Post-ERCP cholecystitis: Incidence, characteristics, and outcomes from a prospective multicenter biliary endoscopy registry.

BACKGROUND AND AIMS: The incidence, risk factors, and outcomes of post-ERCP cholecystitis are poorly described. We aimed to describe cases of post-ERCP cholecystitis from a prospective multicenter registry with protocolized 30-day follow-up. METHODS: Patient- and procedure-related data from 7 centers were obtained. The primary outcome was post-ERCP cholecystitis, defined according to a Delphi-based criteria and causal attribution system. Risk factors and outcomes were described for all cases. RESULTS: Seventeen cases of post-ERCP cholecystitis were identified among 4428 patients with gallbladders undergoing ERCP between 2018 and 2023 (incidence, 0.38%; 95% confidence interval, 0.20-0.57). In ERCPs with covered metal stenting, 7 of 467 resulted in cholecystitis (incidence, 1.50%; 95% confidence interval, 0.40-2.60). Patients had symptoms at a median of 5 days (interquartile range, 5) after ERCP. Management strategies included cholecystectomy, percutaneous cholecystostomy, and endoscopic stent removal/exchange. CONCLUSIONS: Estimates of post-ERCP cholecystitis incidence can inform discussions around procedural risk.

Enhancing cortical network-level participation coefficient as a potential mechanism for transfer in cognitive training in aMCI.

Effective cognitive training must improve cognition beyond the trained domain (show a transfer effect) and be applicable to dementia-risk populations, e.g., amnesic mild cognitive impairment (aMCI). Theories suggest training should target processes that 1) show robust engagement, 2) are domain-general, and 3) reflect long-lasting changes in brain organization. Brain regions that connect to many different networks (i.e., show high participation coefficient; PC) are known to support integration. This capacity is 1) relatively preserved in aMCI, 2) required across a wide range of cognitive domains, and 3) trait-like. In 49 individuals with aMCI that completed a 6-week visual speed of processing training (VSOP) and 28 active controls, enhancement in PC was significantly more related to transfer to working memory at global and network levels in VSOP compared to controls, particularly in networks with many high-PC nodes. This suggests that enhancing brain integration may provide a target for developing effective cognitive training.

Critical food and nutrition science challenges for plant-based meat alternative products.

A reduced reliance on animal-based diets with a move towards a more plant-based diet has driven the market demand for new generation sustainable plant-based meat alternatives. This review covers science and business perspectives relating to the development of plant-based meat alternatives. A conceptual framework to help inform the innovation pathway is provided. The market opportunity, consumer perspectives, the science that underpins the development of plant-based meat alternatives and patent information relating to these products are discussed. Careful navigation through the public domain science literature and patent landscape is necessary for informing the choice of ingredients, formulations and processes for producing plant-based meat alternatives. Attention to design of ingredient systems for optimization of flavor, texture, binding, color and nutrition is necessary for development of plant-based meat alternatives with desirable consumer attributes. Recommendations for further research for developing superior formulations for consumer-acceptable plant-based meat alternative products for improving sustainability outcomes are suggested.

Learning Clique Subgraphs in Structural Brain Network Classification with Application to Crystallized Cognition.

Structural brain networks constructed from diffusion MRI are important biomarkers for understanding human brain structure and its relation to cognitive functioning. There is increasing interest in learning differences in structural brain networks between groups of subjects in neuroimaging studies, leading to a variable selection problem in network classification. Traditional methods often use independent edgewise tests or unstructured generalized linear model (GLM) with regularization on vectorized networks to select edges distinguishing the groups, which ignore the network structure and make the results hard to interpret. In this paper, we develop a symmetric bilinear logistic regression (SBLR) with elastic-net penalty to identify a set of small clique subgraphs in network classification. Clique subgraphs, consisting of all the interconnections among a subset of brain regions, have appealing neurological interpretations as they may correspond to some anatomical circuits in the brain related to the outcome. We apply this method to study differences in the structural connectome between adolescents with high and low crystallized cognitive ability, using the crystallized cognition composite score, picture vocabulary and oral reading recognition tests from NIH Toolbox. A few clique subgraphs containing several small sets of brain regions are identified between different levels of functioning, indicating their importance in crystallized cognition.

Surface-Based Connectivity Integration: An atlas-free approach to jointly study functional and structural connectivity.

There has been increasing interest in jointly studying structural connectivity (SC) and functional connectivity (FC) derived from diffusion and functional MRI. Previous connectome integration studies almost exclusively required predefined atlases. However, there are many potential atlases to choose from and this choice heavily affects all subsequent analyses. To avoid such an arbitrary choice, we propose a novel atlas-free approach, named Surface-Based Connectivity Integration (SBCI), to more accurately study the relationships between SC and FC throughout the intra-cortical gray matter. SBCI represents both SC and FC in a continuous manner on the white surface, avoiding the need for prespecified atlases. The continuous SC is represented as a probability density function and is smoothed for better facilitation of its integration with FC. To infer the relationship between SC and FC, three novel sets of SC-FC coupling (SFC) measures are derived. Using data from the Human Connectome Project, we introduce the high-quality SFC measures produced by SBCI and demonstrate the use of these measures to study sex differences in a cohort of young adults. Compared with atlas-based methods, this atlas-free framework produces more reproducible SFC features and shows greater predictive power in distinguishing biological sex. This opens promising new directions for all connectomics studies.

Endosonography-guided transmural drainage of pancreatic fluid collections: comparative outcomes by stent type.

BACKGROUND: Pancreatic fluid collections (PFCs), including walled-off necrosis (WON), are commonly described sequelae of pancreatitis. Endosonography-guided PFC drainage can be performed using plastic stents (PS), fully covered self-expanding metal stents (FCSEMS), or lumen-apposing metal stents (LAMS). We performed a retrospective study comparing clinical outcomes and adverse events by stent type. METHODS: In this historical cohort, patients undergoing endosonography-guided PFC drainage from 2010 to 2019 were divided into groups: those treated with (1) PS, (2) FCSEMS, and (3) LAMS. Clinical success, the primary outcome, was defined as complete resolution or size reduction of ≥ 50%, with resolution of symptoms and no reintervention required at 3 months following the index procedure. Adverse events (AEs) and procedure times were also evaluated. RESULTS: Fifty-eight patients were included. Procedure times were significantly shorter with LAMS (21.4 ± 10.8 min versus 53.0 ± 24.4 min for FCSEMS and 65.9 ± 23.4 min for PS, p < 0.001). Clinical success rates for WON were higher with LAMS compared with FCSEMS (95.7% vs 66.7%, respectively; p = 0.04). For all PFCs, treatment with LAMS trended towards higher clinical success rates compared with PS and FCSEMS (96.3% vs 81.8% vs 77.8%, respectively; p = 0.14). Early AEs (within 1 week) occurred at significantly lower rates in the LAMS group compared to PS and FCSEMS (0% vs 33.3% vs 10.6%, respectively; p = 0.006), as did late AEs (7.4% vs 44.5% vs 40%, respectively; p = 0.01). CONCLUSIONS: LAMS is superior in terms of WON clinical success, favorable in terms of lower adverse event profile, and shorter in terms of procedural time compared to FCSEMS and PS. LAMS can be considered as an initial approach for WON, given that clinical success in WON is lower when using PS or FCSEMS, though more high-quality data are needed.

Morphology of the major papilla predicts ERCP procedural outcomes and adverse events.

BACKGROUND: The morphology of the major papilla affects the difficulty of endoscopic retrograde cholangiopancreatography (ERCP), but no associations with adverse events have previously been established. We aimed to assess whether papillary morphology predicts ERCP adverse events. METHODS: A retrospective analysis was performed of a prospective registry of patients undergoing ERCP for biliary indications. The primary outcome was post-ERCP pancreatitis (PEP), with secondary outcomes including other adverse events and procedural outcomes such as inadvertent pancreatic duct cannulation, cannulation time, and attempts. Papillae were classified as normal (Type I), small or flat (Type II), bulging (Type IIIa), pendulous (Type IIIb), creased (Type IV), or peri-diverticular (Type D). Outcomes were ascertained prospectively at 30 days from index procedures. RESULTS: A total of 637 patients with native papillae were included. Compared to Type I papillae, Type II and Type IIIb papillae were associated with PEP, with adjusted odds ratios (AOR) of 7.28 (95% confidence intervals, CI, 1.84-28.74) and 4.25 (95% CI 1.26-14.32), respectively. Type II and IIIb papillae were associated with significantly longer cannulation times by 5.37 (95% CI 2.39-8.35) and 4.01 (95% CI 1.72-6.30) minutes, respectively. Type IIIb papillae were associated with lower deep cannulation success (AOR 0.17, 95% CI 0.06-0.48). CONCLUSION: Papillary morphology is an important factor influencing both ERCP success and outcomes. Understanding this is key for managing intraprocedural approaches and minimizing adverse events. PROSPECTIVE REGISTRY REGISTRATION: Clinicaltrials.gov identifier NCT04259580.

The PREvention Program for Alzheimer's RElated Delirium (PREPARED) cluster randomized trial: a study protocol.

BACKGROUND: Delirium is a significant cause of morbidity and mortality among older people admitted to both acute and long-term care facilities (LTCFs). Multicomponent interventions have been shown to reduce delirium incidence in the acute care setting (30-73%) by acting on modifiable risk factors. Little work, however, has focused on using this approach to reduce delirium incidence in LTCFs. METHODS: The objective is to assess the effectiveness of the multicomponent PREPARED Trial intervention in reducing the following primary outcomes: incidence, severity, duration, and frequency of delirium episodes in cognitively impaired residents. This 4-year, parallel-design, cluster randomized study will involve nursing staff and residents in 45-50 LTCFs in Montreal, Canada. Participating public and private LTCFs (clusters) that provide 24-h nursing care will be assigned to either the PREPARED Trial intervention or the control (usual care) arm of the study using a covariate constrained randomization procedure. Approximately 400-600 LTC residents aged 65 and older with dementia and/or cognitive impairment will be enrolled in the study and followed for 18 weeks. Residents must be at risk of delirium, delirium-free at baseline and have resided at the facility for at least 2 weeks. Residents who are unable to communicate verbally, have a history of specific psychiatric conditions, or are receiving end-of-life care will be excluded. The PREPARED Trial intervention consists of four main components: a decision tree, an instruction manual, a training package, and a toolkit. Primary study outcomes will be assessed weekly. Functional autonomy and cognitive levels will be assessed at the beginning and end of follow-up, while information pertaining to modifiable delirium risk factors, medical consultations, and facility transfers will be collected retrospectively for the duration of the follow-up period. Primary outcomes will be reported at the level of intervention assignment. All researchers analyzing the data will be blinded to group allocation. DISCUSSION: This large-scale intervention study will contribute significantly to the development of evidence-based clinical guidelines for delirium prevention in this frail elderly population, as it will be the first to evaluate the efficacy of a multicomponent delirium prevention program translated into LTC clinical practice on a large scale. TRIAL REGISTRATION: NCT03718156 , ClinicalTrials.gov .

Infection control in ERCP using a duodenoscope with a disposable cap (ICECAP): rationale for and design of a randomized controlled trial.

BACKGROUND: Endoscopic retrograde cholangio-pancreatography (ERCP) is commonly performed in the management of pancreatic and biliary disease. Duodenoscopes are specialized endoscopes used to perform ERCP, and inherent to their design, a high rate of persistent bacterial contamination exists even after automated reprocessing and disinfection. Consequently, in recent years, ERCP has been associated with infection transmission, leading to several fatal patient outbreaks. Due to increasing fears over widespread future duodenoscope-related outbreaks, regulatory bodies have called for alterations in the design of duodenoscopes. A duodenoscope has recently been developed that employs a disposable cap. This novel design theoretically eliminates the mechanism behind persistent bacterial contamination and infection transmission. However, there are no data demonstrating persistent bacterial contamination rates, technical success rates, or clinical outcomes associated with these duodenoscopes. METHODS: A parallel arm randomized controlled trial will be performed for which 520 patients will be recruited. The study population will consist of consecutive patients undergoing ERCP procedures for any indication at a high-volume tertiary care centre in Calgary, Alberta, Canada. Patients will be randomized to an intervention group, that will undergo ERCP with a novel duodenoscope with disposable cap, or to a control group who will undergo ERCP with a traditional duodenoscope. Co-primary outcomes will include persistent bacterial contamination rates (post automated reprocessing) and ERCP technical success rates. Secondary outcomes include clinical success rates, overall and specific early and late adverse event rates, 30-day mortality and healthcare utilization rates, procedure and reprocessing times, and ease of device use. DISCUSSION: The ICECAP trial will answer important questions regarding the use of a novel duodenoscope with disposable cap. Specifically, persistent bacterial contamination, technical performance, and relevant clinical outcomes will be assessed. Given the mortality and morbidity burden associated with ERCP-related infectious outbreaks, the results of this study have the capacity to be impactful at an international level. TRIAL REGISTRATION: This trial was registered on clinicaltrials.gov (NCT04040504) on July 31, 2019.

The role of food science and technology in humanitarian response.

BACKGROUND: In humanitarian contexts, ensuring access to safe, nutritious, good quality and culturally appropriate food in the right quantity at the right time and place during an emergency or a protracted crisis is an enormous challenge, which is likely to increase given uncertainties such as climate change, global political and economic instability and emerging pandemics like COVID-19. Several international organizations and non-government organizations have well established systems to respond to food security emergencies. However, the role of food science and technology in humanitarian response is not well understood and is seldom considered in humanitarian circles. SCOPE AND APPROACH: The role of food science and technology in humanitarian response and the importance of addressing the requirements of the local consumers within the local food systems are discussed. KEY FINDINGS AND CONCLUSIONS: Humanitarian food aid policies focus on immediate and short-term assistance to save lives. The implementation of emergency programs and projects tends to induce dependency on aid, rather than strengthening local food systems and ensuring resilience. Transformative change must embrace innovation across the whole food system with an increased emphasis on food science and technology that addresses local food security, generates employment and contributes to the local economy. There needs to be a move beyond rehabilitating and increasing agricultural production to addressing the whole food system with a view to link humanitarian assistance and longer-term support to sustainable livelihoods and resilience.

Latent class analysis of the multivariate Delirium Index in long-term care settings.

ABSTRACTBackground:A few studies examine the time evolution of delirium in long-term care (LTC) settings. In this work, we analyze the multivariate Delirium Index (DI) time evolution in LTC settings. METHODS: The multivariate DI was measured weekly for six months in seven LTC facilities, located in Montreal and Quebec City. Data were analyzed using a hidden Markov chain/latent class model (HMC/LC). RESULTS: The analysis sample included 276 LTC residents. Four ordered latent classes were identified: fairly healthy (low "disorientation" and "memory impairment," negligible other DI symptoms), moderately ill (low "inattention" and "disorientation," medium "memory impairment"), clearly sick (low "disorganized thinking" and "altered level of consciousness," medium "inattention," "disorientation," "memory impairment" and "hypoactivity"), and very sick (low "hypoactivity," medium "altered level of consciousness," high "inattention," "disorganized thinking," "disorientation" and "memory impairment"). Four course types were also identified: stable, improvement, worsening, and non-monotone. Class order was associated with increasing cognitive impairment, frequency of both prevalent/incident delirium and dementia, mortality rate, and decreasing performance in ADL. CONCLUSION: Four ordered latent classes and four course types were found in LTC residents. These results are similar to those reported previously in acute care (AC); however, the proportion of very sick residents at enrolment was larger in LTC residents than in AC patients. In clinical settings, these findings could help identify participants with a chronic clinical disorder. Our HMC/LC approach may help understand coexistent disorders, e.g. delirium and dementia.

Clinical prediction rule to determine the need for repeat ERCP after endoscopic treatment of postsurgical bile leaks.

BACKGROUND AND AIMS: In patients who have undergone ERCP with biliary stenting for postsurgical bile leaks, the optimal method (ERCP or gastroscopy) and timing of stent removal is controversial. We developed a clinical prediction rule to identify cases in which a repeat ERCP is unnecessary. METHODS: Population-based study of all patients who underwent ERCP for management of surgically induced bile leaks between 2000 and 2012. Multivariate and binary recursive partitioning analyses were performed to generate a rule predicting the absence of biliary pathology on repeat endoscopic evaluation. RESULTS: A total of 259 patients were included. On multivariate analysis, postsurgical normal alkaline phosphatase (ALP; OR, 2.26; 95% CI, 1.03-4.99), time from surgery to first ERCP < 8 days (OR, 2.47; 95% CI, 1.15-5.31), and minor leak with no other pathology on initial ERCP (OR, 6.74; 95% CI, 1.75-25.89) were independently associated with the absence of persistent bile leak and other pathology on repeat ERCP. The derived rule included laparoscopic cholecystectomy, normal postsurgical ALP, minor leak with no other pathology on initial ERCP, and an interval from initial to repeat ERCP between 4 and 8 weeks. When all 4 criteria were met, the rule had a sensitivity of 94% (95% CI, 83%-99%) and a negative predictive value of 93% (95% CI, 81%-99%). Optimism-adjusted sensitivity and negative predictive value were 88% (95% CI, 76%-96%) and 86% (95% CI, 73%-96%), respectively. CONCLUSIONS: This clinical decision rule identifies patients who can have their biliary stents removed via gastroscopy, which may improve patient safety and healthcare utilization.

Use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults: a nested case-control study.

OBJECTIVE: The objective of this study is to explore whether the use of medications that antagonize mediators of inflammatory responses reduces the risk of delirium in older adults. METHODS: A nested case-control study was conducted using data from a prospective study of delirium in older long-term care residents from 7 long-term care facilities in Montreal and Quebec City, Canada. The Confusion Assessment Method was used to diagnose incident delirium. The use of medications that antagonize mediators of inflammatory responses was determined by examining facility pharmacy databases and coding medications received daily by each resident. Risk sets were built using incidence density sampling: each risk set consisted of a case with incident delirium and all controls without incident delirium at the same date and facility. Conditional logistic regression was used to assess the association of exposure to inflammation antagonist medications with the incidence of delirium. RESULTS: Of 254 residents, 95 developed incident delirium during 24 weeks (cases); each case was matched with up to 35 controls. Unadjusted and adjusted odds ratios (95% CI) of delirium for residents exposed to at least one inflammation antagonist medication were 0.53 (0.34, 0.81) and 0.60 (0.38, 0.92), respectively. Estimates of the risk of incident delirium associated with specific medications and medication classes were mostly protective but not statistically significant. CONCLUSION: The use of medications that antagonize mediators of inflammatory responses may reduce the risk of delirium in older adults. Despite study limitations, the findings merit further investigation using larger patient samples, more precise measures of exposure and better control of potential confounding variables. Copyright © 2016 John Wiley & Sons, Ltd.

Partial and no recovery from delirium after hospital discharge predict increased adverse events.

Background: The implications of partial and no recovery from delirium after hospital discharge are not clear. We sought to explore whether partial and no recovery from delirium among recently discharged patients predicted increased adverse events (emergency room visits, hospitalisations, death) during the subsequent 3 months. Method: Prospective study of recovery from delirium in older hospital inpatients. The Confusion Assessment Method was used to diagnose delirium in hospital and determine recovery status after discharge (T0). Adverse events were determined during the 3 months T0. Survival analysis to the first adverse event and counting process modelling for one or more adverse events were used to examine associations between recovery status (ordinal variable, 0, 1 or 2 for full, partial or no recovery, respectively) and adverse events. Results: Of 278 hospital inpatients with delirium, 172 were discharged before the assessment of recovery status (T0). Delirium recovery status at T0 was determined for 152: 25 had full recovery, 32 had partial recovery and 95 had no recovery. Forty-four patients had at least one adverse event during the subsequent 3 months. In multivariable analysis of one or more adverse events, poorer recovery status predicted increased adverse events; the hazard ratio (HR) (95% confidence interval, CI) was 1.72 (1.09, 2.71). The association of recovery status with adverse events was stronger among patients without dementia. Conclusion: Partial and no recovery from delirium after hospital discharge appear to predict increased adverse events during the subsequent 3 months These findings have potentially important implications for in-hospital and post-discharge management and policy.

Baseline Psychological Treatment Reduces the Effect of Coaching in a Randomised Trial of a Depression Self-Care Intervention.

OBJECTIVE: To explore the effects of baseline psychological and antidepressant medication treatment in a trial of lay telephone coaching in a low-intensity, supported depression self-care intervention. METHOD: A single blind, individually randomised, pragmatic trial was conducted among primary care adults with chronic physical conditions and comorbid depressive symptoms. Eligible subjects were randomised to receive a depression self-care toolkit with (intervention group) or without (control group) telephone coaching provided by trained lay coaches. For this brief communication, a secondary analysis of the trial data focused on the effects of baseline psychological and antidepressant treatments on mental health outcomes (Patient Health Questionnaire 9 [PHQ-9], SF-12 Mental Component Summary [MCS], Generalized Anxiety Disorder 7 [GAD-7]) and satisfaction with the intervention. RESULTS: In total, 223 patients were randomised, and 165 (74.0%) completed both 3- and 6-month follow-ups. There were 2 significant interactions of baseline treatment and study group for 6-month mental health outcomes. A significant benefit of coaching on 6-month PHQ-9 was seen only among participants who were not receiving baseline psychological treatment. A smaller interaction was found for baseline antidepressant medications and 6-month mental health. There was a significant main effect for baseline psychological treatment and lower 6-month satisfaction. CONCLUSIONS: Depressed patients receiving baseline psychological treatment may not benefit from lay coaching offered as part of a low-intensity depression self-care intervention.

Longitudinal patterns of delirium severity scores in long-term care settings.

BACKGROUND: The delirium index (DI) is a valid measure of delirium severity. We proposed to describe longitudinal patterns of severity scores in older long-term care (LTC) residents. METHODS: A prospective cohort study of 280 residents in seven LTC facilities in Montreal and Quebec City, Canada, was conducted. DI, Barthel Index, Mini-Mental State Examination, Charlson Comorbidity Index, Cornell Scale for Depression in Dementia, dementia assessment by an MD, and prevalent or incident probable delirium defined according to the Confusion Assessment Method were completed at baseline. The DI was also assessed weekly for 6 months. Demographic characteristics were abstracted from resident charts. Cluster analysis for longitudinal data was used to describe longitudinal patterns of DI scores. RESULTS: During the 24 weeks following enrolment, 28 (10.0%) of 280 residents who had prevalent delirium and 76 (27.1%) who had incident delirium were included in our analysis. Average observation period was 18.3 weeks. Four basic types of time evolution patterns were discovered: Improvement, Worsening, Fluctuating, and Steady, including 22%, 18%, 25%, and 35%, of the residents, respectively. With the exception of the Worsening pattern, the average trajectory was stabilized at the 4th week or earlier. Poor baseline cognitive and physical function and greater severity of delirium predicted worse trajectories over 24 weeks. CONCLUSIONS: The longitudinal patterns of DI scores found in LTC residents resemble those found in an earlier study of delirium in acute care (AC) settings. However, compared to AC patients, LTC residents have a smaller DI variability over time, a less frequent Improvement pattern, and more frequent Worsening and Fluctuating patterns.

[The Management of Depression in Older Adults and Their Family Caregivers: Findings from a Research Program in Quebec]. / La gestion de la dépression chez les aînés et leurs aidants naturels : résultats d'un programme de recherche au Québec.

Objectives A research group based at St. Mary's Research Centre, St. Mary's Hospital, Montreal, has conducted a research program over the past two decades that aims to inform improvements in the management of depression in primary care and general medical settings, among older adults. This paper reviews the findings from this research program, discusses the findings in the context of other research, and highlights the implications for practice and health policy.Methods Narrative review and synthesis of 25 published articles, that included: 4 systematic reviews, 10 observational studies, 9 intervention trials, and 2 consensus conference reports.Results The results pertain to 4 research areas: detection of depression in primary care and general medical settings; collaborative care of depression; depression self-care interventions; and the role of family and friends in supporting depression self-care interventions.Conclusions We propose six recommendations for improving the management of depression in the target population. 1) Depression detection and treatment can be improved through collaborative care models that involve primary care physicians, mental health specialists and non-physician mental health workers who are trained to assist with the detection of depression, with the delivery of brief, low-intensity psychological interventions and with self-care support. More research and evaluation are necessary to determine the factors that enhance the effectiveness, cost-efficiency, and consumer-centeredness of these interventions. 2) Supported depression self-care (and other low-intensity interventions such as short problem-solving therapy) offered by telephone or via internet, either as part of collaborative or usual care are feasible treatment options but more research is necessary to determine their effectiveness in different clinical populations. Some populations (e.g., those aged 75 and over, with visual and/or mild cognitive impairment) are likely to need greater or face-to-face support. 3) As most family physicians are unlikely to have the necessary time or interest to support depression self-care interventions, other sustainable programmatic contexts are needed for delivery of these interventions. Options include: nurses or other mental health workers in multidisciplinary family medicine groups; regional mental health programs; and voluntary organizations dedicated to assisting in the management of chronic illnesses. Research is needed on the feasibility and effectiveness of using peer support workers or volunteers to provide coaching of depression self-care interventions. 4) Involvement of family or friends in depression self-care may improve outcomes (e.g., dyadic interventions) but further research is necessary. 5) Further research should explore the potential of depression self-care interventions to prevent major depression and in depression relapse prevention in this population.

Frequency of full, partial and no recovery from subsyndromal deliriumin older hospital inpatients.

OBJECTIVES: To determine the frequencies of full, partial and no recovery from subsyndromal delirium (SSD) in older hospital inpatients. A secondary objective was to compare the recovery status of patients with SSD or delirium. METHODS: SSD was defined as acute onset of one or more Confusion Assessment Method core symptoms of delirium (fluctuation, inattention, disorganized thinking and altered level of consciousness) not meeting criteria for delirium and not progressing to delirium. The recovery status of medical or surgical inpatients aged 65 and older with SSD was assessed approximately 1 and 3 months after enrolment. Primary outcome categories were full recovery (no core symptoms of delirium), partial recovery (presence of one or more core symptoms but fewer symptoms than at enrolment), no recovery (same number of core symptoms as at enrolment) or death. Nominal logistic regression was used to compare the recovery status of patients with SSD or delirium. RESULTS: Twenty-eight patients with SSD were enrolled. At the first follow-up, the frequencies of full, partial and no recovery and death were 40%, 12%, 32% and 16%, respectively; at the second follow-up, the frequencies were 54%, 8%, 21% and 17%, respectively. The frequency of full recovery was much higher in patients with SSD than delirium. CONCLUSION: Small study sample size notwithstanding, the majority (54%) of patients with SSD recovered fully, but a substantial proportion (29%) had a protracted course. It may be important to monitor the longer-term course of SSD and develop strategies to ensure full recovery in all patients.

Delirium in older adults: a chronic cognitive disorder?

Delirium is defined as a neurocognitive disorder characterized by sudden onset, fluctuating course, and disturbances in level of consciousness, attention, orientation, memory, thought, perception, and behavior (American Psychiatric Association, 2013). It occurs in hyperactive, hypoactive, or mixed forms in up to 50% of older hospital patients (Inouye et al., 2014) and 70% of older long-term care residents (McCusker et al., 2011), many with pre-existing dementia (Fick et al., 2002).

Six-month trajectories of self-reported depressive symptoms in long-term care.

BACKGROUND: Depression is a common problem in long-term care (LTC) settings. We sought to characterize depression symptom trajectories over six months among older residents, and to identify resident characteristics at baseline that predict symptom trajectory. METHODS: This study was a secondary analysis of data from a six-month prospective, observational, and multi-site study. Severity of depressive symptoms was assessed with the 15-item Geriatric Depression Scale (GDS) at baseline and with up to six monthly follow-up assessments. Participants were 130 residents with a Mini-Mental State Examination score of 15 or more at baseline and of at least two of the six monthly follow-up assessments. Individual resident GDS trajectories were grouped using hierarchical clustering. The baseline predictors of a more severe trajectory were identified using the Proportional Odds Model. RESULTS: Three clusters of depression symptom trajectory were found that described "lower," "intermediate," and "higher" levels of depressive symptoms over time (mean GDS scores for three clusters at baseline were 2.2, 4.9, and 9.0 respectively). The GDS scores in all groups were generally stable over time. Baseline predictors of a more severe trajectory were as follows: Initial GDS score of 7 or more, female sex, LTC residence for less than 12 months, and corrected visual impairment. CONCLUSIONS: The six-month course of depressive symptoms in LTC is generally stable. Most residents who experience a more severe symptom trajectory can be identified at baseline.