The relevance of dysfunctional reasoning to OCD and its treatment: Further evidence for inferential confusion utilizing a new task-based measure.

BACKGROUND AND OBJECTIVES: Previous research has highlighted the role of dysfunctional reasoning processes (i.e. "inferential confusion") in the development and maintenance of Obsessive-Compulsive Disorder (OCD). Inferential confusion has previously been found to be a unique predictor of OC symptoms and has shown specificity for OCD. However, these findings have primarily relied on a single self-report questionnaire, and only a limited number of experimentations have been conducted to establish the specificity of inferential confusion to OCD with alternate measures. The current paper demonstrates the relationship of inferential confusion with OCD symptoms in clinical samples by using a task-based measure of inferential confusion. METHODS: Sixty-four OCD participants, as well as thirty anxious and thirty-four healthy controls completed the recently developed Dysfunctional Reasoning Processes Task (DRPT) and related measures. Thirty-five OCD participants then completed sixteen sessions of cognitive-behavioural therapy (CBT) and completed the same measures post-treatment. RESULTS: As predicted, dysfunctional reasoning was significantly more elevated for those with OCD relative to control groups. Reduced levels of dysfunctional reasoning during CBT were significantly associated with successful treatment outcome. LIMITATIONS: Clinical implications should be interpreted with caution due to the relatively small sample size. CONCLUSIONS: Our findings support the notion that inferential confusion is an important cognitive factor particularly relevant to OCD that needs to be directly addressed as a mechanism of change in CBT.

Dream-Reality confusion: differential psychiatric diagnosis in narcoleptic subjects / Confusão sonho-realidade: diagnóstico psiquiátrico diferencial em narcolépticos

Dream-reality confusion (DRC) is the consequence of hypnagogic content confusion with real events and memories. Narcoleptic subjects eventually have DRC and can be misdiagnosed as schizophrenic or with another disorder with delusional or hallucinatory symptoms. Although dream-related experiences and hallucinatory perception share neurophysiological pathways, they are phenomenologically distinct. The lack of phenomenological intentionality in Dreamrelated perceptions, the different cognitive pathways for delusion generation, and other differences between mental disorders psychopathology, and DRC-related phenomena are here discussed. The lived world and awake experience interpretation, and dream neurobiology in narcoleptic subjects related to DRC, might indicate some hints for the mind-brain gap issue that still exists in neurology and psychiatry.

A confusão entre realidade e sonho (CRS) é a consequência da confusão do conteúdo hipnagógico com eventos e memórias reais. Sujeitos narcolépticos eventualmente têm CRS e podem ser diagnosticados erroneamente como esquizofrênicos ou com outro transtorno com sintomas delirantes ou alucinatórios. Embora as experiências relacionadas ao sonho e à percepção alucinatória compartilhem vias neurofisiológicas, elas são fenomenologicamente distintas. A falta de intencionalidade fenomenológica nas percepções relacionadas ao sonho, as diferentes vias cognitivas para a geração do delírio e outras diferenças entre a psicopatologia dos transtornos mentais e os fenômenos relacionados à CRS são discutidos aqui. A interpretação do mundo vivido e da experiência de vigília, e a neurobiologia dos sonhos em sujeitos narcolépticos relacionados à CRS, podem indicar algumas dicas para a questão do gap mente-cérebro que ainda existe na neurologia e na psiquiatria.

Parents' perspectives on conflict in paediatric healthcare: a scoping review.

BACKGROUND: Conflict in paediatric healthcare is becoming increasingly prevalent, in particular relation to paediatric end of life. This is damaging to patients, families, professionals and healthcare resources. Current research has begun to explore perspectives of healthcare professionals (HCPs), but the parental views on conflict are lacking. OBJECTIVES: This scoping review explores parental views on conflict during a child's end of life. In addition, parental views are mapped onto HCPs' views. METHODS: A search was completed of the databases CINAHL, PubMed, Web of Science, Embase and Medline between 1997 and 2019, focused on parents of children with involvement with palliative or end-of-life care referring to conflict or disagreements. RESULTS: The review found 10 papers that included parental views on conflict. Data on conflict were categorised into the following seven themes: communication breakdown, trust, suffering, different understanding of 'best interest', disagreements over treatment, spirituality and types of decision-making. In particular, parental expertise, perspectives on suffering and ways of making decisions were significant themes. A subset of themes mirror those of HCPs. However, parents identified views of conflict unique to their perspective. CONCLUSIONS: Parents identified important themes, in particular their perspective of what constitutes suffering and 'best interest'. In addition, parents highlight the importance of being recognised as an expert.

COVID-19 Presenting With Confusion: An Unusual but Suggestive Electroencephalography Pattern of Encephalitis.

SUMMARY: A 78-year-old man was admitted for acute confusion. At initial investigation physical examination, blood and cerebrospinal fluid tests were unremarkable and EEG showed synchronous bifrontal periodic discharges, an evocative pattern of encephalitis. Coronavirus disease 2019 was diagnosed later after fever onset. Isolated mild confusion may thus be an initial clinical picture of Coronavirus disease 2019 infection.

Low molecular weight heparin in COVID-19 patients prevents delirium and shortens hospitalization.

BACKGROUND: COVID-19 patients present with delirium during their hospitalization. AIMS: To assess the incidence of delirium in hospitalized COVID-19 patients and analyze the possible association with demographic, clinical, laboratory, and pharmacological factors. METHODS: COVID-19 patients were assessed for clinical signs of delirium and administered the assessment test for delirium and cognitive impairment (4AT) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scales. RESULTS: Out of the 56 patients of our cohort, 14 (25.0%) experienced delirium. The use of low molecular weight heparin (LMWH) (enoxaparin 1 mg/kg/daily) was less frequent in patients with delirium (p = 0.004) and was accompanied by lower C reactive protein (CRP) levels (p = 0.006). DISCUSSION: The use of LMWH was associated with absence of delirium, independently of comorbidities and age. CONCLUSIONS: The use of LMWH may help preventing the occurrence of delirium in COVID-19 patients, with possible reduction of length of stay in the hospital and sequelae.

Acutely altered mental status as the main clinical presentation of multiple strokes in critically ill patients with COVID-19.

BACKGROUND AND AIMS: Cerebral infarction in COVID-19 patients might be associated with a hypercoagulable state related to a systemic inflammatory response. Its diagnosis might be challenging. We present two critically ill patients with COVID-19 who presented acutely altered mental status as the main manifestation of multiple strokes. METHODS: Clinical presentation and diagnostic work-up of the patients. RESULTS: Two patients in their sixties were hospitalized with a bilateral pneumonia COVID-19. They developed respiratory failure and were admitted to ICU for mechanical ventilation and intense medical treatment. They were started on low-molecular-weight heparin since admission. Their laboratory results showed lymphopenia and increased levels of C-reactive protein and D-dimer. Case 1 developed hypofibrinogenemia and presented several cutaneous lesions with biopsy features of thrombotic vasculopathy. Case 2 was performed a CT pulmonary angiogram at ICU showing a bilateral pulmonary embolism. When waking up, both patients were conscious but with a remarkable global altered mental status without focal neurological deficits. A brain MRI revealed multiple acute bilateral ischemic lesions with areas of hemorrhagic transformation in both patients (case 1: affecting the left frontal and temporal lobes and both occipital lobes; case 2: affecting both frontal and left occipital lobes). Cardioembolic source and acquired antiphospholipid syndrome were ruled out. COVID-19-associated coagulopathy was suspected as the possible main etiology of the strokes. CONCLUSION: Acutely altered mental status might be the main manifestation of multiple brain infarctions in critically ill COVID-19 patients. It should be specially considered in those with suspected COVID-19-associated coagulopathy. Full-dose anticoagulation and clinical-radiological monitoring might reduce their neurological consequences.

Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria.

In response to the need to better define the natural history of emerging consciousness after traumatic brain injury and to better describe the characteristics of the condition commonly labeled posttraumatic amnesia, a case definition and diagnostic criteria for the posttraumatic confusional state (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and 3 rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances, and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state, while upper boundary is marked by significant improvement in the 4 core and 5 associated features. Key research goals are establishment of cutoffs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery.

Assessing sluggish cognitive tempo and ADHD inattention in elementary students: Empirical differentiation, invariance across sex and grade, and measurement precision.

To advance the research examining the sluggish cognitive tempo (SCT) construct, a key priority has been to develop assessment tools that are reliable and valid. The current study builds upon existing work by conducting the most thorough psychometric evaluation to date of the teacher-reported Child and Adolescent Behavior Inventory (CABI) SCT and attention-deficit/hyperactivity disorder inattention (ADHD-IN) modules in a large sample of elementary students. Participants were 7,613 students (Grades 2-5; 50.3% boys) attending 24 elementary schools in 3 school districts. Teachers (N = 398) provided ratings of SCT, ADHD-IN, academic impairment, and social impairment. An a priori 2-factor model with cross-loadings found the SCT items to demonstrate excellent structural validity with ADHD-IN items. The measurement properties of the SCT and ADHD-IN constructs were also invariant across sex and grade. SCT and ADHD-IN were both uniquely associated with academic and social impairment. Graded response item response theory analysis indicated that the SCT and ADHD-IN scales provided a high level of information and precision. The current study replicates and extends previous research and provides the strongest psychometric evidence to date of teacher-rated SCT using the CABI. The teacher-report CABI may be especially useful in the school-based screening of SCT and ADHD-IN. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Psychophysiological Response to Disorientation Training in Different Aircraft Pilots.

Disorientation is one of the most important hazards in flights, but there is a need for a deeper analysis of its effect on the psychophysiological response of pilots. This study aimed to analyse the effect of disorientation training in cortical arousal, autonomic modulation, muscle strength, and perception. We analysed 39 male pilots of the Spanish Army and Air Force (27 Helicopter Pilots, 7 Transport Pilots and 5 F-18 Fighter Pilots) before and after disorientation training. Disorientation training produced an increase in perceived stress and effort in Helicopter Pilots (HP) and Transport Pilots (TP), and lower Heart Rate Variability (RMSSD) in all pilots. Rating of Perceived Exertion (RPE) and Handgrip Strength were more negatively affected among HP than in TP. RPE was more negatively affected in HP than among Fighter Pilots (FP). Forced Vital Capacity (FVC) and Forced Expiratory Volume in 1 s (FEV1) were significantly higher in FP (FVC 5.44 ± .407 l, FEV1 4.57 ± .407 l) than in HP (FVC 4.73 ± .547 l, FEV1 3.79 ± .712 l). Disorientation training affects the psychophysiological response of pilots, and different responses are depending on each job profile. These results could help to improve specific training for better preparation of pilots that face disorientation threats.

Incidental finding of age and time disorientation in a clinical sample of patients with schizophrenia: Findings from a short term follow up survey regarding cannabis use.

Age disorientation has been described in a subtype of patients with schizophrenia. The current article reports on an incidental finding from our survey study on patterns of cannabis use pre-post legalization in patients with schizophrenia. For the purpose of the survey study, patients were asked to fill out a total of 41 survey questions. The same participants were contacted over the phone 8 weeks post-legalization. Responses to the survey questions were consistent pre- and post-legalization except for four items which required estimation of time/age. This incidental finding highlights the need for further exploration of this phenomenon by future studies.

The postictal state - What do we know?

This narrative review provides a broad and comprehensive overview of the most important discoveries on the postictal state over the past decades as well as recent developments. After a description and definition of the postictal state, we discuss postictal sypmtoms, their clinical manifestations, and related findings. Moreover, pathophysiological advances are reviewed, followed by current treatment options.

Decision-making capacity assessment for confused patients in a regional hospital: A before and after study.

OBJECTIVE: Clinicians are challenged to decide when and how to conduct decision-making capacity assessment and guardianship applications for confused hospitalised older patients. This study aimed to understand the characteristics of confused hospitalised older patients who require decision-making capacity assessment and guardianship applications and to determine the impact of a locally introduced capacity testing procedure on the conduct of decision-making capacity assessment and guardianship application in a regional hospital setting. DESIGN: Before and after study. SETTING: Regional New South Wales hospital. PARTICIPANTS: Twenty-four confused hospitalised older patients who had decision-making capacity assessment during November 2014-April 2015 and November 2015-April 2016. MAIN OUTCOME MEASURE: The impact of a standardised capacity testing procedure on the conduct of decision-making capacity assessment. RESULTS: After capacity testing procedure implementation, there were significant improvements in the number of multidisciplinary team meetings, documentation of decision-making capacity assessment process and length of stay. The majority of patients who required guardianship application was aged over 70 years, had a medical history of dementia, >20 days of acute hospital admission and had no evidence of future care-planning. CONCLUSION: Implementation of capacity testing procedure is likely to have contributed to the positive changes in the conduct of decision-making capacity assessment and guardianship application process for confused hospitalised older patients. This study provides some evidence of decision-making capacity assessment process gaps; and indicates clinical and demographic characteristics of confused hospitalised older patients who might require decision-making capacity assessment and guardianship applications. The evidence of lack of appropriate future care-planning for ageing patients and increasing hospital admissions of confused hospitalised older patients presents future challenges in rural health.

Association between Use of Angiotensin-converting Enzyme Inhibitors or Angiotensin Receptor Blockers and Postoperative Delirium.

BACKGROUND: Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve cognitive function. The authors therefore tested the primary hypothesis that preoperative use of angiotensin inhibitors is associated with less delirium in critical care patients. Post hoc, the association between postoperative use of angiotensin system inhibitors and delirium was assessed. METHODS: The authors conducted a single-site cohort study of adults admitted to Cleveland Clinic critical care units after noncardiac procedures between 2013 and 2018 who had at least one Confusion Assessment Method delirium assessment. Patients with preexisting dementia, Alzheimer's disease or other cognitive decline, and patients who had neurosurgical procedures were excluded. For the primary analysis, the confounder-adjusted association between preoperative angiotensin inhibitor use and the incidence of postoperative delirium was assessed. Post hoc, the confounder-adjusted association between postoperative angiotensin system inhibitor use and the incidence of delirium was assessed. RESULTS: The incidence of delirium was 39% (551 of 1,396) among patients who were treated preoperatively with angiotensin system inhibitors and 39% (1,344 of 3,468) in patients who were not. The adjusted odds ratio of experiencing delirium during critical care was 0.98 (95% CI, 0.86 to 1.10; P = 0.700) for preoperative use of angiotensin system inhibitors versus control. Delirium was observed in 23% (100 of 440) of patients who used angiotensin system inhibitors postoperatively before intensive care discharge, and in 41% (1,795 of 4,424) of patients who did not (unadjusted P < 0.001). The confounder-adjusted odds ratio for experiencing delirium in patients who used angiotensin system inhibitors postoperatively was 0.55 (95% CI, 0.43 to 0.72; P < 0.001). CONCLUSIONS: Preoperative use of angiotensin system inhibitors is not associated with reduced postoperative delirium. In contrast, treatment during intensive care was associated with lower odds of delirium. Randomized trials of postoperative angiotensin-converting enzymes inhibitors and angiotensin receptor blockers seem justified.

Spanish version of the Inferential Confusion Questionnaire-Expanded Version: Further support for the role of inferential confusion in obsessive-compulsive symptoms.

The purposes of this research were (1) to analyse the psychometric properties of the Inferential Confusion Questionnaire-Expanded Version (ICQ-EV) in a Spanish population; (2) to explore the role of inferential confusion in obsessive-compulsive disorder (OCD); and (3) to compare the inferential confusion construct in nonclinical and clinical samples. A sample of 342 nonclinical participants and 66 patients with OCD completed the ICQ-EV Spanish adaptation as well as a set of questionnaires. Results confirmed a good fit of the ICQ-EV Spanish version to the original unifactorial structure and excellent internal consistency and test-retest reliability. Moreover, results confirmed that the ICQ-EV predicts Obsessing, Checking, Washing, and Hoarding symptoms, independently of the contribution of dysfunctional beliefs. In addition, OCD patients scored significantly higher on the ICQ-EV than nonclinical participants. The Spanish version of the ICQ-EV is a reliable instrument to assess inferential confusion, and further support is provided for the relevance of the inferential confusion construct in OCD.

Demographic characteristics and delayed neurological sequelae risk factors in carbon monoxide poisoning.

AIM: Carbon monoxide (CO) is a colorless, odorless gas and tasteless. CO poisoning (COP) is one of the most frequently encountered inhalation poisonings. The most common cause of morbidity in COP is delayed neurological sequelae (DNS). DNS is the occurrence of neuropsychiatric findings within 2-240 days after discharge of patients with COP and there are no definitive diagnostic criteria. The aim of our study is; to determine the risk factors and incidence of DNS. METHOD: Our study is a retrospective, observational study. Patients with the diagnosis of COP in the emergency department between 2015 and 2016 were included in the study. Patients age, gender, findings in the initial physical examination (PE) and neurological examination (NE), blood carboxyhemoglobin (COHb) level, relation between hyperbaric oxygen (HBO) treatment and DNS were assessed. RESULTS: Total of 72 patients were included in the study. Mean age was 33.43 ±â€¯20.89. It was determined that pathological findings in the initial NE are a significant predictive factor for DNS (Odds ratio 18.600, p:0.004). Significant relation between NE and HBO treatment was present (p:00.1). There was no statistically significant relationship between initial COHb level and receiving HBO treatment (p:0.9). Median COHb level of patients with DNS was 30 (min:10, max: 43), median COHb level of patients without DNS was 25 (min:10, max:44) and there was no statistically significant relationship between the two groups according to COHb levels (p:0.7). CONCLUSION: Pathological findings in the initial neurological examination had a predictive value for delayed neurological sequelae in patients with carbon monoxide poisoning.

Surprised-curious-confused: Epistemic emotions and knowledge exploration.

Some epistemic emotions, such as surprise and curiosity, have attracted increasing scientific attention, whereas others, such as confusion, have yet to receive the attention they deserve. In addition, little is known about the relations between these emotions, their joint antecedents and outcomes, and how they differ from other emotions prompted during learning and knowledge generation (e.g., achievement emotions). In 3 studies (Ns = 102, 373, 125) using a trivia task with immediate feedback, we examined within-person interrelations, antecedents, and effects of 3 epistemic emotions (surprise, curiosity, and confusion). Studies 2 and 3 additionally included 2 achievement emotions (pride and shame). Using multilevel modeling to disentangle within- and between-person variance, we found that achievement emotions were associated with accuracy (i.e., correctness of the answer), whereas epistemic emotions were related to high-confidence errors (i.e., incorrect answers a person was confident in) generating cognitive incongruity. Furthermore, as compared with achievement emotions, epistemic emotions were more strongly and positively related to subsequent knowledge exploration. Specifically, surprise and curiosity were positive predictors of exploration. Confusion had positive predictive effects on exploration which were significant in Studies 1 and 3 but not in Study 2, suggesting that the effects of confusion are less stable and need to be investigated further. Apart from the findings for confusion, the results were fully robust across all 3 studies. They shed light on the distinct origins and outcomes of epistemic emotions. Directions for future research and practical implications are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Virtual Reality in Anatomy: A Pilot Study Evaluating Different Delivery Modalities.

Technologies such as virtual reality are used in higher education to develop virtual learning resources (VLRs). These VLRs can be delivered in multiple modalities, from truly immersive involving wearable devices to less immersive modalities such as desktop. However, research investigating perceptions of VLRs in anatomy has mainly focused on a single delivery modality and a limited-demographic participant cohort, warranting a comparison of different modalities and a consideration of different cohorts. This pilot study aimed to compare perceptions of highly immersive and less immersive VLR deliveries among anatomy students and tutors and evaluate the impact of prior university experience on students' perceptions of VLRs. A skull anatomy VLR was developed using the Unity® gaming platform and participants were voluntarily recruited to assess highly immersive stereoscopic and less immersive desktop deliveries of the VLR. A validated survey tool was used to gather perceptions of both deliveries. Most participants agreed that both VLR deliveries were interesting and engaging and provided an immersive experience. Anatomy students perceived the stereoscopic delivery to be significantly more useful for understanding (P = 0.013), while anatomy tutors perceived the desktop delivery as more useful. A degree of physical discomfort and disorientation was reported by some participants for both deliveries, although to a greater extent for the stereoscopic delivery. The stereoscopic delivery was also found to be more mentally taxing than desktop delivery. These results suggest that desktop VLR delivery may minimize the risk of discomfort and disorientation associated with more immersive modalities while still providing a valuable learning experience.

Confusion, dissociation and bizarre behaviour as the onset of an early Susac syndrome.

A 47-year-old woman presented an episode of confusion and disorientation. According to remarkable psychiatric records, she had been treated for major depression and obsessive-compulsive disorder; however, no other relevant background was known. After preliminary examinations, blood analysis and neurological tests were unspecific and inconclusive. Therefore, the case was treated as a possible psychiatric episode related to her previous psychiatric disorders. However, due to the atypical presentation of the case, a cerebral MRI was performed, which demonstrated multiple central lesions of the corpus callosum ('snowball lesions'), as well as several supratentorial white matter lesions. As a result of the follow-up of the case, sensorineural hearing loss and branch retinal artery were detected, which concluded in the classic triad and the confirmation of the diagnosis of a Susac syndrome.

Delirium in Elderly Patients:Frequency and Precipitants in a Tertiary Hospital Setting.

OBJECTIVE: There is paucity of information on delirium in sub-Saharan Africa (SSA) particularly in the older persons (>60 years of age), leaving questions about the burden of the disease in an environment with lower health care standards. In this article, we set out to determine the frequency, precipitants and symptomatology of delirium in elderly patients admitted into medical wards in a teaching hospital in South-West Nigeria. METHODS: This was a descriptive study involving a pre-planned sample of one hundred and fifty patients aged 60 years and over, assessed for cognitive impairment and delirium using the previously validated IDEA cognitive screen, and the Confusion Assessment Method (CAM) respectively. Diagnosis of delirium was made using the CAM and DSM-IV criteria. RESULTS: Delirium was diagnosed in 32 patients giving a frequency of 21.3% (95%CI: 14.7-30.0%). Patients with delirium were significantly older (p<0.05). A quarter of the patients had dementia. Hypertension was a notable co-morbid condition. All the patients had altered sleep wake cycle, inattention, disorientation, and altered consciousness. Neurological diseases were the most common precipitant. There was a good agreement between the DSM-IV and CAM diagnoses. CONCLUSION: Delirium is common in hospitalised elderly patients particularly those with neurological diseases. Co-morbidities like hypertension, dementia, and depression should be looked for in delirious elderly patients.

"Just got to live life as it comes": A case study of the spousal-dyad longitudinal mild stroke transitional experience.

Objective: To longitudinally explore the transition home for a spousal dyad following mild stroke, in the context of a mild stroke-specific health service. Research Design: A case study approach, using an Interpretative Phenomenological Analysis (IPA), was identified as suitable for this study, as it enabled the essence of the phenomenon to be examined. Method: Participants were purposively chosen from a Randomised Control Trial (RCT), to reflect the average age, gender and marital status of the mild stroke population. The participants were a male (age 64) and his wife (age 62). Participants received the RCT intervention. Semi-structured interviews were completed separately with participants at 1-, 3-, 6- and 9- months post stroke. Results: Two themes were identified: (1) The Unexpected, Undesirable and Short-Lived, and (2) The New 'Normal'. The first theme reflects the confusion, adjustment and adaptation that occurred for the couple, especially during the first month at home. The second represents the couple's journey back to their everyday lives following hospital discharge, but also the questions and changes that remained present at 9-months post-discharge. Conclusions: Themes demonstrate an ongoing process of adjustment and the contextual nature of the transitional experience. Results also indicate the need to ensure that individuals have access to mild-stroke specific information across the transition continuum.