Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient’s best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.     

Paternal Positivity and Child Mental Health: A Meta-Analysis

Journal of Child and Family Studies - Children whose mothers display more positivity during interactions tend to have better mental health. Some studies investigating associations between...     

Assessing Psychosocial Distress in Cystic Fibrosis: Validation of the ‘Distress in Cystic Fibrosis Scale’

Experiences of anxiety and depression are common in adults with Cystic Fibrosis (AwCF) (e.g. Quittner in Thorax 69:1090-1097, 2014) and may impact on a wide range of important health-related behaviours, such as adherence to medication and timely attendance for medical review when experiencing pulmonary exacerbation. Common screening measures used in CF such as the PHQ-9 and GAD-7 may reflect an absence of anxiety or depression when clinically significant emotional difficulties are apparent on further assessment. This study preliminarily validated the previously developed Distress in Cystic Fibrosis Scale (DCFS) (Patel in Journal of Cystic Fibrosis 15:S26, 2016); a 23-item questionnaire to assess psychosocial distress in AwCF. Inpatient and outpatient participants with CF (N?=?119) completed a battery of questionnaires, including the DCFS. PCA results supported a single component model. The DCFS showed high internal consistency and correlated significantly with measures of mood and quality of life. The DCFS shows promise as a screening tool to assess clinically significant psychosocial distress in an adult CF population.

     

Finding a Balance: Reconciling the Needs of the Institution,Patient, and Genetic Counselor for Optimal Resource Utilization

The current practice of cancer genetic counseling is undergoing widespread change and scrutiny. While there are clinical resources for genetic counselors (GCs) regarding the delivery of cancer genetic services, there is limited literature regarding effective management of a genetic counseling clinical program. We have developed administrative tools to manage a large team of GCs at a single academic medical center over a period of increasing demand for genetics services, with the initial aim of decreasing wait time for urgent genetic counseling visits. Here, we describe the three main elements of the clinical operations: Balancing patient volume between GCs, scheduling tracks for both routine and urgent appointments, and a team of triaging GCs to ensure appropriate patient referrals. For each of these elements, we describe how they have been modified over time and present data to support the utility of these strategies. The preliminary evidence offered here suggests that these tools allow for an equitable distribution of patient volume between team members, as well as the timely and accurate scheduling of urgent patients. As a result of the experiences presented here, other genetic counseling programs grappling with similar issues should be aware that it is possible to shift clinical operations to serve certain patient populations in a more timely fashion while keeping both providers and GC staff satisfied.     

Acceptability,Feasibility, and Effectiveness of Internet-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in New York

Cognitive-behavioral therapy (CBT), consisting of exposure and response prevention (EX/RP), is both efficacious and preferred by patients with obsessive–compulsive disorder (OCD), yet few receive this treatment in practice. This study describes the implementation of an Internet-based CBT program (ICBT) developed in Sweden in individuals seeking OCD treatment in New York. After translating and adapting the Swedish ICBT for OCD, we conducted an open trial with 40 adults with OCD. Using the RE-AIM implementation science framework, we assessed the acceptability, feasibility, and effectiveness of ICBT. The Yale–Brown Obsessive Compulsive Scale (Y-BOCS) was the primary outcome measure. Of 40 enrolled, 28 participants completed the 10-week ICBT. In the intent-to-treat sample (N = 40), Y-BOCS scores decreased significantly over time (F = 28.12, df = 2, 49, p < . 001). Depressive severity (F = 5.87, df = 2, 48, p < . 001), and quality of life (F = 12.34, df = 2, 48, p < . 001) also improved. Sensitivity analyses among treatment completers (N = 28) confirmed the intent-to-treat results, with a large effect size for Y-BOCS change (Cohen’s d = 1.38). ICBT took less time to implement than face-to face EX/RP and participants were very to mostly satisfied with ICBT. On a par with results in Sweden, the adapted ICBT program reduced OCD and depressive symptoms and improved quality of life among individuals with moderate to severe OCD. Given its acceptability and feasibility, ICBT deserves further study as a way to increase access to CBT for OCD in the United States.     

Examination stress as an ecological inducer of cortisol and psychological responses to stress in undergraduate students

The purpose of the present study was to investigate basic methodological issues related to the usage of an examination stress protocol in studies of psychoneuroendocrinology. In the present study, 57 undergraduate students served as participants. All subjects provided salivary samples and completed psychological inventories during a low examination stress period and again during a high examination stress period. Salivary samples were analyzed for cortisol. Three major findings were observed. First, the examination stress protocol proved to be an effective trigger of elevations in both psychological measures of stress and in cortisol levels. Second, sex differences were observed in cortisol levels, such that males showed an elevation in cortisol during the high examination stress session whereas females did not. Finally, no significant correlations were observed between elevations in psychological measures of stress and elevations in cortisol levels. These findings suggest that the examination stress protocol used in the present study effectively elevated both psychological stress and cortisol levels. Furthermore, these findings suggest that there are biological differences in how males and females respond to stress. Finally, no evidence was found to suggest a relationship between psychological and hormonal levels of stress. Together, these findings suggest the need to better define and consider the implications of both the specific measures of stress being used and individual differences in the subject samples in psychoendocrine studies.     

Linking Religion and Spirituality with Psychological Well-being: Examining Self-actualisation, Meaning in Life, and Personal Growth Initiative

Research largely shows that religion and spirituality have a positive correlation to psychological well-being. However, there has been a great deal of confusion and debate over their operational definitions. This study attempted to delineate the two constructs and categorise participants into different groups based on measured levels of religious involvement and spirituality. The groups were then scored against specific measures of well-being. A total of 205 participants from a wide range of religious affiliations and faith groups were recruited from various religious institutions and spiritual meetings. They were assigned to one of four groups with the following characteristics: (1) a high level of religious involvement and spirituality, (2) a low level of religious involvement with a high level of spirituality, (3) a high level of religious involvement with a low level of spirituality, and (4) a low level of religious involvement and spirituality. Multiple comparisons were made between the groups on three measures of psychological well-being: levels of self-actualisation, meaning in life, and personal growth initiative. As predicted, it was discovered that, aside from a few exceptions, groups (1) and (2) obtained higher scores on all three measures. As such, these results confirm the importance of spirituality on psychological well-being, regardless of whether it is experienced through religious participation.