Perspectives and Recommendations from Hospitalized Patients with Substance Use Disorders: A Qualitative Study.

BACKGROUND: Individuals with substance use disorders (SUDs) are hospitalized in growing numbers. Stigma is pervasive among their hospital providers, and SUD management during medical admissions is often inadequate. However, little is known about how these patients perceive their care quality. In particular, few studies have explored their positive care perceptions or recommendations for improvement. OBJECTIVE: To explore perspectives on positive aspects, negative aspects, and consequences of care, as well as recommendations for improvement among hospitalized patients with SUDs. DESIGN AND PARTICIPANTS: We conducted semi-structured, in-depth bedside interviews (n = 15) with patients who have been diagnosed with a SUD and were admitted to medical or surgical floors of an urban academic medical center. APPROACH: Interviews explored patients' hospital experiences and recommendations for improvement. The interviews were audio-recorded, transcribed verbatim, and imported into NVivo software. Two reviewers independently coded the transcripts using interpretative phenomenological analysis and inductive thematic analysis according to grounded theory, and recurring themes were identified from the data. Patients' demographic and clinical data were analyzed with descriptive statistics. KEY RESULTS: Perceived clinical and emotional proficiency were the most important components of positive experiences, whereas perceived bias and stigmatized attitudes, clinical improficiency, and inhumane treatment were characteristic of negative experiences. Such care components were most consequential for patients' emotional well-being, trust, and care quality. Recommendations for improving care included specific suggestions for initiating and promoting continued recovery, educating, and partnering in compassionate care. CONCLUSIONS: Hospitalized patients with SUDs often experience lower quality and less compassionate care linked to pervasive stigma and poor outcomes. Our study highlights under-recognized perspectives from this patient population, including socioemotional consequences of care and recommendations grounded in lived experiences. By striving to advance our care in accordance with patients' viewpoints, we can turn hospitalizations into opportunities for engagement and promoting recovery.

Decision-making and autonomy among participants in early-phase cancer immunotherapy trials: a qualitative study.

BACKGROUND: Participants considering early-phase cancer clinical trials (CTs) need to understand the unique risks and benefits prior to providing informed consent. This qualitative study explored the factors that influence patients' decisions about participating in early-phase cancer immunotherapy CTs through the ethical lens of relational autonomy. METHODS: Using an interpretive descriptive design, interviews were conducted with 21 adult patients with advanced cancer who had enrolled in an early-phase CT. Data was analyzed using relational autonomy ethical theory and constant comparative analysis. RESULTS: The extent to which participants perceived themselves as having a choice to participate in early-phase cancer immunotherapy CTs was a central construct. Perceptions of choice varied according to whether participants characterized their experience as an act of desperation or as an opportunity to receive a novel treatment. Intersecting psychosocial and structural factors influenced participants' decision making about participating in early-phase cancer immunotherapy trials. These relational factors included: (1) being provided with hope; (2) having trust; (3) having the ability to withdraw; and (4) timing constraints. CONCLUSIONS: Findings highlight the continuum of perceived choice that exists among patients with cancer when considering participation in early-phase cancer immunotherapy CTs. All participants were interpreted as exhibiting some degree of relational autonomy within the psychosocial and structural context of early-phase CT decision making. This study offers insights into the intersection of cancer care delivery, personal beliefs and values, and established CT processes and structures that can inform future practices and policies associated with early-phase cancer immunotherapy CTs to better support patients in making informed decisions.

Advanced Cancer in Young Adults (YAs): Living in a Liminal Space.

Young adults (YAs), defined as individuals between the ages of 18 and 39 years, experience unique challenges when diagnosed with advanced cancer. Using the social constructivist grounded theory approach, we aimed to develop a theoretical understanding of how YAs live day to day with their diagnosis. A sample of 25 YAs (aged 22-39 years) with advanced cancer from across Canada participated in semi-structured interviews. Findings illustrate that the YAs described day-to-day life as an oscillating experience swinging between two opposing disease outcomes: (1) hoping for a cure and (2) facing the possibility of premature death. Oscillating between these potential outcomes was characterized as living in a liminal space wherein participants were unsure how to live from one day to the next. The participants oscillated at various rates, with different factors influencing the rate of oscillation, including inconsistent and poor messaging from their oncologists or treatment team, progression or regression of their cancer, and changes in their physical functioning and mental health. These findings provide a theoretical framework for designing interventions to help YAs adapt to their circumstance.

Palliative care for adolescents and young adults with advanced illness: A scoping review.

BACKGROUND: Age-related complex medical conditions have been commonly reported among adolescents and young adults with advanced life-limiting illness. There is increasing interest in exploring their palliative care needs and end-of-life experiences. AIM: This scoping review aimed to explore the available literature about providing palliative and end-of-life care to adolescents and young adults with advanced life-limiting illnesses. DESIGN: Scoping review. This review was registered on Open Science Framework (https://doi.org/10.17605/OSF.IO/SPTD7). DATA SOURCES: Electronic databases (MEDLINEALL, Embase, Emcare, Cochrane Central Register of Controlled Trial CENTRAL, Scopus, PsycINFO, Cochrane Database of Systematic Reviews), Google Scholar and reference lists were searched up to October 2021. We included studies reporting on adolescents and/or young adults with advanced life-limiting illnesses. There were no limitations concerning location, type of illness or study design. RESULTS: We identified 51 studies published between 2002 and 2021. Most studies were published in the United States (n = 34, 67%), and nine studies (18%) reported exclusively on patients with non-malignant illnesses. Two thirds of the identified studies were case reports and retrospective chart reviews (n = 33). Three main topics were identified: Physical symptom burden (n = 26, 51%), Psychological and social needs (n = 33, 65%), and end-of-life care (n = 30, 59%). Twenty-six studies (51%) were focused only on one topic, and the age range used to identify adolescents and young adults varied based on the study location. CONCLUSION: The findings of this review shed light on the different palliative care experiences and knowledge gaps related to adolescents and young adults as an underserved and vulnerable patient population. Further research needs to be dedicated toward palliative care programs tailored for adolescents and young adults.

Empowering Cancer Survivors in Managing Their Own Health: A Paradoxical Dynamic Process of Taking and Letting Go of Control.

In cancer care, gaps in support to help patients manage and live with the side-effects from cancer treatments have increased the emphasis on empowering patients to be more active and involved in managing their own health. However, empowerment in relation to promoting self-management behaviors is not well understood. Using the social constructivist grounded theory approach, our goal was to develop a theoretical understanding of this phenomenon in relation to the self-management behaviors of post-treatment cancer patients. Twenty-two post-treatment cancer patients participated in a semi-structured focused interview to co-construct with us how empowerment is defined, described, and experienced in relation to their capacity to self-manage. Through this co-construction, we defined empowerment as a process of personal growth, a display of fortitude and strength when participants confronted the impact of their illness that emerged in two dynamic and paradoxical ways: 1) establishing control over the impact of the illness as a means to maintain normalcy and to circumvent change over an eroding and changing sense of self and 2) relinquishing control over aspects of the illness deemed irrepressible and acknowledging and accepting change. When successful at establishing and/or relinquishing control, participants no longer viewed cancer as a threat, but re-interpreted their illness as also having a beneficial "empowering" experience and more capable of managing. Findings will guide the development of self-management interventions that use empowerment as a core construct.

A Psychodynamic Approach to Co-occurring Borderline Personality and Substance Use Disorders in the Emergency Department.

Patients with co-occurring substance use disorders and borderline personality disorder have high rates of morbidity, mortality, and utilization of medical services. Their acute symptoms present complex challenges to clinical staff in the medical emergency department related to both logistics and management of countertransference. This article examines patterns in countertransference and proposes application of psychodynamically informed principles and strategies to facilitate safety and enhance communication during fraught clinical encounters.

Impact of Medical Assistance in Dying on palliative care: A qualitative study.

BACKGROUND: Medical Assistance in Dying comprises interventions that can be provided by medical practitioners to cause death of a person at their request if they meet predefined criteria. In June 2016, Medical Assistance in Dying became legal in Canada, sparking intense debate in the palliative care community. AIM: This study aims to explore the experience of frontline palliative care providers about the impact of Medical Assistance in Dying on palliative care practice. DESIGN: Qualitative descriptive design using semi-structured interviews and thematic analysis. SETTINGS/PARTICIPANTS: We interviewed palliative care physicians and nurses who practiced in settings where patients could access Medical Assistance in Dying for at least 6 months before and after its legalization. Purposeful sampling was used to recruit participants with diverse personal views and experiences with assisted death. Conceptual saturation was achieved after interviewing 23 palliative care providers (13 physicians and 10 nurses) in Southern Ontario. RESULTS: Themes identified included a new dying experience with assisted death; challenges with symptom control; challenges with communication; impact on palliative care providers personally and on their relationships with patients; and consumption of palliative care resources to support assisted death. CONCLUSION: Medical Assistance in Dying has had a profound impact on palliative care providers and their practice. Communication training with access to resources for ethical decision-making and a review of legislation may help address new challenges. Further research is needed to understand palliative care provider distress around Medical Assistance in Dying, and additional resources are necessary to support palliative care delivery.

Physicians' and Attorneys' Beliefs and Attitudes Related to the Brain Disease Model of Addiction.

BACKGROUND AND OBJECTIVES: Addiction is increasingly considered a chronic, relapsing brain disease; however, many scholars still disagree with the brain disease model of addiction. We set out to provide evidence of attorneys' and physicians' beliefs regarding the model. First, we asked the following question: do attorneys and physicians affirm the full brain disease model, or its modified form, or do they believe that addiction is driven by deficits in self-control or moral weakness? Second, we evaluated the extent to which such beliefs correspond to attitudes toward individuals with substance use disorders (SUDs). METHODS: A questionnaire was sent to resident physicians (N = 301) and criminal defense attorneys (N = 483) practicing in the United States. It was comprised of (i) an attitudes measure, (ii) a measure regarding conceptions of addiction, and (iii) demographic questions. RESULTS: Attorneys were more likely to believe that individuals with SUDs had "practically no choice" about whether to seek and use, whereas physicians were more likely to believe that such individuals had "genuine choice." For both groups of participants, the rejection of the full brain disease model of addiction was associated with more negative attitudes toward individuals with SUDs. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: These results represent an important advance, as past research has neglected attorneys' attitudes and is inconclusive regarding the manner in which beliefs about the brain disease model of addiction are related to attitudes toward individuals with SUDs. Educating practitioners regarding this relationship would raise awareness regarding when and to what extent stigma is likely to be present, which may in turn provide a foundation from which to address stigma. (Am J Addict 2020;00:00-00).

Risk factors and effects of hypocalcemia prior to discharge following thyroidectomy.

PURPOSE: To find patient and surgical characteristics associated with hypocalcemia prior to discharge (HPTD) in thyroidectomy patients. MATERIALS AND METHODS: In a retrospective analysis of the 2016-2017 National Surgical Quality Improvement Program, eligible total thyroidectomy patients were stratified into cohorts based on development of HPTD. We identified demographic and surgical risk factors for the development of hypocalcemia via binary logistic regression and identified the negative sequelae of HPTD utilizing univariate and multivariate methods. RESULTS: We identified a total of 6519 patients who underwent total thyroidectomy, of which 450 (6.9%) had HPTD. Predictors associated with an increased incidence of HPTD included female sex (OR: 1.737 [95% CI: 1.319-2.288]; p < .001), increased operative time (OR: 1.003 [1.002-1.004]; p < .001), and central neck dissection (OR: 1.484 [1.190-1.850]; p < .001). However, factors that decreased incidence of HPTD included increased age, obesity (OR: 0.648 [0.501-0.837]; p = .001), and the use of vessel sealant devices (VSD) (OR: 0.650 [0.527-0.803]; p < .001). Multivariate analysis further revealed that HPTD independently led to an increased hospitalization length after surgery (B: 0.708 [0.607-0.809]; p < .001) and an increased 30-day readmission rate (OR: 2.429 [1.594-3.704]; p < .001). CONCLUSION: Obesity, increased age, and intra-operative VSD use were significantly associated with decreased rates of HPTD after total thyroidectomy. Female sex, longer operations, and central neck dissections were associated with HPTD. Delineating risk factors and protective factors for HPTD in total thyroidectomy patients is important as patients with HPTD were found to be at a significantly higher risk for longer post-operative stays, increased odds of 30-day readmission, and increased hypocalcemia-related event.

Targeted Drug Delivery to Stroke via Chemotactic Recruitment of Nanoparticles Coated with Membrane of Engineered Neural Stem Cells.

Cell membrane coating has recently emerged as a promising biomimetic approach to engineering nanoparticles (NPs) for targeted drug delivery. However, simple cell membrane coating may not meet the need for efficient drug delivery to the brain. Here, a novel molecular engineering strategy to modify the surface of NPs with a cell membrane coating for enhanced brain penetration is reported. By using poly(lactic-co-glycolic) acid NPs as a model, it is shown that delivery of NPs to the ischemic brain is enhanced through surface coating with the membrane of neural stem cells (NSCs), and the delivery efficiency can be further increased using membrane isolated from NSCs engineered for overexpression of CXCR4. It is found that this enhancement is mediated by the chemotactic interaction of CXCR4 with SDF-1, which is enriched in the ischemic microenvironment. It is demonstrated that the resulting CXCR4-overexpressing membrane-coated NPs, termed CMNPs, significantly augment the efficacy of glyburide, an anti-edema agent, for stroke treatment. The study suggests a new approach to improving drug delivery to the ischemic brain and establishes a novel formulation of glyburide that can be potentially translated into clinical applications to improve management of human patients with stroke.

Attitudes toward defendants with substance-related charges: An analysis of a national sample of criminal defense attorneys.

BACKGROUND AND OBJECTIVES: While a large percentage of criminal offenders suffer from substance use disorders (SUDs), virtually nothing is known about the attitudes criminal defense attorneys possess toward their clients who are facing substance-related charges. This is a serious concern, as the burden of steering individuals with SUDs into treatment often falls to criminal defense attorneys. The goal of this study was to examine the attitudes of criminal defense attorneys toward individuals who have been accused of drug crimes. METHODS: A questionnaire was sent to criminal defense attorneys (N = 1,933) from all 50 U.S. states and the District of Columbia. It was comprised of (i) demographic information and (ii) a version of the 11-item Medical Condition Regard Scale (MCRS). RESULTS: Criminal defense attorneys held generally positive attitudes toward clients with substance-related charges, but there was a significant divergence in attitudes between private and public attorneys, with the latter showing both greater familiarity with and better attitudes toward this same group of clients. These differences were impactful: worse attitudes toward clients strongly correlated with greater predictions that the clients would reoffend. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Given the magnitude of the incarcerated population with SUDs and the centrality of defense attorneys in the treatment process, especially its initiation, the divergence in attitudes between private and public criminal defense attorneys is concerning. There is a clear need for increased collaboration between physicians and attorneys, with an aim of increasing the number of individuals with SUDs receiving proper treatment (Am J Addict 2018;XX:1-7).

Changes in psychiatry residents' attitudes towards individuals with substance use disorders over the course of residency training.

BACKGROUND AND OBJECTIVES: Psychiatry residents provide care for individuals diagnosed with co-occurring mental illness and substance use disorders (SUDs). Small studies have shown that clinicians in general possess negative attitudes towards these dually diagnosed individuals. This is a serious concern, as clinicians' stigmatizing attitudes towards individuals with mental illnesses may have a particularly potent adverse impact on treatment. The goal of this study was to examine the attitudes of psychiatry residents towards individuals with diagnoses of schizophrenia, multiple SUDs, co-occurring schizophrenia and SUDs, and major depressive disorder. METHODS: A questionnaire was sent to psychiatry residents (N = 159) around the country. It was comprised of two sections: (i) demographic information, which included information about level of training; and (ii) the 11-item Medical Condition Regard Scale (MCRS) for individuals with the four different diagnoses. RESULTS: Psychiatry residents had more stigmatizing attitudes towards individuals with diagnoses of SUDs with and without schizophrenia than towards those individuals with diagnoses of schizophrenia or major depressive disorder alone. Senior residents possessed more negative attitudes towards individuals with SUDs than junior residents. DISCUSSION AND CONCLUSIONS: The attitudes of psychiatry residents' towards individuals with SUDs with and without schizophrenia were negative and were worse among senior residents. There were many potential reasons for these findings, including repeat negative experiences in providing care for these individuals. SCIENTIFIC SIGNIFICANCE: The negative attitudes of psychiatry residents towards individuals with SUDs are worrisome. Future work is needed to better understand these attitudes and to develop interventions to improve them. (Am J Addict 2017;26:75-79).

Remote symptom support training programs for oncology nurses in Canada: an environmental scan.

The overall aim of this study was to explore current remote symptom support training programs provided to nurses in ambulatory oncology programs across Canada, using a survey-methods environmental scan. Of 36 delivered invitations, 28 programs responded (77.8%) representing 10 provinces. Of 25 programs that offer telephone symptom support, 17 provide symptom support training, seven do not, and one did not say. Seven programs shared training materials with the investigators and elements of training included: symptom management guidelines (n = 6), telephone triage process/principles (n = 5), competent telephone practices (n = 4), documentation (n = 4), professional standards (n = 3), role-play (n = 3), communication skills/etiquette (n = 3), and monitoring quality (n = 1). Formats included: presentations (n = 3), paper-based resources (n = 3), or e-learning modules (n = 1). No training programs were rigorously evaluated. Training in telephone nursing symptom support across oncology programs is variable. Opportunities exist to identify core competencies and evaluate if training programs enhance delivery of remote cancer symptom support.

Association of opioid or other substance use disorders with health care use among patients with suicidal symptoms.

INTRODUCTION: Prior literature establishes noteworthy relationships between suicidal symptoms and substance use disorders (SUDs), particularly opioid use disorder (OUD). However, engagement with health care services among this vulnerable population remains underinvestigated. This study sought to examine patterns of health care use, identify risk factors in seeking treatment, and assess associations between outpatient service use and emergency department (ED) visits. METHODS: Using electronic health records (EHRs) derived from five health systems across New York City, the study selected 7881 adults with suicidal symptoms (including suicidal ideation, suicide attempt, or self-harm) and SUDs between 2010 and 2019. To examine the association between SUDs (including OUD) and all-cause service use (outpatient, inpatient, and ED), we performed quasi-Poisson regressions adjusted for age, gender, and chronic disease burden, and we estimated the relative risks (RR) of associated factors. Next, the study evaluated cause-specific utilization within each resource category (SUD-related, suicide-related, and other-psychiatric) and compared them using Mann-Whitney U tests. Finally, we used adjusted quasi-Poisson regression models to analyze the association between outpatient and ED utilization among different risk groups. RESULTS: Among patients with suicidal symptoms and SUD diagnoses, relative to other SUDs, a diagnosis of OUD was associated with higher all-cause outpatient visits (RR: 1.22), ED visits (RR: 1.54), and inpatient hospitalizations (RR: 1.67) (ps < 0.001). Men had a lower risk of having outpatient visits (RR: 0.80) and inpatient hospitalizations (RR: 0.90), and older age protected against ED visits (RR range: 0.59-0.69) (ps < 0.001). OUD was associated with increased SUD-related encounters across all settings, and increased suicide-related ED visits and inpatient hospitalizations (p < 0.001). Individuals with more mental health outpatient visits were less likely to have suicide-related ED visits (RR: 0.86, p < 0.01), however this association was not found among younger and male patients with OUD. Although few OUD patients received medications for OUD (MOUD) treatment (9.9 %), methadone composed the majority of MOUD prescriptions (77.7 %), of which over 70 % were prescribed during an ED encounter. CONCLUSIONS: This study reinforces the importance of tailoring SUD and suicide risk interventions to different age groups and types of SUDs, and highlights missed opportunities for deploying screening and prevention resources among the male and OUD populations. Redressing underutilization of MOUD remains a priority to reduce acute health outcomes among younger patients with OUD.

Omission and Commission in Morally Injurious Experiences Among COVID-19 Health Care Professionals.

Objective: To produce a qualitative description of the impact of moral injury on medical providers during the COVID-19 pandemic.Methods: A convergent mixed-methods study design was used to explore experiences of health care workers during the first 12 months of the COVID-19 pandemic. Participants completed the Moral Injury Symptom Scale-HP (MISS-HP) and a 60-minute interview, in which they described their work experiences from March 2020 through January 2021. The study was conducted between May 2021 and August 2021.Results: Eight physicians and 6 nurses were interviewed. Most participants (71%) worked in the emergency department, while 29% worked in the medical intensive care unit (MICU). MISS-HP scores were 49 on average and ranged from 29 to 73. Among the demographic groups, MICU participants scored the highest (56) and men scored the lowest (40). There were no significant differences in scores between any demographic group. The analysis of interview data showed how omissions and commissions in one's professional duties created internal conflicts, which were inextricably linked to a deeper sense of feelings of guilt and blame around experiences of betraying or being betrayed and an inability to uphold one's moral values.Conclusions: The pandemic upended a previously reliable and imperceptible experience of a background of safety, in which the provision of both material resources and human presence was expected without question. Future directions generated from this study might examine the role of dependency on leadership structures and relationships with self and others that create the conditions for moral injury.Prim Care Companion CNS Disord 2024;26(1):23m03651. Author affiliations are listed at the end of this article.

FISH Panel for Leukemic Cutaneous T-Cell Lymphoma: Extended Patient Cohort Correlation with Blood Involvement and Clinical Outcomes.

The genomic basis of cutaneous T-cell lymphoma has been characterized by gene copy number alterations and genomic sequencing, but there are few clinical tests that are being widely used to inform the diagnosis and prognosis of leukemic cutaneous T-cell lymphoma that may arise as a progression from mycosis fungoides or de novo as Sézary syndrome. An 11-gene FISH panel of TP53, RB1, DNMT3A, FAS, ZEB1, ARID1A, ATM, and CDKN2A deletions and MYC, signal transducer and activator of transcription gene (STAT)3/5B, and CARD11 amplifications was previously found to encapsulate >95% of gene copy number variations in leukemic cutaneous T-cell lymphoma. Through a retrospective analysis of patients with leukemic cutaneous T-cell lymphoma seen at the Yale Cancer Center from 2014 to 2020, we gathered the relevant genes as they became available and correlated them to factors with prognostic relevance as a proof of concept to show the potential utility in further developing a limited gene panel for prognosis. In this study, we show that the abnormal FISH results show an association with clinically relevant factors (blood stage, CD4:8 ratio, and percentage blood involvement) and have a nonsignificant statistical trend (>90%) toward correlation with overall survival. In addition, the previous cost-effective panels were signal transducer and activator of transcription (STAT)3/5B, MYC, TP53, and ARID1A. We now suggest adding RB1 and ZEB1 on the basis of our findings.