Advancing survivorship at a comprehensive cancer center: integrating clinical care, education and research initiatives at Northwestern Medicine and the Robert H. Lurie Comprehensive Cancer Center.

The unprecedented and growing number of cancer survivors requires comprehensive quality care that includes cancer surveillance, symptom management, and health promotion to reduce morbidity and mortality and improve quality of life. However, coordinated and sustainable survivorship care has been challenged by barriers at multiple levels. We outline the survivorship programs at Northwestern Medicine and the Robert H. Lurie Comprehensive Cancer Center that have evolved over two decades. Our current survivorship clinics comprise STAR (Survivors Taking Action and Responsibility) for adult survivors of childhood cancers; Adult Specialty Survivorship for survivors of breast, colorectal and testicular cancers, lymphomas, and leukemias; and Gynecologic Oncology Survivorship. Care provision models align with general, disease/treatment-specific, and integrated survivorship models, respectively. Reimbursement for survivorship services has been bolstered by institutional budget allocations. We have standardized survivor education, counseling, and referrals through electronic health record (EHR)-integrated survivorship care plan (SCP) templates that incorporate partial auto-population. We developed EHR-integrated data collection tools (e.g., dashboards; SmartForm, and registry) to facilitate data analytics, personalized patient referrals, and reports to the Commission on Cancer (CoC). We report to the CoC on SCP delivery, dietitian encounters, and DEXA scans. For the last decade, our Cancer Survivorship Institute has aligned the efforts of clinicians, researchers, and educators. The institute promotes evidence-based care, high-impact research, and state-of-the-science educational programs for professionals, survivors, and the community. Future plans include expansion of clinical services and funding for applied research centered on the unique needs of post-treatment cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: The survivorship programs at Northwestern Medicine and the Robert H. Lurie Comprehensive Cancer Center underscore the imperative for comprehensive, coordinated, and sustainable survivorship care to address the needs of increasing numbers of cancer survivors, with a focus on evidence-based clinical practices, associated research, and educational initiatives.

Associations of religious and existential variables with psychosocial factors and biomarkers of cardiovascular risk in bereavement.

Bereavement increases in prevalence as people age and is associated with multiple psychological and health risks, including cardiovascular risk. Religious and existential variables may play an important role in the health impacts of bereavement. Theorized pathways linking religious and existential variables with health have suggested these associations are due to intermediary psychosocial variables, but have not been tested in bereavement. This research empirically tested these pathways in a bereaved population. In N = 73 adults within 1 year of bereavement (mean age = 64.36), this study examined associations between (1) religious and existential characteristics (religious and spiritual struggles, intrinsic religiosity, and existential quest) and intermediary psychosocial variables (depression, loneliness, and difficulties in emotion regulation), and between (2) intermediary psychosocial variables and bereavement-relevant health outcomes (self-reported health, change in health since last year, grief severity, and cardiovascular biomarkers). Cardiovascular biomarkers (heart rate, heart rate variability, and blood pressure) were collected before, during, and after a laboratory grief recall emotion elicitation. Anticipated associations between self-reported religious and existential characteristics and intermediary variables, and between intermediary variables and self-reported bereavement-relevant outcomes, were consistently observed. However, associations between intermediary variables and cardiovascular biomarkers were largely unobserved. This study examined the role of religious and existential variables in whole-person health after bereavement and is among the first to include biomarkers of cardiovascular risk. Results suggest that although religious and existential variables are associated with important bereavement-related outcomes, these associations may be "skin-deep," and extensions to cardiovascular functioning should be re-examined.

"God was with me": A qualitative study of Christian meaning-making among refugees.

In this consensual qualitative research study, we investigated the role of refugees' Christian faith in meaning-making coping. High percentages of religiosity in refugee populations support the need to understand the role of religion in their coping processes. Interviews with 20 Christian refugees from 10 African and Asian countries revealed that participants drew heavily from their faith resources to cope with their experiences. Specifically, refugees reported coping practices that included trust in God, prayer, intimacy with God, spiritual surrender, lament, worship, and social support. Although many participants described spiritual struggles, including doubting God, feeling distant from God, and questioning God, most found meaning amid refugee-related suffering and reported perspective shifts, a deepening of faith, seeing suffering as part of God's plan, experiencing a deepened sense of purpose, and growing in the likeness of Christ. Refugees also reported growth through suffering in the form of gratitude, altruism, testimony, and humility. Clinical implications include encouraging the use of religious resources for meaning-making and supporting the resolution of spiritual struggles.

Pediatric strength training: benefits, concerns, and current trends.

PURPOSE OF REVIEW: With the advent of social media combined with several large-scale promotions by nationwide gym chains, pediatric interest in strength training has reached new heights during the past few years. While this is a healthy way for young gym users to build strength and stay active, there are significant risks associated with improper utilization of exercise resources. Lack of adult supervision and guidance in the gym can lead to physical injury, inappropriate use of supplements, and body image issues. The purpose of this review is to provide pediatricians with up-to-date information about well tolerated exercise practices for pubertal and prepubertal youth. RECENT FINDINGS: Current exercise trends may negatively impact both the physical and mental health of participants. Various physical injuries may occur when adolescents use gym equipment incorrectly under inadequate adult supervision. Use of unproven equipment such as waist trainers may cause bodily injury, and social media content on exercising and weight loss can negatively influence adolescent body image. Potential consequences include low self-esteem and uncommon body dysmorphic disorders, such as muscle dysmorphia. Further, the intense marketing of supplements can induce pediatric gym users to engage in inappropriate consumption behaviors. The increasing accessibility of commercial gyms to youth has increased the potential for children and adolescents to be exposed to such physical and mental health hazards. SUMMARY: Greater knowledge regarding strength training techniques will help pediatricians guide their patients toward well tolerated and healthy gym habits. Caregivers and medical professionals should recognize the necessity of supervision, as well as the dangers of incorrect equipment use and unsafe trends to mitigate risks and maximize benefits of pediatric gym use.

A controlled trial of two mind-body interventions for grief in widows and widowers.

Objective: Following bereavement, yearning and grief rumination are repetitive cognitive processes that can lead to disordered grief. Mindfulness training (MT) has been shown to reduce maladaptive repetitive thought. The current quasi-randomized controlled trial examined the feasibility, acceptability, and preliminary efficacy of MT for bereavement-related grief. Method: Ninety-five widow(er)s (Mage = 67.5, 79% women, 98% White) between 6 months to 4 years post-loss were assigned to a 6-week MT intervention or a progressive muscle relaxation (PMR) intervention, or a wait-list condition. Outcome measures were grief severity (Revised Inventory of Complicated Grief), yearning (Yearning in Situations of Loss), rumination (Utrecht Grief Rumination Scale), and decentering (Experiences Questionnaire-Decentering) assessed at baseline, Weeks 2 and 4 of intervention, post-intervention, and 1-month post-intervention. Growth curve analysis examined group differences in rates of improvement in outcomes through follow-up and associations with improvement in grief severity. Results: The MT and PMR groups showed significant rates of decline in grief severity and yearning, though only the PMR group showed a greater rate of decline in grief severity than wait-list. All groups showed significant rates of decline in grief rumination. The PMR and wait-list groups showed significant rates of increase in decentering compared to the MT group. Conclusions: Results support the feasibility and acceptability of MT and PMR for widow(er)s as well as the preliminary efficacy of PMR for improving grief severity in widow(er)s compared to a wait-list control condition. With replication, PMR could be a standalone intervention for non-disordered grief or a component of treatment for disordered grief. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Aquatic biodiversity enhances multiple nutritional benefits to humans.

Humanity depends on biodiversity for health, well-being, and a stable environment. As biodiversity change accelerates, we are still discovering the full range of consequences for human health and well-being. Here, we test the hypothesis-derived from biodiversity-ecosystem functioning theory-that species richness and ecological functional diversity allow seafood diets to fulfill multiple nutritional requirements, a condition necessary for human health. We analyzed a newly synthesized dataset of 7,245 observations of nutrient and contaminant concentrations in 801 aquatic animal taxa and found that species with different ecological traits have distinct and complementary micronutrient profiles but little difference in protein content. The same complementarity mechanisms that generate positive biodiversity effects on ecosystem functioning in terrestrial ecosystems also operate in seafood assemblages, allowing more diverse diets to yield increased nutritional benefits independent of total biomass consumed. Notably, nutritional metrics that capture multiple micronutrients and fatty acids essential for human well-being depend more strongly on biodiversity than common ecological measures of function such as productivity, typically reported for grasslands and forests. Furthermore, we found that increasing species richness did not increase the amount of protein in seafood diets and also increased concentrations of toxic metal contaminants in the diet. Seafood-derived micronutrients and fatty acids are important for human health and are a pillar of global food and nutrition security. By drawing upon biodiversity-ecosystem functioning theory, we demonstrate that ecological concepts of biodiversity can deepen our understanding of nature's benefits to people and unite sustainability goals for biodiversity and human well-being.

The role of personal and communal religiosity in the context of bereavement.

Religion and spirituality often become relevant after the death of a loved one. In light of the multidimensionality of religion and spirituality, we investigate the role of communal religiosity in predicting associations between personal religiosity and bereavement outcomes. A mixed-methods analysis of interviews and questionnaires from 33 bereaved adults was conducted. Interview mentions of personal and communal religiosity, and their associations with self-reported religious coping and grief symptoms, were assessed. Personal (ß = 0.55, p < .01) and communal religiosity (ß = 0.50, p < .01) predicted positive religious coping, as well as negative religious coping and grief severity (ß = 0.53, p < .01). In addition, personal religiosity predicted more negative religious coping for participants who expressed low communal religiosity, ß = 1.58, SE = .15, t(28) = 4.08, p < .001. After loss, personal religiosity by itself is not necessarily protective. The presence of personal and communal religiosity contributes to positive religious coping, and reduced negative religious coping. However, the absence of communal religiosity indicates vulnerability.

Grief: A Brief History of Research on How Body, Mind, and Brain Adapt.

OBJECTIVE: Using an integrative view of psychology, neuroscience, immunology, and psychophysiology, the present review of literature curates the findings that have had an impact on the field of bereavement research and shaped its development. METHODS: Beginning with pivotal systematic descriptions of medical and psychological responses to the death of a loved one by Lindemann in the mid-1940s, this selective review integrates findings in bereavement research from studies that investigate medical outcomes after loss, their psychological predictors, and biopsychosocial mechanisms. RESULTS: Morbidity and mortality after the death of a loved one have long been a topic of research. Early researchers characterized somatic and psychological symptoms and studied immune cell changes in bereaved samples. More recent research has repeatedly demonstrated increased rates of morbidity and mortality in bereaved samples, as compared with married controls, in large epidemiological studies. Recent developments also include the development of criteria for prolonged grief disorder (also termed complicated grief). Newer methods, including neuroimaging, have observed that the greatest impact of the death of a loved one is in those who have the most severe psychological grief reactions. Research addressing the mechanisms tying bereavement to medical outcomes is relatively scarce, but differences in rumination, in inflammation, and in cortisol dysregulation between those who adapt well and those who do not have been offered with some evidence. CONCLUSIONS: Recommendations to propel the field forward include longitudinal studies to understand differences between acute reactions and later adaptation, comparing samples with grief disorders from those with more typical responses, and integrating responses in brain, mind, and body.

Thalamic-hippocampal-prefrontal disruption in relapsing-remitting multiple sclerosis.

BACKGROUND: Cortical, thalamic and hippocampal gray matter atrophy in relapsing-remitting MS (RRMS) is associated cognitive deficits. However, the role of interconnecting white matter pathways including the fornix, cingulum, and uncinate fasciculus (UF) is less well studied. OBJECTIVE: To assess MS damage to a hippocampal-thalamic-prefrontal network and the relative contributions of its components to specific cognitive domains. METHODS: We calculated diffusion tensor fractional anisotropy (FA) in the fornix, cingulum and UF as well as thalamic and hippocampal volumes in 27 RRMS patients and 20 healthy controls. A neuropsychological battery was administered and 4 core tests known to be sensitive to MS changes were used to assess cognitive impairment. To determine the relationships between structure and cognition, all tests were grouped into 4 domains: attention/executive function, processing speed, verbal memory, and spatial memory. Univariate correlations with structural measures and depressive symptoms identified potential contributors to cognitive performance and subsequent linear regression determined their relative effects on performance in each domain. For significant predictors, we also explored the effects of laterality and axial versus radial diffusivity. RESULTS: RRMS patients had worse performance on the Symbol Digit Modalities Test, but no significant impairment in the 4 cognitive domains. RRMS had reduced mean FA of all 3 pathways and reduced thalamic and hippocampal volumes compared to controls. In RRMS we found that thalamic volume and BDI predicted attention/executive function, UF FA predicted processing speed, thalamic volume predicted verbal memory, and UF FA and BDI predicted spatial memory. CONCLUSIONS: Hippocampal-thalamic-prefrontal disruption affects cognitive performance in early RRMS with mild to minimal cognitive impairment, confirming both white and gray matter involvement in MS and demonstrating utility in assessing functional networks to monitor cognition.

Optimizing screening for osteoporosis in patients with fragility hip fracture.

BACKGROUND: Osteoporosis, the underlying cause of most hip fractures, is underdiagnosed and undertreated. The 2008 Joint Commission report Improving and Measuring Osteoporosis Management showed only an average of 20% of patients with low-impact fracture are ever tested or treated for osteoporosis. We developed an integrated model utilizing hospitalists and orthopaedic surgeons to improve care of osteoporosis in patients with hip fracture. QUESTIONS/PURPOSES: Does our integrated model combining hospitalists and orthopaedic surgeons improve the frequency of evaluation for osteoporosis, screening for secondary causes, and patients' education on osteoporosis? PATIENTS AND METHODS: Our Hospitalist-Orthopaedic Surgeon Integrated Model of Care was implemented in September 2009. We compared the rate of evaluation and treatment of osteoporosis in 140 patients admitted with fragility hip fracture at our institution before (70 patients) and after (70 patients) implementation of the care plan. RESULTS: Evaluation of patients for osteoporosis was higher in the postimplementation group compared to the preimplementation group (89% versus 24%). Screening of patients for secondary causes of osteoporosis was also improved in the postimplementation group (89% versus 0%), as was the proportion of patients who received education for osteoporosis management (89% versus 0%). CONCLUSION: Our model of integrated care by hospitalists and orthopaedic surgeons resulted in improvement in the evaluation for osteoporosis, screening for secondary causes of osteoporosis, and education on osteoporosis management in patients with hip fracture at our institution. This may have important implications for treatment of these patients. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

An Internet-based education program improves breastfeeding knowledge of maternal-child healthcare providers.

BACKGROUND AND OBJECTIVES: Breastfeeding rates in the United States remain below the Surgeon General's Healthy People 2010 goals. Encouragement of breastfeeding and education by maternal-child healthcare (MCH) providers (physicians, residents, and midlevel providers) improves breastfeeding initiation and duration. Surveys of MCH providers show lack of knowledge about breastfeeding. This study evaluated the effect of usage of "BreastfeedingBasics," a free Internet-based educational course, on the knowledge of MCH providers and evaluation of the baseline knowledge of course users. METHODS: A before and after intervention study was done of MCH providers using the "BreastfeedingBasics" website between 1999 and 2008. Baseline knowledge and change in knowledge were assessed by computer-scored pretests and posttests. RESULTS: Of 3,456 MCH providers enrolled, 2,237 (65%) completed one or more pretest. Total mean pretest/posttest scores were as follows: midlevel providers, 81%/89%; residents, 84%/93%; and physicians, 85%/92% (p < 0.001 among groups and between pretests and posttests). Mean pretest/posttest scores of the modules were as follows: Anatomy/Physiology, 79%/93%; Growth/Development, 72%/91%; Mother-Infant Couple (normal newborn), 82%/92%; and Breastfed Infant with Problems, 77%/91% (p < 0.001 for all). Specific topics with the lowest pretest scores and subsequent posttest scores were as follows (pretest/posttest): supplementation with vitamin D, 61%/93%; breastfeeding physiology, 38%/65%; growth of breastfed infants at 10 days, 80%/95%, 14 days, 72%/91%, and 3-4 months, 39%/84%; and stopping breastfeeding for maternal problems when not indicated, 69%/93% (p < 0.001 for all). CONCLUSIONS: Use of an Internet-based educational program improved knowledge of MCH providers as measured by pretest and posttest scores. Knowledge of the growth of breastfed infants is particularly poor. Increasing knowledge is the first step in improving clinical practice that is necessary for increasing breastfeeding rates and duration.

Intervention for individuals with fetal alcohol spectrum disorders: treatment approaches and case management.

Exposure to alcohol in utero is considered to be the leading cause of developmental disabilities of known etiology. The most severe consequence of such exposure, fetal alcohol syndrome (FAS), is characterized by a distinct constellation of characteristic facial anomalies, growth retardation, and central nervous system (CNS) dysfunction. Some individuals with prenatal alcohol exposure (PAE) do not meet the full criteria for FAS, but instead are diagnosed with partial FAS, alcohol related neurodevelopmental disorder (ARND), or alcohol related birth defects (ARBD). The entire continuum of effects from PAE is increasingly being referred to under the umbrella term of fetal alcohol spectrum disorders (FASDs). An extensive body of research has documented major cognitive, behavioral, adaptive, social, and emotional impairments among individuals with FASDs. Although FAS was identified in the U.S. over 35 years ago, the development, evaluation, and dissemination of evidence-based interventions for individuals with FASDs have lagged behind significantly. Encouragingly, however, in recent years there has been a marked increase in efforts to design and test interventions to remediate the impairments associated with prenatal alcohol exposure. This article will review treatment needs and considerations for individuals with FASDs and their families, current empirically tested treatment approaches, case management issues, and suggestions for future directions in research on the treatment of FASDs.

Osteoporosis: management and treatment strategies for orthopaedic surgeons.

Osteoporosis is a metabolic condition that is gaining increasing attention as people live longer. It may frequently be present in patients with and without fracture. Nonpharmacologic methods and pharmacologic methods may be used to treat osteoporosis and related fractures. The ultimate goal in managing and treating osteoporosis is to optimize fracture risk reduction. Commonly used nonpharmacologic interventions include calcium and vitamin D supplementation, fall prevention, hip protectors, and balance and exercise programs. These interventions act in conjunction with pharmacologic methods, if prescribed.

Early infant feeding decisions in low-income Latinas.

Breastfeeding rates remain low, especially among low-income minority women. The objective of this qualitative study was to assess barriers to breastfeeding and reasons for combination feeding among low-income Latina women and their families. Meetings were held with key informants to inform the sampling plan and develop questions for focus groups. Data were collected from eight qualitative focus groups with primiparous mothers postpartum, mothers breastfeeding at 4 to 6 months, mothers formula feeding at 4 to 6 months, grandmothers and fathers, and 29 individual interviews with formula- and combination-feeding mothers. Transcripts of focus groups and interviews were content coded and analyzed for thematic domains and then compared for concurrence and differences. Four main domains with 15 categories were identified: (a) Best of both: Mothers desire to ensure their babies get both the healthy aspects of breast milk and "vitamins" in formula. (b) Breastfeeding can be a struggle: Breastfeeding is natural but can be painful, embarrassing, and associated with breast changes and diet restrictions. (c) Not in Mother's Control: Mothers want to breastfeed, but things happen that cause them to discontinue breastfeeding. (d) Family and cultural beliefs: Relatives give messages about supplementation for babies who are crying or not chubby. Negative emotions are to be avoided so as to not affect mother's milk. Those counseling Latina mothers about infant feeding should discourage and/or limit early supplementation with formula, discuss the myth of "best of both," understand the fatalism involved in problem-solving breastfeeding issues, and enlist the altruism embedded in the family unit for support of the mother-infant pair.

Functional neuroanatomy of grief: an FMRI study.

OBJECTIVE: In this study the authors examined the functional neuroanatomy of grief, which to their knowledge has not been studied previously in functional neuroimaging research. METHOD: Grief was elicited in eight bereaved women through photographs of the deceased versus a stranger, combined with words specific to the death event versus neutral words. Use of both pictures and words resulted in a 2x2 factorial design. RESULTS: Three brain regions were independently activated by the picture and word factors: posterior cingulate cortex, medial/superior frontal gyrus, and cerebellum. The two factors also activated distinct regions: for the picture factor, they were the cuneus, superior lingual gyrus, insula, dorsal anterior cingulate cortex, inferior temporal gyrus, and fusiform gyrus; and for the word factor, they were the precuneus, precentral gyrus, midbrain, and vermis. The interaction of the two factors showed significant activation in the cerebellar vermis. CONCLUSIONS: Grief is mediated by a distributed neural network that subserves affect processing, mentalizing, episodic memory retrieval, processing of familiar faces, visual imagery, autonomic regulation, and modulation/coordination of these functions. This neural network may account for the unique, subjective quality of grief and provide new leads in understanding the health consequences of grief and the neurobiology of attachment.