Clinical Care of Patients with Neurocognitive Disorders: A Qualitative Study of the Psychiatric Residency Training Experience.

OBJECTIVE: Few data describe how general psychiatry residencies prepare trainees to care for individuals with neurocognitive disorders (NCDs), despite increasing recognition of the need for psychiatrists to provide care for the growing numbers of patients with NCD. This study aims to identify training needs and approaches, as the resident experience is one important perspective that can be added to others, such as milestones developed by expert educators. METHODS: The authors conducted three focus groups of third- and fourth-year general adult psychiatry residency trainees from three different training programs in May and June of 2021. Focus groups consisted of three to eight unique participants per group. Qualitative data analysis techniques derived in grounded theory were utilized to identify themes. RESULTS: Four main themes emerged from the focus groups: unique challenges of NCD care, intrinsic rewards of working with families, perceived gaps in educational experiences, and limited comfort in future practice. CONCLUSIONS: Participants expressed that aspects of NCD care were fundamentally different than care for other mental health conditions encountered in psychiatry residency. They found the progressive nature of the disease to be particularly challenging, and they also expressed challenges with clinical interviews and establishing rapport with individuals with NCDs. However, working with families was especially rewarding. Regardless of training program, participants expressed a need for additional longitudinal and diversified training opportunities to prepare them for future practice in this area.

Psychiatry Resident Education in Neurocognitive Disorders: a National Survey of Program Directors in Psychiatry.

OBJECTIVE: As major neurocognitive disorders increase, little research has examined how psychiatry residents are prepared to provide neurocognitive care to patients. METHODS: A national survey was sent to program directors of general psychiatry in the USA and Canada, including questions about satisfaction, attitudes, and graduation expectations for training in major neurocognitive disorders. The authors examined descriptive statistics and a series of chi-squared analyses by training setting, residency type, and presence of subspecialty fellowships. The authors also collected free text responses about perceived needs for enhancing training. RESULTS: Program directors agreed that the scope of general psychiatry includes the evaluation of cognitive disorders (78.8%) and the treatment of cognitive symptoms (77.5%) and behavioral/psychological symptoms (78.8%). Required clinical rotations were the preferred method of teaching (63.7%), but didactics were most used (93.8%). The most frequently used clinical teaching setting was geriatric psychiatry (61.3%) and didactics were most frequently taught by geriatric psychiatrists (75.0%). Fifty-six percent were satisfied or very satisfied with their clinical training and 66.3% with their didactics. There were no significant differences in satisfaction or attitudes when compared by training setting, residency type, or presence of subspecialty fellowships. Additional trained faculty were most frequently listed as a need for improving clinical and didactic training. CONCLUSIONS: Psychiatry program directors view major neurocognitive disorders as part of the scope of psychiatric practice. The majority of training is provided within psychiatry rotations, especially geriatric psychiatry. Program directors reported several unmet needs for optimal training, particularly related to clinical training services.

Current Educational Practices for Major Neurocognitive Disorders in Psychiatry: a Scoping Review.

OBJECTIVE: A scoping review of the literature was performed to examine the current state of education on major neurocognitive disorders within psychiatry, to review influential factors for pursuing a career working with these patients, and to review what has been done in education to address the shortage of providers to care for patients with major neurocognitive disorders. METHODS: Using the Arksey and O'Malley framework for conducting scoping reviews, twenty-eight studies on education in geriatric psychiatry, neuropsychiatry, and major neurocognitive disorders were selected. Learner groups included medical students, residents, and psychiatrists. The results from the studies were compared, and major themes were presented. RESULTS: Several studies found that positive clinical experiences with older adult patients and effective teachers in geriatric psychiatry play a role in influencing trainees to pursue a career in geriatric psychiatry. Topics pertaining to major neurocognitive disorders are taught by the majority of medical schools during the psychiatry rotation and are rated as the most important teaching topic in neurology among psychiatry residency program directors. Several interventions have resulted in increased comfort working with geriatric patients and patients who have major neurocognitive disorders among students, but fewer studies have resulted in an increase in interest seeing these patients in practice. There is a lack of research pertaining to psychiatry residents working with patients that have major neurocognitive disorders. CONCLUSIONS: While research on geriatric psychiatry and neuropsychiatry education exists, more research is needed that focuses specifically on how medical students and psychiatry residents are being taught major neurocognitive disorders.

Addicts and Admits: Metonymy in Medical Students' Reflective Writing.

Phenomenon: Metonymy refers to the substitution of the name of an attribute or adjunct for the name of the object or person being described. In medical contexts, this may involve referring to a person as a disease, body part, or other health-related noun. In this study, we explore the use of metonymy in medical students' reflective writing. Approach: Using content analysis, we identified all usages of metonymy in a sample of 802 medical student reflective essays. We analyzed them for associated themes and used the Fisher's exact test to compare frequencies of clinical ethics themes that occurred in the essays with metonymy to those without metonymy. Findings: Metonymy was used 60 times in the essays. The uses were grouped into thematic clusters of substance abuse (n = 27), illness (n = 9), body part (n = 4), clinical status (n = 6), reproductive health (n = 5), challenging clinical situations (n = 6), and other thoughts on patients as people (n = 3). Several ethical themes associated with essays using metonymy (p < .05): moral distress, substance abuse, adequate treatment, jumping to conclusions, awakening, and pain. Insights: Metonymy was relatively uncommon, and some students explicitly described the practice as dehumanizing to patients. Even so, metonymy did present in a variety of forms and was used most frequently to describe individuals with substance use disorders. Essays involving metonymy were more likely to describe a scenario that elicited moral distress in the students, which may indicate that metonymy occurs more frequently in some troubling situations.

Chia: Host Status for Meloidogyne incognita and Activity of Plant Extracts.

Chia (Salvia hispanica L.) seeds are used for food, drinks, oil, and animal feed, and all plant parts are employed in traditional medicine. The growing demand for the seed has created a need for improved disease management. Plant-parasitic nematodes have been found on other Salvia spp., but none have been reported from S. hispanica. Chia has also not been tested for production of compounds active against these nematodes. Therefore, aqueous extracts from shoots and roots of six chia lines, Brad's Organic, Cono, E2, G3, G5, and W13.1, were tested in laboratory assays. Some concentrations of all extracts were nematotoxic, killing about one-third of Meloidogyne incognita (Kofoid & White) Chitwood second-stage juveniles (J2s) in shoot extracts and up to nearly half of J2s in root extracts. Hatch was generally not affected by the extracts. In greenhouse trials, all six chia lines were hosts of M. incognita. Chia line G3 had approximately two times or more eggs per gram of root than Brad's Organic or Cono. When cucumber seedlings were transplanted into soil amended with chopped chia shoots (2.3 or 2.5% weight of fresh shoots/weight of dry soil), galling and egg production on cucumber roots were not suppressed. To our knowledge, this is the first report that chia is a host to M. incognita (or any phytoparasitic nematode) and that chia shoots and roots produce compounds active against a nematode.

"He Bore it Like a Scarlet Letter": Medical Student Reflections on Substance Use Disorders.

OBJECTIVE: Substance abuse in the context of the opioid crisis presents a major public health concern. Despite some evidence that medical students' attitudes towards substance use disorders worsen during medical school, very few studies have examined how students' early clinical experiences with substance use disorders shape their views of this clinical population. This study uses student reflective essays to explore these formative educational experiences. METHODS: Using content analysis, the authors analyzed a collection of 802 medical student reflective essays written during core clerkships (excluding Psychiatry), coding for ethical and professional themes as well as descriptions of substance use disorders. In addition to the qualitative identification of themes, the authors used chi-square analysis to determine which themes had statistically significant associations with substance use disorders. RESULTS: Fifty-three essays described patients with substance use disorders. The most common substances described were opioids (n = 25), alcohol (n = 18), and cocaine (n = 11). There were five themes statistically associated with substance use disorders (p < 0.05): (1) adequate treatment, (2) pain, (3) difficult patient, (4) jumping to conclusions, and (5) malingering. CONCLUSIONS: In the sample, students found the treatment of pain to be a significant ethical challenge related to substance use disorders. In considering a comprehensive educational plan, medical educators may need to consider educational venues outside of the Psychiatry clerkship to address substance use disorders.

Geriatric Psychiatry Inpatient Primer for Residents.

OBJECTIVE: The authors describe a novel curricular intervention that enhances first- and second-year psychiatry residents' geriatric psychiatry knowledge while preparing them for overnight call. METHODS: A brief, four-page document covering evaluation and management of common clinical scenarios in older adults, including agitation, falls, insomnia, chest pain, abnormal vital signs, and review of pharmacologic interventions, was presented to first- and second-year psychiatry residents. The residents completed an anonymous survey including their comfort level in answering pages and knowledge-based questions regarding evidence-based interventions both before and after the intervention. The pre-survey and post-survey were analyzed using the Wilcoxon-signed rank test, paired T test, and Mann-Whitney U test. RESULTS: The residents demonstrated statistically significant changes in first-line medication choices for common clinical scenarios such as non-aggressive agitation and insomnia. They were less likely to choose medications that should be avoided in elderly based on expert panel recommendations. CONCLUSIONS: Findings support the need for educational interventions designed to help residents taking call with geriatric patients. The results demonstrated an improvement in clinical knowledge following this brief intervention.

Medical student reflections on geriatrics: Moral distress, empathy, ethics and end of life.

Medical students' early clinical encounters may influence their perceptions of geriatrics. This study examines reflective essays written by 3rd-year medical students on required clinical rotations. Using content analysis, the authors analyzed the essays' thematic content. The authors then used chi-squared analysis to compare themes with geriatric patients (age 60+) to themes with other age groups. One hundred twenty out of 802 essays described a geriatric patient. The most common geriatric themes were (1) death and dying, (2) decision making, (3) meaningful physician-patient interactions, (4) quality of care, and (5) professional development. Geriatric essays were more likely to discuss death/dying and risk-benefit themes and less likely to discuss abuse. Geriatric essays were more likely to describe students' moral distress. Geriatric essays with moral distress were more likely to include empathy themes compared to geriatric essays without moral distress. Geriatric patients may pose unique ethical challenges for early clinical students.

Dark Period Following UV-C Treatment Enhances Killing of Botrytis cinerea Conidia and Controls Gray Mold of Strawberries.

Strawberries are available throughout the year either from production in the field or from high and low tunnel culture. Diversity of production conditions results in new challenges in controlling diseases before and after harvest. Fungicides have traditionally been used to control these diseases; however, their limitations necessitate a search for new approaches. We found that UV-C irradiation of Botrytis cinerea, a major pathogen of strawberry, can effectively kill this fungus if a dark period follows the treatment. The inclusion of a 4-h dark period resulted in almost complete kill of B. cinerea conidia on agar media at a dose of 12.36 J/m2. The UV-C dose did not cause a reduction in photosynthesis in strawberry leaves or discoloration of sepals, even after exposing plants repeatedly (twice a week) for 7 weeks. Although irradiation of dry conidia of B. cinerea with this dose resulted in some survival, the conidia were not infective and not able to cause decay even when inoculated onto a highly susceptible mature apple fruit. Irradiation of strawberry pollen at 12.36 J/m2 did not affect pollen germination, tube growth and length in vitro, or germination and tube growth in the style of hand-pollinated emasculated strawberry flowers. No negative effect of the UV-C treatment was observed on fruit yield and quality in high tunnel culture. In the fruit and flower petal inoculation tests, the UV-C treatment was highly effective in reducing fruit decay and petal infection. This UV-C treatment with an exposure time of 60 s may be useful in controlling gray mold in tunnel production of strawberries and may also have the potential for use in intensive field and indoor production of other fruits and vegetables providing that a 4-h dark period follows the irradiation.

The Effect of Different Temperatures and Moisture Levels on Survival of Calonectria pseudonaviculata in Boxwood Leaves and Twigs and as Microsclerotia Produced in Culture.

Leaves and twig sections of boxwood infected with Calonectria pseudonaviculata were incubated in sand at two moisture levels (36% [carrying capacity] and 5% water [vol/vol]) and at five temperatures (-10, 0, 10, 20, and 30°C). Percent sporulation from monthly tissue samples plated on glucose yeast-extract tyrosine media declined to zero after 5 months at 30°C and after 7 months at -10°C. At 0, 10, and 20°C, sporulation was observed through 30 months. Statistical analysis of data collected over 16 months of sampling showed a significant effect for temperature in all sample types, with maximum survival at 10°C. For discrete microsclerotia grown on cellophane sheets, sporulation was not observed after 2 months at 30°C or after7 months at -10°C. At all other temperatures, they continued to germinate over the 30 months of sampling. Statistical analysis showed significant effects for temperature and moisture level, with maximum survival at 0°C in moist soil over 16 months. These results suggest that extremes of heat and cold will kill the pathogen in plant debris but, at moderate temperatures, it will remain in soil for long periods, making replanting in affected sites in well-moderated climates difficult.

Synergistic streptococcal phage λSA2 and B30 endolysins kill streptococci in cow milk and in a mouse model of mastitis.

Bovine mastitis results in billion dollar losses annually in the USA alone. Streptococci are among the most relevant causative agents of this disease. Conventional antibiotic therapy is often unsuccessful and contributes to development of antibiotic resistance. Bacteriophage endolysins represent a new class of antimicrobials against these bacteria. In this work, we characterized the endolysins (lysins) of the streptococcal phages λSA2 and B30 and evaluated their potential as anti-mastitis agents. When tested in vitro against live streptococci, both enzymes exhibited near-optimum lytic activities at ionic strengths, pH, and Ca(2+) concentrations consistent with cow milk. When tested in combination in a checkerboard assay, the lysins were found to exhibit strong synergy. The λSA2 lysin displayed high activity in milk against Streptococcus dysgalactiae (reduction of CFU/ml by 3.5 log units at 100 µg/ml), Streptococcus agalactiae (2 log), and Streptococcus uberis (4 log), whereas the B30 lysin was less effective. In a mouse model of bovine mastitis, both enzymes significantly reduced intramammary concentrations of all three streptococcal species (except for B30 vs. S. dysgalactiae), and the effects on mammary gland wet weights and TNFα concentrations were consistent with these findings. Unexpectedly, the synergistic effect determined for the two enzymes in vitro was not observed in the mouse model. Overall, our results illustrate the potential of endolysins for treatment of Streptococcus-induced bovine mastitis.

Should Antipsychotics' Risks Be Accepted by Clinicians on Behalf of Patients to Achieve Benefits of Mitigating Older Adults' Behavioral Symptoms in Short-Staffed Units?

This commentary on a case considers risks and benefits of pharmacological and nonpharmacological management of agitation in patients with dementia. Specifically, it considers beneficence and nonmaleficence in treatment decisions that affect both patients and staff as well as autonomy and surrogate decision making.

Chimeric phage lysins act synergistically with lysostaphin to kill mastitis-causing Staphylococcus aureus in murine mammary glands.

Staphylococci cause bovine mastitis, with Staphylococcus aureus being responsible for the majority of the mastitis-based losses to the dairy industry (up to $2 billion/annum). Treatment is primarily with antibiotics, which are often ineffective and potentially contribute to resistance development. Bacteriophage endolysins (peptidoglycan hydrolases) present a promising source of alternative antimicrobials. Here we evaluated two fusion proteins consisting of the streptococcal λSA2 endolysin endopeptidase domain fused to staphylococcal cell wall binding domains from either lysostaphin (λSA2-E-Lyso-SH3b) or the staphylococcal phage K endolysin, LysK (λSA2-E-LysK-SH3b). We demonstrate killing of 16 different S. aureus mastitis isolates, including penicillin-resistant strains, by both constructs. At 100 µg/ml in processed cow milk, λSA2-E-Lyso-SH3b and λSA2-E-LysK-SH3b reduced the S. aureus bacterial load by 3 and 1 log units within 3 h, respectively, compared to a buffer control. In contrast to λSA2-E-Lyso-SH3b, however, λSA2-E-LysK-SH3b permitted regrowth of the pathogen after 1 h. In a mouse model of mastitis, infusion of 25 µg of λSA2-E-Lyso-SH3b or λSA2-E-LysK-SH3b into mammary glands reduced S. aureus CFU by 0.63 or 0.81 log units, compared to >2 log for lysostaphin. Both chimeras were synergistic with lysostaphin against S. aureus in plate lysis checkerboard assays. When tested in combination in mice, λSA2-E-LysK-SH3b and lysostaphin (12.5 µg each/gland) caused a 3.36-log decrease in CFU. Furthermore, most protein treatments reduced gland wet weights and intramammary tumor necrosis factor alpha (TNF-α) concentrations, which serve as indicators of inflammation. Overall, our animal model results demonstrate the potential of fusion peptidoglycan hydrolases as antimicrobials for the treatment of S. aureus-induced mastitis.

Older adults' preferences for religion/spirituality in treatment for anxiety and depression.

OBJECTIVES: To examine patient preferences for incorporating religion and/or spirituality into therapy for anxiety or depression and examine the relations between patient preferences and religious and spiritual coping styles, beliefs and behaviors. METHOD: Participants (66 adults, 55 years or older, from earlier studies of cognitive-behavioral therapy for late-life anxiety and/or depression in primary care) completed these measures by telephone or in-person: Geriatric Anxiety Inventory, Client Attitudes Toward Spirituality in Therapy, Patient Interview, Brief Religious Coping, Religious Problem Solving Scale, Santa Clara Strength of Religious Faith, and Brief Multidimensional Measure of Religiousness and Spirituality. Spearman's rank-order correlations and ordinal logistic regression examined religious/spiritual variables as predictors of preferences for inclusion of religion or spirituality into counseling. RESULTS: Most participants (77-83%) preferred including religion and/or spirituality in therapy for anxiety and depression. Participants who thought it was important to include religion or spirituality in therapy reported more positive religious-based coping, greater strength of religious faith, and greater collaborative and less self-directed problem-solving styles than participants who did not think it was important. CONCLUSION: For individuals like most participants in this study (Christians), incorporating spirituality/religion into counseling for anxiety and depression was desirable.