0467 Benefits of CBT-I for Women Veterans with and without PTSD

Introduction

A quarter of women Veterans (WVs) receiving VA healthcare meet diagnostic criteria for both insomnia disorder and posttraumatic stress disorder (PTSD). Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective at improving sleep among individuals with comorbid psychiatric conditions; however, no studies have examined the impact of CBT-I in women with insomnia plus PTSD. The current analyses examined changes in sleep symptoms, quality of life (QoL), and mental health symptoms from pre- to post-CBT-I in WVs with and without PTSD.

Methods

This was a secondary analysis of 75 WVs with insomnia (32 with probable PTSD), who received CBT-I within a behavioral sleep intervention study (NCT02076165). Measures completed at baseline, posttreatment, and 3-month follow-up included: insomnia severity (Insomnia Severity Index, ISI), sleep quality (Pittsburgh Sleep Quality Index, PSQI), PTSD symptoms (PTSD Checklist-5, PCL-5; probable PTSD=total score ≥33), depressive symptoms (Patient Health Qestionnaire-9, PHQ-9), and mental and physical quality of life (Short Form Health Survey, SF-12). One sample T-tests examined changes in ISI, PSQI, PHQ-9, PCL-5, and SF-12 from baseline to posttreatment and baseline to follow-up. Two samples T-tests compared change scores in ISI, PSQI, PHQ-9, and SF-12 between participants with and without PTSD.

Results

There were significant improvements in ISI (p≤.001), PSQI (p≤.001), PHQ-9 (p≤.001), PCL-5 (p=.001), and SF-12 mental (p≤.001) and physical (p=.03) from baseline to posttreatment and 3-month follow-up (p≤.001-.01). There were no significant change score differences between WVs with and without PTSD from baseline to posttreatment (p=.06-.98) or 3-month follow-up (p=.09-.93).

Conclusion

CBT-I appears to be an effective treatment to improve insomnia symptoms among WVs with and without PTSD, and may reduce psychiatric symptoms as well. These findings suggest WVs with comorbid insomnia and PTSD benefit from CBT-I. The appropriate sequencing of CBT-I and PTSD treatments remains potentially important, but unstudied.

Support

VA/HSR&D IIR-HX002300; NIH/NHLBI K24HL14305; VA Office of Academic Affiliations through the Advanced Fellowship Programs in HSR&D and Women’s Health

Two-colour interferometry and switching through optomechanical dark mode excitation

Efficient switching and routing of photons of different wavelengths is a requirement for realizing a quantum internet. Multimode optomechanical systems can solve this technological challenge and enable studies of fundamental science involving widely separated wavelengths that are inaccessible to single-mode optomechanical systems. To this end, we demonstrate interference between two optomechanically induced transparency processes in a diamond on-chip cavity. This system allows us to directly observe the dynamics of an optomechanical dark mode that interferes photons at different wavelengths via their mutual coupling to a common mechanical resonance. This dark mode does not transfer energy to the dissipative mechanical reservoir and is predicted to enable quantum information processing applications that are insensitive to mechanical decoherence. Control of the dark mode is also utilized to demonstrate all-optical, two-colour switching and interference with light separated by over 5 THz in frequency.

INCIDENCE OF BREAST LYMPHEDEMA AND PREDICTORS OF ITS DEVELOPMENT IN PATIENTS RECEIVING WHOLE BREAST RADIATION THERAPY AFTER BREAST-CONSERVATION SURGERY

One common adverse effect following breast-conservation surgery and adjuvant radiation is lymphedema. While lymphedema of the arm has been well-characterized, there has been less investigation into lymphedema of the breast. We sought to characterize rates of breast lymphedema (BLE) in women with early-stage breast cancer and identify potential predictors in its development. Two hundred and thirty consecutive patients treated with lumpectomy and adjuvant whole breast radiation therapy (WBRT) from January 2016 - June 2017 were included. All patients were seen in our lymphedema monitoring clinic for baseline and at least one follow-up lymphedema measurement. BLE grades were assigned by trained nurses in the lymphedema clinic. Data regarding patient demographic and treatment factors were extracted from the electronic medical record. Comparisons between groups were made using Chi-Square analysis performed in SAS. The median age of the sample was 62 (range 31-90). Median follow-up from surgery was 15.3 months. Forty-three patients were diagnosed with lymphedema of the breast (18.7%). Rates of grade 1 and 2 BLE were 93% and 7%, respectively; there were no cases of severe lymphedema. Sixty-three percent of cases resolved by last follow-up with treatment recommendations. There was no association between development of BLE and patient factors investigated, including age, T stage, radiation dose and fractionation, lymph node biopsy, number of lymph nodes removed, development of arm lymphedema, and use of chemotherapy. Tumor subtype was found to be significant (P = 0.04) and there was a trend towards significance for receipt of trastuzumab (P = 0.09). BLE is a distinct entity from arm lymphedema and is a common finding in women treated with breast-conserving surgery and adjuvant WBRT. It is a generally mild and self-limiting process. There were no treatment or patient-related factors that correlated with increased risk of lymphedema development in our sample except for HER-2 positive disease and receipt of trastuzamab.

197 The use of photostimulation to enhance oocyte cytoplasmic maturation

Phototherapy uses monochromatic light from low-power lasers and light-emitting diodes (LEDs) to modulate biological processes. It has been proposed that the red-to-near infrared optical region (~600-1000nm) enhances cellular metabolic activity by activation of the mitochondrial respiratory chain. However, photostimulation induces the generation of oxide free radicals and could create oxidative stress in exposed cells. The main objective was to use photostimulation to affect the cumulus-oocyte complex metabolic state, aiming to enhance cytoplasmic maturation rates and subsequent embryonic development. A secondary objective was to determine the toxicity of the proposed photostimulation protocol. Abattoir-derived ovaries were used. All media was from IVF Biosciences (Falmouth, Cornwall, UK). Follicles 2 to 6mm in diameter were aspirated. Oocytes with compact cumulus and homogeneous cytoplasm were selected, and 50 oocytes/well were placed in invitro maturation medium (0h) and incubated at 38.5°C in 5% CO2 in air with high humidity in the presence (treatment=exposure for 2min to super-bright LED 1 and 2h after the beginning of maturation; LED wavelength of 660-665 nm; NTE30041; NTE Electronics Inc.) or absence (Control) of light. After maturation (22h), oocytes were split into two wells (25 oocytes/well) and subjected to IVF with semen from two different bulls for 18 to 20h. Cumulus cells were separated by vortexing, zygotes were placed in invitro culture medium, and incubated at 38.5°C in 5% CO2 in air with high humidity. Culture medium was renewed every 48h. Cleavage, morula, and blastocyst rates were recorded as a percentage of the number of oocytes subjected to IVF per treatment. The experiment was replicated 4 times. Statistical analysis was conducted using the Mixed procedure (SAS 9.4, SAS Institute Inc.) with repeated-measures and autoregressive covariance. The model's random effect was well within treatment. Fixed effects were bull, stage of development, and treatment. There was no difference (P=0.8) between treatments for any stage of development measured (cleavage: 76.4±2.7 vs. 74.8±4.1; morula: 36.1±4.8 vs. 35.9±5.8; blastocyst: 20.8±3.2 vs. 20.6±4.4 for control and treatment respectively; mean±s.e.). Sire affected development: bull 1 had a greater percentage (P<0.05) cleavage (82.9±0.02 vs. 68.3±0.02), morula (42.6±0.05 vs. 29.4±0.04), and blastocyst (27.8±0.04 vs. 13.6±0.01) development than bull 2. There was no treatment×bull interaction (P=0.9). In conclusion, there were no stimulatory or toxic effects of this preliminary photostimulation protocol. Further research is needed to develop an optimal protocol that shows a metabolic effect and, potentially, an enhancement of invitro cytoplasmic maturation rates and subsequent embryonic development.

"It's Like Riding Out the Chaos": Caring for Socially Complex Patients in an Ambulatory Intensive Care Unit (A-ICU)

PURPOSE

High-need high-cost (HNHC) patients consume a large proportion of health resources but often receive suboptimal care in traditional primary care. Intensive ambulatory care interventions attempt to better meet these patients' needs, but we know little about how teams delivering these interventions in clinics serving socially complex patient populations perceive their work.

METHODS

We performed a qualitative study of multidisciplinary staff experiences at a Federally Qualified Health Center (FQHC) caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit (A-ICU) intervention. We conducted semistructured interviews with 9 ambulatory intensive care team members and 6 "usual care" members. We conducted a thematic analysis, using an inductive approach, at a semantic level.

RESULTS

Staff viewed complexity as a combination of social, behavioral, and medical challenges that lead to patient-health care system mismatch. Staff perceive the following as key ingredients in caring for HNHC patients: addressing both psychosocial and clinical needs together; persistence in staying connected to patients through chaotic periods; shared commitment and cohesion among interdisciplinary team members; and flexibility to tailor care to patients' individual situations. Participants' definitions of success focused more on improving patient engagement than reducing utilization or cost.

CONCLUSION

FQHC staff working with HNHC patients perceive mismatch between the health care system and patients' clinical and social needs as the key driver of poor outcomes for these patients. Intensive ambulatory care teams may bridge mismatch through provision of psychosocial supports, flexible care delivery, and fostering team cohesion to support patient engagement.

Hexagonal Boron Nitride Cavity Optomechanics

Hexagonal boron nitride (hBN) is an emerging layered material that plays a key role in a variety of two-dimensional devices, and has potential applications in nanophotonics and nanomechanics. Here, we demonstrate the first cavity optomechanical system incorporating hBN. Nanomechanical resonators consisting of hBN beams with average dimensions of 12 μm × 1.2 μm × 28 nm and minimum predicted thickness of 8 nm were fabricated using electron beam induced etching and positioned in the optical near-field of silicon microdisk cavities. Of the multiple devices studied here a maximum 0.16 pm/[Formula: see text] sensitivity to the hBN nanobeam motion is demonstrated, allowing observation of thermally driven mechanical resonances with frequencies between 1 and 23 MHz, and largest mechanical quality factor of 1100 for a 23 MHz mode, at room temperature in high vacuum. In addition, the role of air damping is studied via pressure dependent measurements. Our results constitute an important step toward realizing integrated optomechanical circuits employing hBN.

Incidence of breast lymphedema and predictors of its development in patients receiving whole breast radiation therapy after breast-conservation surgery

One common adverse effect following breast-conservation surgery and adjuvant radiation is lymphedema. While lymphedema of the arm has been well-characterized, there has been less investigation into lymphedema of the breast. We sought to characterize rates of breast lymphedema (BLE) in women with early-stage breast cancer and identify potential predictors in its development. Two hundred and thirty consecutive patients treated with lumpectomy and adjuvant whole breast radiation therapy (WBRT) from January 2016 - June 2017 were included. All patients were seen in our lymphedema monitoring clinic for baseline and at least one follow-up lymphedema measurement. BLE grades were assigned by trained nurses in the lymphedema clinic. Data regarding patient demographic and treatment factors were extracted from the electronic medical record. Comparisons between groups were made using Chi-Square analysis performed in SAS. The median age of the sample was 62 (range 31-90). Median follow-up from surgery was 15.3 months. Forty-three patients were diagnosed with lymphedema of the breast (18.7%). Rates of grade 1 and 2 BLE were 93% and 7%, respectively; there were no cases of severe lymphedema. Sixty-three percent of cases resolved by last follow-up with treatment recommendations. There was no association between development of BLE and patient factors investigated, including age, T stage, radiation dose and fractionation, lymph node biopsy, number of lymph nodes removed, development of arm lymphedema, and use of chemotherapy. Tumor subtype was found to be significant (P = 0.04) and there was a trend towards significance for receipt of trastuzumab (P = 0.09). BLE is a distinct entity from arm lymphedema and is a common finding in women treated with breast-conserving surgery and adjuvant WBRT. It is a generally mild and self-limiting process. There were no treatment or patient-related factors that correlated with increased risk of lymphedema development in our sample except for HER-2 positive disease and receipt of trastuzamab.

The SUMMIT ambulatory-ICU primary care model for medically and socially complex patients in an urban federally qualified health center: study design and rationale

BACKGROUND

Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research.

METHODS/DESIGN

Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have < 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation.

DISCUSSION

The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers. Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858.

Family presence during resuscitation in emergency departments: professionals' attitudes in Brazil

AIM

The study explored the views and attitudes of nurses and physicians on family presence during resuscitation in emergency departments in Brazil.

BACKGROUND

International emergency associations endorse family presence during resuscitation; however, the extent to which it is practiced remains unclear, particularly in the Brazilian context. Research of emergency staff views and attitudes towards this practice is desirable so that actions can be identified to support families at the bedside.

METHODS

A qualitative research was conducted. Thirty-two health professionals (11 physicians and 21 nurses) working in two emergency departments in southern Brazil were purposefully recruited in January 2015. In-depth interviews were conducted, and data were analysed using content analysis.

FINDINGS

Nurses and physicians found family presence during resuscitation controversial and the general attitude towards this practice was negative. They reported that 'changes are needed' to adapt hospital infrastructures for family presence, and to train staff to respond to the information and emotional needs of families.

DISCUSSION

Translating a family nursing framework into clinical practice involves the need for reassessing educational and management policies in clinical contexts.

CONCLUSION

This research brings new understanding about the attitudes of some Brazilian nurses and physicians on the implementation of family presence during resuscitation and identifies the need to develop policies and strategies to improve family presence in emergency departments.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Hospital-based policies are required to improve family-centred care in emergency departments while providing a criterion of legality and safety to professionals to invite families to be present during invasive procedures. Also, family-focused education in health science degrees, continuing education and in the community is required.

Real-time superchannel transmission over 10,500 km submarine link at 4.66 b/s/Hz spectral efficiency

We show real-time measurement of error-free superchannel transmission over more than 10,500 km of large-area fiber at a spectral efficiency of 4.66 b/s/Hz, utilizing subcarrier based signal processing optimized at 5.4 GBd.

Extended C-band tunable multi-channel InP-based coherent receiver PICs

Fully integrated monolithic, multi-channel InP-based coherent receiver PICs and transceiver modules with extended C-band tunability are described. These PICs operate at 33 and 44 Gbaud per channel under dual polarization (DP) 16-QAM modulation. Fourteen-channel monolithic InP receiver PICs show integration and data rate scaling capability to operate at 44 Gbaud under DP 16-QAM modulation for combined 4.9 Tb/s total capacity. Six channel simultaneous operation of a commercial transceiver module at 33 Gbaud is demonstrated for a variety of modulation formats including DP 16-QAM for >1.2Tbit/s aggregate data capacity.

Enhancing OSCE preparedness with video exemplars in undergraduate nursing students. A mixed method study

BACKGROUND

Objective structured clinical examinations (OSCEs) are designed to assess clinical skill performance and competency of students in preparation for 'real world' clinical responsibilities. OSCEs are commonly used in health professional education and are typically associated with high levels of student anxiety, which may present a significant barrier to performance. Students, including nursing students, have identified that flexible access to exemplar OSCEs might reduce their anxiety and enable them to better prepare for such examinations.

AIM

To implement and evaluate an innovative approach to preparing students for OSCEs in an undergraduate (registration) acute care nursing course.

METHOD

A set of digitized OSCE exemplars were prepared and embedded in the University-based course website as part of usual course learning activities. Use of the exemplars was monitored, pre and post OSCE surveys were conducted, and qualitative data were collected to evaluate the approach. OSCE grades were also examined.

FINDINGS

The online OSCE exemplars increased self-rated student confidence, knowledge, and capacity to prepare and provided clarity around assessment expectations. OSCE exemplars were accessed frequently and positively received; but did not impact on performance.

CONCLUSION

Video exemplars aid student preparation for OSCEs, providing a flexible, innovative and clear example of the assessment process. Video exemplars improved self-rated student confidence and understanding of performance expectations, leading to increased engagement and reduced anxiety when preparing for the OSCE, but not overall OSCE performance. Such OSCE exemplars could be used to increase staff capacity and improve the quality of the student learning experience.

Collaborating to Compete: Blood Profiling Atlas in Cancer (BloodPAC) Consortium

The cancer community understands the value of blood profiling measurements in assessing and monitoring cancer. We describe an effort among academic, government, biotechnology, diagnostic, and pharmaceutical companies called the Blood Profiling Atlas in Cancer (BloodPAC) Project. BloodPAC will aggregate, make freely available, and harmonize for further analyses, raw datasets, relevant associated clinical data (e.g., clinical diagnosis, treatment history, and outcomes), and sample preparation and handling protocols to accelerate the development of blood profiling assays.

Pre- and peri-pubertal feed intake: effects on age at puberty and potential litter size of replacement gilts

The effect of moderate restriction of pre- and peri-pubertal liveweight gain on puberty attainment and potential litter size was investigated. At 69 days of age, 48 Large White/Landrace crossbred gilts (28.3 ± 0.3 kg), were fed to attain a liveweight of 70 kg (LIGHT) or 100 kg (HEAVY) at 161 days of age (n = 24 gilts/treatment). At 161 days of age, half the gilts in each group were fed to gain liveweight at 0.5 (LOW) or 1.0 (HIGH) kg/day until puberty (n = 12 gilts/treatment). From 175 days of age, gilts received 20 min/day of full, physical boar contact. Gilts were artificially inseminated at the pubertal oestrus, with reproductive tracts collected 22 ± 0.1 days later, and the number of corpora lutea and viable embryos recorded. LIGHT-LOW gilts were older (P < 0.05) at puberty compared with LIGHT-HIGH, HEAVY-LOW and HEAVY-HIGH gilts; 207.7 ± 3.50 versus 191.7 ± 3.65, 193.1 ± 3.50 and 192.5 ± 3.65, respectively. Treatment (HIGH vs LOW) increased (P < 0.05) pubertal ovulation rate (15.2 ± 0.43 vs 13.1 ± 0.47), oestradiol at oestrus (13.4 ± 1.87 vs 9.1 ± 1.22 pg/mL) and progesterone 72 h post-oestrus (7.1 ± 0.48 vs 4.6 ± 0.50 ng/mL). Embryo number (10.8 ± 0.46) and survival (77.0 ± 3.21) were unaffected (P > 0.05) by treatment. To conclude, puberty was delayed by chronic, but not acute, dietary restriction. Although short-term, moderate increases in feed intake increased pubertal ovulation rates, embryo numbers and survival were unaffected.

The Challenge of Managing Psoriasis: Unmet Medical Needs and Stakeholder Perspectives

BACKGROUND

Psoriasis is a debilitating chronic inflammatory autoimmune disease affecting approximately 7.4 million adults in the United States. Plaque psoriasis is the most common form, affecting 80% to 90% of patients.

OBJECTIVES

To describe the impact and challenges that psoriasis presents for various stakeholders, and to provide nondermatologist healthcare decision makers with information to enhance their contributions to drug and pharmacy benefit design discussions.

DISCUSSION

Psoriasis carries an increased risk for early mortality and an increased prevalence of comorbidities, including psoriatic arthritis, cardiovascular disease, and diabetes. It is also associated with anxiety, depression, and social isolation, and can negatively impact patients' relationships, productivity, and careers. The physical, psychologic, social, and economic impact of psoriasis, plus the associated stigma, result in cumulative impairment over a patient's lifetime. The current treatments for moderate-to-severe psoriasis include topical therapy, phototherapy, and systemic drugs (nonbiologic and biologic); however, patient satisfaction remains low, combination therapy and treatment switching are common, and many patients remain untreated or undertreated. Clinicians should consider the patient holistically, and should select treatment based on a range of factors, including disease severity (with physical and psychosocial manifestations), susceptibility to cumulative life-course impairment (considering personality, behavior, and cognition), comorbidities, concomitant medication, and patient preference. It is estimated that the total annual direct cost of treating psoriasis in the United States in 2015 exceeded $12.2 billion.

CONCLUSION

Psoriasis is a complex disease, and appropriate management is correspondingly complex. Newer psoriasis treatments provide improved efficacy and safety versus traditional treatments, but challenges remain in ensuring patients access to these medications. An improved understanding of the barriers to appropriate treatment is needed, as well as clear and accessible information for payers and clinicians on current treatment options, to ensure that decision makers can control costs while providing patients with optimal care.