Emotional Processing in Borderline Personality Disorder.

OBJECTIVE: The marked impulsivity and instability of clients suffering from borderline personality disorder (BPD) greatly challenge therapists' understanding and responsiveness. This may hinder the development of a constructive therapeutic relationship despite it being of particular importance in their treatment. Recent studies have shown that using motive-oriented therapeutic relationship (MOTR), a possible operationalization of appropriate therapist responsiveness, can enhance treatment outcome for BPD. The overall objective of this study is to examine change in emotional processing in BPD clients following the therapist's use of MOTR. METHOD: The present paper focuses on N = 50 cases, n = 25 taken from each of two conditions of a randomized controlled add-on effectiveness design. Clients were either allocated to a manual-based psychiatric-psychodynamic 10-session version of general psychiatric management (GPM), a borderline-specific treatment, or to a 10-session version of GPM augmented with MOTR. Emotional states were assessed using the Classification of Affective-Meaning States (Pascual-Leone & Greenberg, 2005) at intake, midtreatment, and in the penultimate session. RESULTS: Across treatment, early expressions of distress, especially the emotion state of global distress, were shown to significantly decrease (p = .00), and adaptive emotions were found to emerge (p < .05). Between-condition differences of change were found, including a significant increase in emotional variability and stronger outcome predictors in the MOTR condition. CONCLUSIONS: The findings indicate initial emotional change in BPD clients in a relatively short time frame and suggest the addition of MOTR to psychotherapeutic treatments as promising. Clinical implications are discussed.

Emotional Processing, Interaction Process, and Outcome in Clarification-Oriented Psychotherapy for Personality Disorders: A Process-Outcome Analysis.

It is important to understand the change processes involved in psychotherapies for patients with personality disorders (PDs). One patient process that promises to be useful in relation to the outcome of psychotherapy is emotional processing. In the present process-outcome analysis, we examine this question by using a sequential model of emotional processing and by additionally taking into account a therapist's appropriate responsiveness to a patient's presentation in clarification-oriented psychotherapy (COP), a humanistic-experiential form of therapy. The present study involved 39 patients with a range of PDs undergoing COP. Session 25 was assessed as part of the working phase of each therapy by external raters in terms of emotional processing using the Classification of Affective-Meaning States (CAMS) and in terms of the overall quality of therapist-patient interaction using the Process-Content-Relationship Scale (BIBS). Treatment outcome was assessed pre- and post-therapy using the Global Severity Index (GSI) of the SCL-90-R and the BDI. Results indicate that the good outcome cases showed more self-compassion, more rejecting anger, and a higher quality of therapist-patient interaction compared to poorer outcome cases. For good outcome cases, emotional processing predicted 18% of symptom change at the end of treatment, which was not found for poor outcome cases. These results are discussed within the framework of an integrative understanding of emotional processing as an underlying mechanism of change in COP, and perhaps in other effective therapy approaches for PDs.

Facilitators and Barriers to Noninvasive Ventilation Adherence in Youth with Nocturnal Hypoventilation Secondary to Obesity or Neuromuscular Disease.

OBJECTIVE: Many youth struggle with adherence to bilevel noninvasive ventilation (NIV), often shortly after initiation of treatment. Anecdotal evidence suggests youths with comorbid obesity struggle with adherence while youths with comorbid neuromuscular disease demonstrate better adherence rates. The objective of this study was to explore factors relating to bilevel NIV adherence, and to compare these between youths with underlying obesity or neuromuscular disease. METHODS: An exploratory qualitative approach was used to examine youth and caregivers' experiences with and perceptions of bilevel NIV. Semi-structured interviews (n = 16) of caregivers and youths were conducted. Youths 12 years and older with nocturnal hypoventilation diagnosed on polysomnography and managed with bilevel NIV, with either concurrent obesity or neuromuscular disease were included. Thematic analysis of interview data was conducted using qualitative analysis software. RESULTS: Factors associated with positive bilevel NIV adherence included previous encouraging experiences with therapy; subjective symptom improvement; familiarity with medical treatments; understanding of nocturnal hypoventilation and its consequences; family and health-care team support; and early adaptation to treatments. Factors associated with poor bilevel NIV adherence included previous negative experiences with therapy, negative attitude towards therapy; difficulty adapting; perceived lack of support from family or health-care team; fear/embarrassment regarding treatment; caregivers not being health-minded; technical issues; side effects; and a lack of subjective symptom improvement. CONCLUSIONS: The dimensions which most affect adherence to bilevel NIV are those which contribute to youths' conception of feeling "well" or "unwell." Adherence to treatment may hinge largely on the way in which NIV is initially experienced and framed. COMMENTARY: A commentary on this article appears in this issue on page 1355.

Lactation support and breastfeeding duration in jaundiced infants: a randomized controlled trial.

OBJECTIVES: Neonatal jaundice is the most common problem in full-term infants during the immediate post-natal period. We examined the effect of a lactation support intervention on breastfeeding duration in hospitalized jaundiced infants. STUDY DESIGN: We conducted a randomized controlled trial with a qualitative component involving mothers of hospitalized jaundiced breastfed infants <4 weeks of age. Mothers receiving the intervention met with an International Board-Certified Lactation Consultant in hospital and 1-3 times post discharge. Both groups received the standard care for jaundice. The primary outcome was exclusive breastfeeding at 3 months. To the exception of research assistants enrolling participants and completing qualitative interviews, all research staff, investigators and statisticians were blinded to group assignment. Qualitative interviews elicited feedback on breastfeeding experiences for both groups. RESULTS: 99 participants were recruited, and 86 analyzed for primary outcome. There was no difference in exclusive breastfeeding at 3 months between groups (RR 0.84, 95% CI 0.56-1.24, p = 0.40) or in the secondary outcomes. 31 participants were included in the qualitative analysis. Participants in the intervention group described an increase in comfort and confidence levels with breastfeeding. Participants in the control group reported limited lactation support. CONCLUSIONS: Our hospital-based lactation support program did not result in a higher proportion of mothers exclusively breastfeeding at 3 months compared to current hospital standard care. Qualitative feedback from the intervention group suggests that mothers' confidence was increased, which is linked to breastfeeding duration. The decision to breastfeed is multifactorial and hospital-based lactation support may be only a small piece of the puzzle in hospitalized jaundiced infants. Further studies may be needed to fully elucidate the impact of an in-hospital lactation support program on successful breastfeeding for these infants. TRIAL REGISTRATION: ClinicalTrials.gov NCT00966719 https://www.clinicaltrials.gov/ct2/show/NCT00966719?term=Lactation+Support+and+Breastfeeding+Duration+in+Jaundiced+Infants%3A+a+Randomized+Controlled+Trial&rank=1.