Complicated grief knowledge and practice: a qualitative study of general practitioners in Ireland.

OBJECTIVE: Complicated grief is a debilitating condition that individuals may experience after losing a loved one. General practitioners (GPs) are well positioned to provide patients with support for grief-related issues. Traditionally, Irish GPs play an important role in providing patients with emotional support regarding bereavement. However, GPs have commonly reported not being aptly trained to respond to bereavement-related issues. This study explores GPs' current knowledge of and practice regarding complicated grief. METHODS: A qualitative study adopting a phenomenological approach to explore the experiences of GPs on this issue. Semi-structured interviews were carried out with a purposive sample of nine GPs (five men and four women) in Ireland. Potential participants were contacted via email and phone. Interviews were audio-recorded, transcribed and analysed using Braun & Clarke's () model of thematic analysis. RESULTS: GPs had limited awareness of the concept of complicated grief and were unfamiliar with relevant research. They also reported that their training was either non-existent or outdated. GPs formed their own knowledge of grief-related issues based on their intuition and experiences. For these reasons, there was not one agreed method of how to respond to grief-related issues reported by patients, though participants recognised the need for intervention, onward referral and review. CONCLUSIONS: The research highlighted that GPs felt they required training in complicated grief so that they would be better able to identify and respond to complicated grief.

Complicated grief knowledge, attitudes, skills, and training among mental health professionals: A qualitative exploration.

The knowledge, attitudes, skills, and training of professionals regarding complicated grief influence their practice. We conducted 30 semi-structured interviews with psychiatrists, psychologists, and counselor/psychotherapists; the preliminary findings were contextualized via interviews with three experts in complicated grief research/practice. Findings suggest that professionals did not substantially rely on research evidence, favoring instead personal and professional knowledge. They expressed concern regarding the possible pathologization of normal grief that might arise from having a diagnosis of complicated grief. Deficits in professional training were evident. A need for an improved culture of collaboration between researchers and practitioners was identified.

How can we know what we don't know? An exploration of professionals' engagement with complicated grief.

OBJECTIVE: Research has shown that complicated grief has the potential to adversely affect bereaved individuals, and in this context, understanding how mental health professionals engage with it in practice is of relevance. Gaining an understanding of professionals' knowledge, attitudes, skills and training in relation to complicated grief could provide insights that will inform their training and professional development. The aim of this study was to consider professionals' engagement with complicated grief, as represented by self-reported knowledge, attitudes, skills and training. METHODS: The study used a three-phase mixed methods design (systematic review, qualitative interviews, and a quantitative survey) with empirical data being collected from psychologists, psychiatrists and counselor/psychotherapists. RESULTS: Analysis yielded 15 integrated findings across the three phases, which were grouped into two clusters: the first highlighted tension between professionals' reported confidence and competence and the second explored the parameters and contribution of research and training in this area. CONCLUSION: Professionals' perception of their competence to work with complicated grief seems overstated and research and professional practice are not aligned. PRACTICE IMPLICATIONS: These findings are positioned to inform empirically supported training that addresses identified deficits in professionals' knowledge, attitudes and skills. It is important therefore that training is reflective of the needs of different professional groups.

Psychiatrists', psychologists' and counselors' attitudes regarding complicated grief.

BACKGROUND: Complicated grief encompasses various presentations where aspects of grief do not become integrated into the bereaved person's life. Professionals' attitudes to complicated grief may impact how they engage with bereaved patients/clients. The aim of this study was to empirically examine the attitudes of mental health professionals, specifically psychologists, psychiatrists and counselor/psychotherapists, regarding complicated grief and to investigate any between profession-differences. METHOD: Psychiatrists, counselor/psychotherapists and psychologists were recruited using publicly available databases managed by professional bodies. A total of 185 professionals (71.8% female), returned a questionnaire containing usable data (23.8% response rate). RESULTS: Over two-thirds of the professionals (68.5%) supported the inclusion of complicated grief in diagnostic manuals while only a quarter (25.1%) thought that recognition of complicated grief might lead to the pathologization of 'normal' grief. The majority of respondents (83.0%) thought that diagnosing complicated grief would increase the likelihood of clients accessing support and there was no significant difference between the groups. LIMITATIONS: Although the response rate compares favorably with other studies it is nonetheless somewhat lower than optimum, and it is possible that those who responded were more interested in bereavement and consequently, that the attitudes held by participants are different from those who did not participate. CONCLUSION: The attitude to a diagnosis of complicated grief was more positive than the specialist literature suggests, with the benefits of having a diagnosis of complicated grief outweighing the risks of pathologization.

Precision Military Medicine: Conducting a multi-site clinical utility study of genomic and lifestyle risk factors in the United States Air Force.

Following several years enrolling disease-specific and otherwise healthy cohorts into the Coriell Personalized Medicine Collaborative, a prospective study aimed at evaluating the clinical utility of personal genomic information for common complex disease and pharmacogenomics, the Coriell Personalized Medicine Collaborative expanded to create a military cohort, specifically, the United States Air Force. Initial recruitment focused on Air Force Medical Service personnel and later expanded to include all Active Duty Air Force members and beneficiaries. Now in its 6th year, the study has produced a wide variety of insights, including optimal study design for military-sponsored genomic research, and discussion on genetic information sharing between and amongst Air Force study participants, civilian and military researchers, and the United States Department of Defense. Over the longer term, analyses will further contribute to the development of policies and processes relevant to clinical decision support and data sharing within the US military, and on-going work with the Air Force Medical Service sub-cohort will generate critical insights into how best to deploy useful genomic information in clinical care. Here we discuss challenges faced and critical success factors for military-civilian collaborations around genomic research.

Complicated grief: Knowledge, attitudes, skills and training of mental health professionals: A systematic review.

OBJECTIVE: A systematic review and qualitative synthesis was undertaken to deduce the knowledge, attitudes, skills and training of mental health professionals regarding complicated grief (CG). METHODS: PsychInfo, Embase, Medline, CINAHL, PBSC, Web of Science and ERIC databases were used to identify relevant literature. Searches were executed from inception to September 2014. RESULTS: The electronic search yielded 305 results. Forty-one papers were selected for full text review, 20 were included for analysis. 6 examined primary data, the remaining 14 being reviews, opinion or guideline pieces. CONCLUSIONS: Despite the lack of consensus on terminology, criteria and diagnosis, it appears that there is more than sufficient agreement within the CG research community regarding the knowledge and skills required to assist someone presenting with CG. A palpable fear of medicalising grief exists, but this would seem to be based on a conflation of normal grief and CG. This review highlights the mainly unidirectional nature of current research, the voice of the practitioner being largely unheard. A need for and an interest in training in CG was expressed. PRACTICE IMPLICATIONS: There is an urgent need to translate research findings into clinical practice. Training must take account of attitudinal barriers to implementation, balancing evidence and stories.

Toward clinical genomics in everyday medicine: perspectives and recommendations.

Precision or personalized medicine through clinical genome and exome sequencing has been described by some as a revolution that could transform healthcare delivery, yet it is currently used in only a small fraction of patients, principally for the diagnosis of suspected Mendelian conditions and for targeting cancer treatments. Given the burden of illness in our society, it is of interest to ask how clinical genome and exome sequencing can be constructively integrated more broadly into the routine practice of medicine for the betterment of public health. In November 2014, 46 experts from academia, industry, policy and patient advocacy gathered in a conference sponsored by Illumina, Inc. to discuss this question, share viewpoints and propose recommendations. This perspective summarizes that work and identifies some of the obstacles and opportunities that must be considered in translating advances in genomics more widely into the practice of medicine.

Using the Coriell Personalized Medicine Collaborative Data to conduct a genome-wide association study of sleep duration.

Sleep is critical to health and functionality, and several studies have investigated the inherited component of insomnia and other sleep disorders using genome-wide association studies (GWAS). However, genome-wide studies focused on sleep duration are less common. Here, we used data from participants in the Coriell Personalized Medicine Collaborative (CPMC) (n = 4,401) to examine putative associations between self-reported sleep duration, demographic and lifestyle variables, and genome-wide single nucleotide polymorphism (SNP) data to better understand genetic contributions to variation in sleep duration. We employed stepwise ordered logistic regression to select our model and retained the following predictive variables: age, gender, weight, physical activity, physical activity at work, smoking status, alcohol consumption, ethnicity, and ancestry (as measured by principal components analysis) in our association testing. Several of our strongest candidate genes were previously identified in GWAS related to sleep duration (TSHZ2, ABCC9, FBXO15) and narcolepsy (NFATC2, SALL4). In addition, we have identified novel candidate genes for involvement in sleep duration including SORCS1 and ELOVL2. Our results demonstrate that the self-reported data collected through the CPMC are robust, and our genome-wide association analysis has identified novel candidate genes involved in sleep duration. More generally, this study contributes to a better understanding of the complexity of human sleep.

Common genetic risk for melanoma encourages preventive behavior change.

There is currently great interest in using genetic risk estimates for common disease in personalized healthcare. Here we assess melanoma risk-related preventive behavioral change in the context of the Coriell Personalized Medicine Collaborative (CPMC). As part of on-going reporting activities within the project, participants received a personalized risk assessment including information related to their own self-reported family history of melanoma and a genetic risk variant showing a moderate effect size (1.7, 3.0 respectively for heterozygous and homozygous individuals). Participants who opted to view their report were sent an optional outcome survey assessing risk perception and behavioral change in the months that followed. Participants that report family history risk, genetic risk, or both risk factors for melanoma were significantly more likely to increase skin cancer preventive behaviors when compared to participants with neither risk factor (ORs = 2.04, 2.79, 4.06 and p-values = 0.02, 2.86 × 10-5, 4.67 × 10-5, respectively), and we found the relationship between risk information and behavior to be partially mediated by anxiety. Genomic risk assessments appear to encourage positive behavioral change in a manner that is complementary to family history risk information and therefore may represent a useful addition to standard of care for melanoma prevention.

Broadening research consent in the era of genome-informed medicine.

Genetic variant associations and advances in research technologies are generating an unprecedented volume of genomic data. Whole-genome sequencing will introduce even greater depth to current data sets and will propel medical research and development. Yet as one area of biomedical research evolves, another stagnates: informed consent. As presently employed, informed consent is not entirely attuned to the era of whole-genome sequencing. The greatest value of genomic data lays in its accessibility over time; the current model of informed consent restricts the use of data and does not readily accommodate prospective basic and clinical research, a priori research, or opportunities to act upon incidental findings. It also disengages the research participant from the discovery process, discouraging the provision of research results that may have clinical value to that individual. A revisited informed consent approach-the Informed Cohort Oversight Board (ICOB)-has been proven successful at consenting individuals to a model which facilitates the simultaneous construction of longitudinal data with the return of results to participants as scientific knowledge and technology allows. The opportunity to sequence once and consult often is cost-effective, encourages scientific innovation, and provides the opportunity to quickly translate genomics into better clinical care.

Radiation doses from small-bowel follow-through and abdomen/pelvis MDCT in pediatric Crohn disease.

BACKGROUND: The onset of Crohn disease (CD) can occur in childhood. Imaging, which often involves radiation, is frequent in CD both for disease diagnosis and follow-up. However, information regarding radiation dose for contemporary CT and fluoroscopy is not available for determining the cost/benefit ratio for imaging strategies. OBJECTIVE: To compare effective dose (ED) for small-bowel follow-through (SBFT) and abdomen/pelvis MDCT in pediatric CD. MATERIALS AND METHODS: Average fluoroscopic time and number of radiographs were obtained for 30 consecutive pediatric SBFTs. The numbers of SBFTs and CT scans performed per child among children with CD (1990-2005) were determined. The ED was determined (ICRP 60, 10-year-old phantom, MOSFET) for a 5-min fluoroscopy examination of the central abdomen and right lower quadrant (110 kVp, 0.3 mA) and pelvis (110 kVp, 0.35 mA). The ED for a 16-slice abdomen/pelvis MDCT scan was determined using the 10-year-old protocol: 16 x 1.25 mm, pitch 1.375, 27.5 mm/rotation, 0.5 s, 140 kVp, 85 mA. RESULTS: A total of 176 children with CD underwent imaging, averaging 1.2 SBFTs and 1.1 CT scans. On average SBFT took 5.1 min with 3.3 abdominal radiographs. The EDs (mSv) for a 5-min fluoroscopy were 0.15 for the central abdomen, 0.35 for the right lower quadrant, and 0.56 for the pelvis, yielding an average ED for SBFT (5-min fluoroscopy, 3.3 abdominal radiographs) of 1.8-2.2 mSv. The ED for MDCT was 3.48 mSv. CONCLUSION: Although the ED for MDCT might be up to twice that for SBFT, excessive fluoroscopy time and number of abdominal radiographs can result in actual EDs that are equivalent. Attention must be paid to SBFT technique to minimize radiation dose and to the indication to determine the appropriate examination.

Radiation doses from small-bowel follow-through and abdominopelvic MDCT in Crohn's disease.

OBJECTIVE: The purpose of our study was to compare organ and effective doses for small-bowel follow-through (SBFT) and abdominopelvic MDCT in adults with Crohn's disease, to retrospectively evaluate the number of radiographic examinations performed for Crohn's disease indications, and to identify those patients undergoing serial examinations to better delineate the use of radiology in the diagnosis and clinical management of Crohn's disease. MATERIALS AND METHODS: Using an anthropomorphic phantom and metal-oxide semiconductor field-effect transistor (MOSFET) dosimeters, specific organ doses were measured for 5 minutes of continuous fluoroscopy (kVp, 120; mA, 0.6) of each of the following: right lower quadrant, central abdomen, and pelvis. Effective doses were determined based on International Commission on Radiological Protection (ICRP) 60 weighting factors. Organ and effective doses were determined for abdominal and pelvic 16-MDCT: detector configuration, 16 x 0.625 mm; pitch, 1.75; 17.5 mm per rotation; rotation time, 0.5 second; 140 kVp; 340 mA. Electronic records were reviewed to determine the number of patients imaged for Crohn's disease indications and the number of studies per patient. RESULTS: The highest fluoroscopic organ doses were as follows: in the right lower quadrant, right kidney (0.78 cGy) and marrow (0.66 cGy); in the central abdomen, kidneys (1.5 and 1.6 cGy) and marrow (0.76 cGy); and in the pelvis, marrow (0.67-0.95 cGy). Effective doses for the right lower quadrant, central abdomen, and pelvis were 1.37, 2.02, and 3.83 mSv, respectively. For MDCT, the highest organ doses were to the liver (2.95-3.33 cGy). The effective dose for abdominopelvic MDCT was 16.1 mSv. Three hundred seventy-three patients underwent imaging for Crohn's disease. The average number of SBFT and CT examinations was 1.8 and 2.3, respectively. Thirty-four (9%) of 373 patients underwent more than five CT examinations and 11 (3%) had more than 10. CONCLUSION: Organ and effective doses are up to five times higher with MDCT than with SBFT. Crohn's disease is more frequently imaged with CT. For a subset of patients who undergo numerous CT examinations, efforts should be made to minimize the number of CT examinations, decrease the CT dose, or consider MR enterography.