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Potter KM, Prendergast NT, Boyd JG. From Traditional Typing to Intelligent Insights: A Narrative Review of Directions Toward Targeted Therapies in Delirium. Crit Care Med 2024; 52:1285-1294. [PMID: 39007569 DOI: 10.1097/ccm.0000000000006362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
Delirium is a heterogeneous syndrome characterized by an acute change in level of consciousness that is associated with inattention and disorganized thinking. Delirium affects most critically ill patients and is associated with poor patient-oriented outcomes such as increased mortality, longer ICU and hospital length of stay, and worse long-term cognitive outcomes. The concept of delirium and its subtypes has existed since nearly the beginning of recorded medical literature, yet robust therapies have yet to be identified. Analogous to other critical illness syndromes, we suspect the lack of identified therapies stems from patient heterogeneity and prior subtyping efforts that do not capture the underlying etiology of delirium. The time has come to leverage machine learning approaches, such as supervised and unsupervised clustering, to identify clinical and pathophysiological distinct clusters of delirium that will likely respond differently to various interventions. We use sedation in the ICU as an example of how precision therapies can be applied to critically ill patients, highlighting the fact that while for some patients a sedative drug may cause delirium, in another cohort sedation is the specific treatment. Finally, we conclude with a proposition to move away from the term delirium, and rather focus on the treatable traits that may allow precision therapies to be tested.
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Affiliation(s)
- Kelly M Potter
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Niall T Prendergast
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - J Gordon Boyd
- Department of Medicine (Neurology) and Critical Care Medicine, Queen's University, Kingston, ON, Canada
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Aggar C, Craswell A, Bail K, Compton RM, Hughes M, Sorwar G, Baker J, Greenhill J, Shinners L, Nichols B, Langheim R, Wallis A, Bowen K, Bridgett H. A Toolkit for Delirium Identification and Promoting Partnerships Between Carers and Nurses: A Pilot Pre-Post Feasibility Study. J Gen Intern Med 2024:10.1007/s11606-024-08734-6. [PMID: 38647970 DOI: 10.1007/s11606-024-08734-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/15/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Delirium is frightening for people experiencing it and their carers, and it is the most common hospital-acquired complication worldwide. Delirium is associated with higher rates of morbidity, mortality, residential care home admission, dementia, and carer stress and burden, yet strategies to embed the prevention and management of delirium as part of standard hospital care remain challenging. Carers are well placed to recognize subtle changes indicative of delirium, and partner with nurses in the prevention and management of delirium. OBJECTIVE To evaluate a Prevention & Early Delirium Identification Carer Toolkit (PREDICT), to support partnerships between carers and nurses to prevent and manage delirium. DESIGN A pre-post-test intervention and observation study. MAIN MEASURES Changes in carer knowledge of delirium; beliefs about their role in partnering with nurses and intended and actual use of PREDICT; carer burden and psychological distress. Secondary measures were rates of delirium. PARTICIPANTS Participants were carers of Indigenous patients aged 45 years and older and non-Indigenous patients aged 65 years and older. INTERVENTION Nurses implemented PREDICT, with a view to provide carers with information about delirium and strategies to address caregiving stress and burden. KEY RESULTS Participants included 25 carers (43% response rate) (n = 17, 68% female) aged 29-88 (M = 65, SD = 17.7 years). Carer delirium knowledge increased significantly from pre-to-post intervention (p = < .001; CI 2.07-4.73). Carers' intent and actual use of PREDICT was (n = 18, 72%; and n = 17, 68%). Carer burden and psychological distress did not significantly change. The incidence of delirium in the intervention ward although not significant, decreased, indicating opportunity for scaling up. CONCLUSION The prevention and management of delirium are imperative for safe and quality care for patients, carers, and staff. Further comprehensive and in-depth research is required to better understand underlying mechanisms of change and explore facets of nursing practice influenced by this innovative approach.
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Affiliation(s)
- Christina Aggar
- Faculty of Health, Southern Cross University, Bilinga, QLD, Australia.
- Northern NSW Local Health District, Lismore, NSW, Australia.
| | - Alison Craswell
- School of Health, University of the Sunshine Coast, Maroochydore BC, QLD, Australia
| | - Kasia Bail
- Faculty of Health, University of Canberra, Bruce, ACT, Australia
| | - Roslyn M Compton
- College of Nursing, University of Saskatchewan, Saskatoon, SK, Canada
| | - Mark Hughes
- Faculty of Health, Southern Cross University, Bilinga, QLD, Australia
| | - Golam Sorwar
- Faculty of Business, Law and Arts, Southern Cross University, Bilinga, QLD, Australia
| | - James Baker
- Faculty of Health, Southern Cross University, Bilinga, QLD, Australia
| | - Jennene Greenhill
- Faculty of Health, Southern Cross University, Bilinga, QLD, Australia
| | - Lucy Shinners
- Faculty of Health, Southern Cross University, Bilinga, QLD, Australia
| | - Belinda Nichols
- Faculty of Health, Southern Cross University, Bilinga, QLD, Australia
- Northern NSW Local Health District, Lismore, NSW, Australia
| | | | - Allison Wallis
- Northern NSW Local Health District, Lismore, NSW, Australia
| | - Karen Bowen
- Northern NSW Local Health District, Lismore, NSW, Australia
| | - Hazel Bridgett
- Northern NSW Local Health District, Lismore, NSW, Australia
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Lin L, Peng Y, Huang X, Li S, Chen L, Lin Y. A family intervention to prevent postoperative delirium in patients undergoing cardiac valve surgery: A randomized controlled study. Heart Lung 2024; 63:1-8. [PMID: 37714079 DOI: 10.1016/j.hrtlng.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/24/2023] [Accepted: 09/03/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Multiple guidelines recommend that families be involved in the care of ICU patients, which has been widely used in ICU delirium management in recent years. Postoperative delirium (POD) occurs frequently after cardiac surgery and is associated with poor outcomes; however, the effects of family intervention on this group are rarely studied. OBJECTIVES This study aimed to investigate the effects of family intervention on the incidence of POD and the ICU prognoses of patients undergoing cardiac valve surgery. METHODS This was a two-group, single-blind, randomized controlled trial involving 80 patients undergoing cardiac valve surgery, with 40 patients in each group. The control group received routine ICU visits, and the experimental group implemented a family intervention that instructed family caregivers to participate in delirium management during ICU visits. The occurrence of POD, ICU stay, mechanical ventilation time of patients; as well as the anxiety, depression, and satisfaction levels of family caregivers were compared between the two groups. RESULTS The incidence of POD and ICU stay of patients were significantly lower in the experimental group compared to the control group (P < 0.05). The anxiety and depression incidence of family caregivers in the experimental group was lower than those of the control group (P < 0.05), and satisfaction scores were higher than those of the control group (P < 0.05). CONCLUSIONS Family intervention has the potential to reduce the incidence of POD in patients undergoing cardiac valve surgery, shorten ICU stays, reduce the incidence of anxiety and depression in family caregivers, and improve their satisfaction. These findings suggest that family intervention could be incorporated into routine nursing practice.
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Affiliation(s)
- Lingyu Lin
- Department of Nursing, Fujian medical university, Fuzhou, Fujian, China; Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China; Heart Center of Fujian Medical University, Fuzhou, Fujian, China
| | - Yanchun Peng
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China; Heart Center of Fujian Medical University, Fuzhou, Fujian, China
| | - Xizhen Huang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China; Heart Center of Fujian Medical University, Fuzhou, Fujian, China
| | - Sailan Li
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China; Heart Center of Fujian Medical University, Fuzhou, Fujian, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China; Heart Center of Fujian Medical University, Fuzhou, Fujian, China
| | - Yanjuan Lin
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China; Heart Center of Fujian Medical University, Fuzhou, Fujian, China; Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.
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Shirasaki K, Hifumi T, Nakanishi N, Nosaka N, Miyamoto K, Komachi MH, Haruna J, Inoue S, Otani N. Postintensive care syndrome family: A comprehensive review. Acute Med Surg 2024; 11:e939. [PMID: 38476451 PMCID: PMC10928249 DOI: 10.1002/ams2.939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
Families of critically ill patients are predisposed to tremendous burdens when their relatives are admitted to the intensive care unit (ICU). Postintensive care syndrome family (PICS-F) can be described as a devastated life, encompassing psychological, physical, and socioeconomical burdens that begin with the emotional impact experienced by the family when the patient is admitted to the ICU. PICS-F was primarily proposed as a clinically significant psychological impairment, but it needs to be extended beyond the psychological impairment of the family to include physical and socioeconomical impairments in the future. The prevalence of physiological problems including depression, anxiety and post-traumatic syndrome is 20-40%, and that of non-physiological problems including fatigue is 15% at 6 months after the ICU stay. Assessment of PICS-F was frequently conducted at 3- or 6-month points, although the beginning of the evaluation was based on different assessment points among each of the studies. Families of ICU patients need to be given and understand accurate information, such as the patient's diagnosis, planned care, and prognosis. Prevention of PICS-F requires a continuous bundle of multifaceted and/or multidisciplinary interventions including providing a family information leaflet, ICU diary, communication facilitators, supportive grief care, and follow-up, for the patient and families from during the ICU stay to after discharge from the ICU. This is the first comprehensive review of PICS-F to address the concept, risk factors, assessment tools, prevalence, and management to prevent PICS-F to facilitate acute care physicians' understanding of PICS-F.
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Affiliation(s)
- Kasumi Shirasaki
- Department of Emergency and Critical Care MedicineSt. Luke's International HospitalTokyoJapan
| | - Toru Hifumi
- Department of Emergency and Critical Care MedicineSt. Luke's International HospitalTokyoJapan
| | - Nobuto Nakanishi
- Division of Disaster and Emergency Medicine, Department of Surgery RelatedKobe University Graduate School of MedicineKobeJapan
| | - Nobuyuki Nosaka
- Department of Intensive Care MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Kyohei Miyamoto
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Miyuki H. Komachi
- School of Clinical Medicine, Department of Psychiatry, Child and Adolescent Resilience and Mental HealthUniversity of CambridgeCambridgeUK
| | - Junpei Haruna
- Department of Intensive Care Medicine, School of MedicineSapporo Medical UniversityHokkaidoJapan
| | - Shigeaki Inoue
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Norio Otani
- Department of Emergency and Critical Care MedicineSt. Luke's International HospitalTokyoJapan
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Ito Y, Tsubaki M, Kobayashi M, Yagome S, Sakaguchi Y. Effect size estimates of risk factors for post-intensive care syndrome-family: A systematic review and meta-analysis. Heart Lung 2023; 59:1-7. [PMID: 36642001 DOI: 10.1016/j.hrtlng.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/05/2022] [Accepted: 01/08/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Families of patients admitted to ICUs often experience post-intensive care syndrome-family, and previous studies have reported several possible risk factors. However, to date, no meta-analyses have been conducted on the numerous risk factors associated with the development of post-intensive care syndrome-family and how strongly these factors are in association with post-intensive care syndrome-family. OBJECTIVES To identify risk factors for post-intensive care syndrome-family and determine the effect size of individual risk factors. METHODS This systematic review used MEDLINE, CINAHL, PsycINFO, and EMBASE databases to search all studies through December 1, 2021, that reported risk factors for anxiety, depression, PTSD, and prolonged grief disorder in the families of adult patients in ICUs. A meta-analysis was conducted to calculate an overall estimate for key risk factors, and odds ratio and 95% confidence intervals were used as summary statistics using the random-effects model. RESULTS Of 2964 identified studies, 17 were included. Nine factors for anxiety, eight for depression, and three for PTSD were assessed using results from 13 studies. The risk factor with the largest effect size was "history of mental illness," which, along with "female sex," was a significant risk factor common to anxiety, depression, and PTSD. "Poor communication with ICU staff," "severely ill patient," and "patients' spouse" were common risk factors for anxiety and depression. CONCLUSIONS We identified several risk factors related to patient and family demographic characteristics. Further research is required to identify and validate modifiable risk factors for the psychosocial experiences of families of ICU patients.
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Affiliation(s)
- Yoshiyasu Ito
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan; Department of Nursing, Graduate School of Health Sciences, Kobe University, Kobe, Japan.
| | | | | | | | - Yukihiro Sakaguchi
- School of Human Welfare Studies, Kwansei Gakuin University, Nishinomiya, Japan
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Moradi J, Mikhail M, Lee LA, Traube C, Sarti AJ, Choong K. Lived Experiences of Delirium in Critically Ill Children: A Qualitative Study. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1758695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AbstractThe aim of this study was to understand the lived experiences of delirium in critically ill children. We conducted phenomenological qualitative interviews with critically ill pediatric survivors aged 0 to 18 years who had experienced delirium, along with their family caregivers and health care providers, from pediatric intensive care units in two tertiary care children's hospitals in Canada. Cases were identified if they had a Cornell Assessment of Pediatric Delirium (CAPD) score of ≥ 9 for at least 48 hours. Thirteen interviews were conducted, representing 10 index patients with delirium (age range: 7 weeks to 17 years). Participants shared experiences that were divided into themes of delirium symptoms, the impact of delirium, and their experience with the care of delirium. Within each theme, subthemes were identified. Symptoms of delirium included hallucinations, fluctuating symptoms, and lack of eye contact. Children were often described as “not himself/herself.” Delirium had long-lasting impact on patients; memories remained prominent even after the hospital stay. Family members and health care providers often felt helpless and ill-prepared to manage delirium. The delirium experience had significant impact on loved ones, causing persistent and vicarious suffering after the critical illness course. Family members and health care providers prioritized nonpharmacological strategies, family presence, and education as key strategies for delirium management. The lived experience of delirium in both infants and older children is physically, psychologically, and emotionally distressing. Given the traumatic long-term consequences, there is an urgent need to target delirium education, management, and prevention to improve long-term outcomes in PICU survivors and their families.
Trial Registration number: NCT04168515.
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Affiliation(s)
- Jasmin Moradi
- Department of Pediatric Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Mirriam Mikhail
- Department of Pediatrics, Toronto Sick Children's Hospital, Toronto, Ontario, Canada
| | - Laurie A. Lee
- Alberta Children's Hospital, University of Calgary, Pediatric Critical Care, Calgary, AB, Canada
| | - Chani Traube
- Department of Pediatric Critical Care, Weill Cornell Medical College, New York, New York, United States
| | - Aimee J. Sarti
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Karen Choong
- Department of Pediatric Critical Care, McMaster University, Hamilton, Ontario, Canada
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Lange S, Mȩdrzycka-Da̧browska W, Friganović A, Religa D, Krupa S. Family experiences and attitudes toward care of ICU patients with delirium: A scoping review. Front Public Health 2022; 10:1060518. [PMID: 36505003 PMCID: PMC9727388 DOI: 10.3389/fpubh.2022.1060518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction The family has an important role in the care of the ICU patient. Research shows that the implementation of non-pharmacological interventions to prevent delirium, including interventions with the family, can reduce the incidence of delirium. The aim of this review was to search the available literature about the experiences and attitudes of family/carers of ICU patients diagnosed with delirium during hospitalization. Methods A scoping review method was used to map terms relevant to the involvement of relatives in the care of critically ill patients with delirium. To identify studies, the following databases were searched: PubMed, Scopus, EBSCO, Web of Science, and Cochrane Library. The database search was ongoing from 15 July 2022, with a final search on 4 August 2022. Results Thirteen articles reporting on the experiences and attitudes of family/carers of ICU patients who developed delirium during hospitalization were included in the scoping review. Of the included studies, eight were qualitative studies, three were quantitative studies and two were reviews (systematic review and integrative review). The studies were conducted in North America, Europe, South Africa, and Asia. Our findings show that carers experienced adverse effects associated with delirium in ICU patients such as stress, anxiety, embarrassment, uncertainty, anger, shock. Families/relatives need both emotional and informational support from medical staff. Conclusion Relatives want to be involved in the care of the delirium patient, although this needs improvement in some aspects of care such as: lack of awareness, family/relatives knowledge of delirium, improved education, and communication with medical staff. Recognition of delirium by families is acceptable and feasible. Family involvement may induce an increased anxiety, but this aspect needs further research.
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Affiliation(s)
- Sandra Lange
- Department of Internal and Pediatric Nursing, Medical University of Gdańsk, Gdańsk, Poland
| | - Wioletta Mȩdrzycka-Da̧browska
- Department of Anaesthesiology Nursing and Intensive Care, Faculty of Health Sciences, Medical University of Gdańsk, Gdańsk, Poland
| | - Adriano Friganović
- Department of Anesthesiology and Intensive Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Nursing, University of Applied Health Sciences, Zagreb, Croatia
| | - Dorota Religa
- Division for Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institute, Solna, Sweden
| | - Sabina Krupa
- Institute of Health Sciences, College of Medical Sciences of the University of Rzeszow, Rzeszow, Poland
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Traube C. Beware the Aftermath: Delirium and Post-Intensive Care Syndrome in Critically Ill Children. Pediatr Crit Care Med 2022; 23:144-146. [PMID: 35119435 DOI: 10.1097/pcc.0000000000002874] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Chani Traube
- Department of Pediatrics, Joan and Sanford I Weill Medical College of Cornell University, New York, NY
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Poulin TG, Krewulak KD, Rosgen BK, Stelfox HT, Fiest KM, Moss SJ. The impact of patient delirium in the intensive care unit: patterns of anxiety symptoms in family caregivers. BMC Health Serv Res 2021; 21:1202. [PMID: 34740349 PMCID: PMC8571897 DOI: 10.1186/s12913-021-07218-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 10/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine the association of patient delirium in the intensive care unit (ICU) with patterns of anxiety symptoms in family caregivers when delirium was determined by clinical assessment and family-administered delirium detection. METHODS In this cross-sectional study, consecutive adult patients anticipated to remain in the ICU for longer than 24 h were eligible for participation given at least one present family caregiver (e.g., spouse, friend) provided informed consent (to be enrolled as a dyad) and were eligible for delirium detection (i.e., Richmond Agitation-Sedation Scale score ≥ - 3). Generalized Anxiety Disorder-7 (GAD-7) was used to assess self-reported symptoms of anxiety. Clinical assessment (Confusion Assessment Method for ICU, CAM-ICU) and family-administered delirium detection (Sour Seven) were completed once daily for up to five days. RESULTS We included 147 family caregivers; the mean age was 54.3 years (standard deviation [SD] 14.3 years) and 74% (n = 129) were female. Fifty (34% [95% confidence interval [CI] 26.4-42.2]) caregivers experienced clinically significant symptoms of anxiety (median GAD-7 score 16.0 [interquartile range 6]). The most prevalent symptoms of anxiety were "Feeling nervous, anxious or on edge" (96.0% [95%CI 85.2-99.0]); "Not being able to stop or control worrying" (88.0% [95%CI 75.6-94.5]; "Worrying too much about different things" and "Feeling afraid as if something awful might happen" (84.0% [95%CI 71.0-91.8], for both). Family caregivers of critically ill adults with delirium were significantly more likely to report "Worrying too much about different things" more than half of the time (CAM-ICU, Odds Ratio [OR] 2.27 [95%CI 1.04-4.91]; Sour Seven, OR 2.28 [95%CI 1.00-5.23]). CONCLUSIONS Family caregivers of critically ill adults with delirium frequently experience clinically significant anxiety and are significantly more likely to report frequently worrying too much about different things. Future work is needed to develop mental health interventions for the diversity of anxiety symptoms experienced by family members of critically ill patients. TRIAL REGISTRATION This study is registered on ClinicalTrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03379129 ).
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Affiliation(s)
- Therese G Poulin
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - Brianna K Rosgen
- Departments of Community Health Sciences and Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - Henry T Stelfox
- Departments of Community Health Sciences and Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - Kirsten M Fiest
- Departments of Critical Care Medicine, Community Health Sciences & Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada.
| | - Stephana J Moss
- Departments of Community Health Sciences and Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 1N4, Canada
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