Reminiscence Therapy for Prevention of Post-Stroke Anxiety and Depression in Adults

Introduction Anxiety and depression are prevalent after a stroke.1,2 Peer support is a non-pharmacologic intervention utilized to manage post-stroke anxiety and depression with inconsistent results.3 Reminiscence therapy is an intervention that has been studied in the dementia population but is a relatively new intervention for the stroke population and has the potential to impact the psychological care provided to stroke patients.4https://jdc.jefferson.edu/mspas_capstones/1012/thumbnail.jp

Emotion Regulation and Borderline Personality Features

Despite evidence showing that emotion dysregulation is a key feature of Borderline Personality Disorder (BPD), it remains unclear how the process of emotion regulation is disrupted in this population. This thesis makes an original contribution to knowledge by exploring how emotion regulation is conducted by individuals with high levels of Borderline Personality Features (BPF), in an attempt to clarify the features of emotion regulation that may be problematic for these individuals. This was achieved using a multi-methodological approach with student samples to investigate several aspects of emotion regulation that have been identified in the literature as being important for emotion regulation success in relation to BPF. Study 1 investigated the overall experiences of emotion regulation and the types of emotion regulation strategies used by individuals with high levels of BPF using semi-structured interviews. Study 2a built on findings of Study 1 by quantifying the type and number of strategies used for positive and negative emotion regulation attempts using self-report questionnaires. Study 2b investigated the intensity of emotions when regulated and the duration of emotion regulation attempts using Experience Sampling Methodology (ESM).The final study, Study 2c, investigated implicit valuing of emotion regulation and emotion utility using two computer-based implicit tasks. Findings from studies 1 and 2a demonstrated that although individuals with high-levels of BPF demonstrate knowledge of a range of strategies, they appear to select and implement more unhelpful strategies and less helpful strategies. Moreover, this was found for the regulation of negative and positive emotion regulation. This finding provides evidence for a sufficient knowledge of emotion regulation strategies in this population, an area currently disputed within the literature. Additionally these findings address important gaps in the literature regarding positive emotion regulation and the use of helpful strategies in this population, areas neglected in past research. Findings from study 2b demonstrated that individuals with high levels of BPF appear to regulate their negative emotions when emotion intensity is higher. Theoretically, this indicates that these individuals attempt to regulate their emotions later in the emotion generation process, when intensity is high. However, BPF did not predict an increase in the duration of negative emotion regulation attempts, despite past research demonstrating that longer periods of emotion regulation may be necessary when emotion intensity is high. Together these findings highlight two potentially problematic areas of emotion regulation for individuals with high levels of BPF; timing and duration of emotion regulation attempts. Past research suggests that this pattern of emotion regulation influence emotion regulation strategy choice and limits emotion regulation success. In addition, it was also found that BPF predicted shorter durations of positive emotion regulation attempts. The investigation of positive emotion regulation has been largely neglected in the field of BPF. Thus this finding makes a unique contribution to the literature by indicating that these individuals may also demonstrate disturbances in positive emotion regulation processes. Findings from the final study, Study 2c, suggest that individuals with high levels of BPF do not differ in their implicit evaluations of emotion expression or emotion control, suggesting that implicit motivation for emotion regulation is not disrupted in this population. However, it was found that these individuals implicitly perceive avoidance emotions, such as worry or nervousness, as unhelpful when faced with a threatening task. This suggests that these individuals may demonstrate deficits in their understanding of emotion utility and ability to use emotions effectively. Overall, the research included in this thesis makes an important theoretical contribution to the literature by identifying specific features within the emotion regulation process that may be problematic for individuals with high levels of BPF. The identification of these features has important implications for non-clinical support services by highlighting specific targets for treatment. These findings may also be useful in informing clinical interventions for emotion dysregulation, subject to replication in clinical populations

Exploration of emotion regulation experiences associated with borderline personality features in a non-clinical sample

Background Emotion dysregulation is a core feature associated with borderline personality features (BPF). Little research has explored how individuals with high levels of BPF regulate their emotions. This study aimed to explore how individuals with high versus low levels of BPF compare on the strategies they use to regulate emotions and in their experiences of emotion regulation. Methods Twenty-nine university students were recruited and assessed for the presence of BPF using self-report questionnaires. Each participant took part in a semi-structured interview about their experiences of emotion regulation. All interview transcripts then underwent thematic analysis. In addition chi square analyses were conducted to explore the association between level of BPF (High vs Low) and each qualitative theme identified. Results Findings indicated similarities in the types of emotion regulation strategies used by the high and low-BPF groups. However, the groups differed in their experiences and thought processes surrounding emotion regulation. High-BPF participants were found to describe a need to communicate negative emotions with others and demonstrated difficulty maintaining attention on positive experiences. In addition there was a trend towards High-BPF participants demonstrating less forward-planning in emotion regulation. Conclusions This study provides insights into some of the unique aspects of emotion regulation in individuals with high BPF that may make emotion regulation attempts less successful

Cancer memory mate: implementing a healthcare innovation to support the management of cancer treatments and side effects in people with memory problems in South Wales, UK

Introduction: An estimated 11% of patients have dementia prior to a cancer diagnosis (Ornstein et al. 2020). These patients have poorer cancer treatment outcomes compared to those without dementia (Hopkinson et al. 2016). Cancer Memory Mate developed from our previous research (Hopkinson et al. 2020) is a specially trained oncology professional who offers advice and resources to support safe cancer treatment in someone with a memory problem, a common symptom of dementia. Aims: To report obstacles and enablers influencing implementation of Cancer Memory Mate in a cancer centre in South Wales, UK. Methodology: The Cancer Memory Mate project was launched on 30/9/2020. Clinical observations (n=3), and semi-structured interviews with staff (n=9) were conducted prior to training of 24 Memory Mates and launch. Further observations (n=7) and staff interviews (n=28) were conducted post-launch to explore the obstacles and enablers to implementation. Data were analysed using the Normalisation Process Theory framework of Duke et al. (2020). Results: The concept of Memory Mate had some level of coherence for staff who described how it can improve the patient pathway and experience. Moreover, staff invested time in becoming Memory Mates, demonstrating cognitive participation. Staff strived to take collective action to provide the best possible care for cancer patients, although certain professionals might only champion particular elements of being a Memory Mate. Reflecting on implementation, Memory Mates expressed the need for further service promotion, as some staff members had limited awareness of the project. This obstacle could be attributed to service organisation issues and the COVID-19 pandemic. Conclusion: Cancer Memory Mates were enthusiastic about the project and gave examples of Memory Mate improving the supportive care of patients and carers. Obstacles to implementation were wider staff awareness and service organisation issues that need to be addressed for Memory Mate to be fully embedded into practice

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570