A controlled examination of acute warning signs for suicide attempts among hospitalized patients

BACKGROUND

Near-term risk factors for suicidal behavior, referred to as 'warning signs' (WS), distinguish periods of acute heightened risk from periods of lower risk within an individual. No prior published study has examined, using a controlled study design, a broad set of hypothesized WS for suicide attempt. This study addressed this gap through examination of hypothesized behavioral/experiential, cognitive, and affective WS among patients recently hospitalized following a suicide attempt.

METHODS

Participants were recruited during hospitalization from five medical centers across the USA including two civilian hospitals and three Veterans Health Administration facilities (n = 349). A within-person case-crossover study design was used, where each patient served as her/his own control. WS were measured by the Timeline Follow-back for Suicide Attempts Interview and were operationalized as factors that were present (v. absent) or that increased in frequency/intensity within an individual during the 6 h preceding the suicide attempt (case period) compared to the corresponding 6 h on the day before (control period).

RESULTS

Select WS were associated with near-term risk for suicide attempt including suicide-related communications, preparing personal affairs, drinking alcohol, experiencing a negative interpersonal event, and increases in key affective (e.g. emptiness) and cognitive (e.g. burdensomeness) responses.

CONCLUSIONS

The identification of WS for suicidal behavior can enhance risk recognition efforts by medical providers, patients, their families, and other stakeholders that can serve to inform acute risk management decisions.

Nursing Home Social Services Directors' Roles and Self-Efficacy in Suicide Risk Management

Nursing home (NH) residents face many risk factors for late life suicide, and transitions into and out of NHs represent risk periods for suicide. Based on data from the 2019 National Nursing Home Social Services Directors survey (n = 924), this presentation describes NH social services directors (SSDs) roles in managing suicide risk and factors that influence self-efficacy in this area. Nearly one-fifth (19.7%) of SSDs lack of self-efficacy in suicide risk management, reporting needing significant preparation time or being not able to train others on this topic. Results of ordinal logistic regression indicate that SSDs who consider insufficient social services staffing as a minor barrier (comparing with a major barrier) to psychosocial care, those who report greater involvement in safety planning for suicide risk, and those with Master’s degree, are more likely to perceive greater self-efficacy in suicide risk management. Implications for training and staffing will be discussed.

Nursing Home Social Services Directors Caring for Residents With Serious Mental Illness

Psychosocial care for residents with serious mental illness (SMI) requires understanding of co-morbidities and careful attention to needs, rights, and preferences. Analyses of social services directors (SSDs) responses (n=924) to the National Nursing Home Social Service Director Survey considered perceived roles and competence to provide care stratified by the percentage of NH residents with SMI. Depression screenings and biopsychosocial assessments were common roles regardless of the percentage of residents with SMI. About one-quarter lacked confidence to train colleagues in recognizing distinctions between depression, delirium and depression (23.4% unable) or to develop care plans for residents with SMI (26% unable). A bachelor’s degree (OR=0.64, 95% CI:0.43, 0.97) or less (OR= 0.47, 95% CI:0.25, 0.89) was associated with less perceived competence in care planning compared to those with a master’s degree. SSDs reported less involvement in referrals or interventions for resident aggression in homes with a high proportion of residents with SMI.

Social Service Directors' Roles and Self-Efficacy in Suicide Risk Management in US Nursing Homes

Nursing home (NH) residents have many risk factors for suicide in later life and transitions into and out of NHs are periods of increased suicide risk. The purpose of this study was to describe NH social service directors (SSDs) roles in managing suicide risk and to identify factors that influence self-efficacy in this area. This study used data from the 2019 National Nursing Home Social Services Directors survey (n = 924). One-fifth (19.7%) of SSDs reported a lack of self-efficacy in suicide risk management, as indicated by either needing significant preparation time or being unable to train others on intervening with residents at risk for suicide. Ordinal logistic regression identified SSDs who were master's prepared, reported insufficient social service staffing as a minor barrier (versus a major barrier) to psychosocial care, and those most involved in safety planning for suicide risk were more likely to report self-efficacy for training others. Implications include the need for targeted training of NH social service staff on suicide prevention, such as safety planning as an evidence-based practice. Likewise, sufficient staffing of qualified NH social service providers is critically important given the acute and chronic mental health needs of NH residents.

Assessing Social Functioning During COVID-19 and Beyond: Tools and Considerations for Nursing Home Staff

Social functioning is defined as how a person operates in their unique social environment (ie, engagement in activities, connectedness with others, and contributions to social roles). Healthy social functioning is important for nursing home residents as they are at increased risk for loneliness and isolation. Social functioning has long been an underacknowledged aspect of nursing home residents' health, but now, with the COVID-19 pandemic, residents' risk for decreased social functioning is increased. Several reliable and well-validated tools are available to supplement routine care planning and delivery and track and improve changes in social functioning over time. The overarching aim of this article is to provide resources and recommendations for interdisciplinary team assessment related to social functioning for nursing home residents. We describe 2 domains of social functioning measures, care-planning measures and outcome measures, and provide recommendations for how to integrate said measures into practice. Healthy social functioning is needed to maintain nursing home residents' well-being and quality of life. Measures and recommendations outlined in this article can be used by nursing home staff to understand residents' social preferences and address social functioning during COVID-19 and beyond.

Serious Mental Illness in Nursing Homes: Roles and Perceived Competence of Social Services Directors

Providing nursing home psychosocial care to persons with serious mental illnesses (SMI) requires understanding of comorbidities and attention to resident rights, needs and preferences. This quantitative study reports how 924 social service directors (SSDs) taking part in the National Nursing Home Social Service Director survey identified their roles and competence, stratified by the percentage of residents with SMI. More than 70% of SSDs, across all categories of homes, reported the social services department was "always" involved in conducting depression screening, biopsychosocial assessments and PASRR planning. SSDs in homes with lower concentrations of residents with SMI reported less involvement in anxiety screening. Those employed in homes with higher concentrations of residents with SMI reported lower involvement conducting staff interventions for resident aggression or making referrals. More than one-fifth of SSDs lacked confidence in their ability to compare/contrast dementia, depression, and delirium or to develop care plans for residents with SMI. SSDs' perceived competence in developing care plans for residents with SMI was associated with education and involvement in care planning. About one-quarter of social services directors reported not being prepared to train a colleague on how to develop care plans for residents with SMI. Training in SMI could enhance psychosocial care.

About a Third of Nursing Home Social Services Directors Have Earned a Social Work Degree and License

Nursing home (NH) residents have high psychosocial needs related to illness, disability, and changing life circumstances. The staff member with the most expertise in addressing psychosocial needs is the social worker. However, federal regulations indicate that only NHs with 120+ beds need hire a social services staff member and that a "qualified social worker" need not have a social work degree. Therefore, two-thirds of NHs are not required to employ a social services staff member and none are required to hire a degreed social worker. This is in stark contrast to NASW professional standards. Reporting findings from this nationally representative sample of 924 social services directors, we describe the NH social services workforce and document that most NHs do hire social services staff, although 42% of social services directors are not social work educated. 37% of NHs have a degreed and licensed social worker at the helm of social services. The odds of hiring a degreed and licensed social workers are higher for larger NHs, especially if not-for-profit and not part of a chain. NH residents deserve psychosocial care planned by staff with such expertise. Quality of psychosocial care impacts quality of life.

SAVE-CLC: An Intervention to Reduce Suicide Risk in Veterans Who Discharge From VA Nursing Homes

Prior research has established transitions into and out of nursing homes as periods of suicide risk for older adults. Deaths by suicide were found to be 2.4 times as likely among Veterans within six months of discharge from US Veterans Health Administration (VA) nursing homes when compared with gender and age-matched Veterans from the general VA patient population (McCarthy, Szymanski, Karlin, & Katz, 2013). Despite these trends, suicide prevention interventions implemented during nursing home and post-acute care transitions, including those taking place from Centers for Medicare and Medicaid Services regulated nursing homes, are lacking. Suicide Awareness for Veterans Exiting the Community Living Center (SAVE-CLC) was piloted as a quality improvement intervention to reduce suicide risk for older Veterans discharging from VA nursing homes. VA clinicians from three sites provided a friendly contact by phone after discharge (n = 66) to screen for depression, facilitate a strengths-based discussion about service needs, and provide service referrals. Compared to a group of patients discharged prior to the start of the intervention (matched on location, age range, and Care Assessment Need scores), SAVE-CLC patients received more depression screening within 30 days after discharge (chi square = 38.7, p < .001) and were seen more quickly for mental health care (t = 3.1, p = .005) when indicated. Implications for suicide prevention with older Veterans and for the general population of older adults receiving short stay services in US nursing homes will be addressed.

SAVE-CLC: An Intervention to Reduce Suicide Risk in Older Veterans following Discharge from VA Nursing Facilities

Objective: We describe the development and implementation of a telephonic intervention (SAVE-CLC) piloted at three VA sites for Veterans returning to the community from VA nursing facilities (Community Living Centers or "CLCs"). Care transitions present a known period of medical risk for older adults and may pose increased risk for suicide. Veterans discharging from CLCs are at elevated risk compared to age and gender matched controls.Methods: Using a quality improvement approach, input was gathered from key stakeholders to aid in the development of the intervention. Veterans were screened for depressive symptoms and need for additional support by phone.Results: Of the Veterans who received the SAVE-CLC intervention, 87.9% had at least one prior mental health diagnosis, though only 19.7% had an outpatient mental health appointment arranged at CLC discharge. Results suggest that the intervention is feasible across multiple outpatient settings and is generally well-received by Veterans and caregivers, with 97% of those contacted reporting that the telephone calls were helpful.Conclusion: This flexible, telephone-based intervention addresses the unmet need of integrating mental health care into discharge planning during care transitions.Clinical Implications: SAVE-CLC offers a feasible and acceptable solution to suicide risk in older Veterans exiting a CLC.

THE IMPORTANCE OF CREATING SHARED EXPECTATIONS FOLLOWING NURSING HOME DISCHARGE

Nursing home stays often represent a time of change for residents and their social networks (e.g., family, friends, and other social supports). Nursing home residents may be experiencing exacerbations of medical conditions, changes in physical functioning, and/or cognitive impairment. These changes often preclude the resident from returning to their pre-admission level of functioning, resulting in the need for adjustments for both residents and their social network. However, nursing home staff and residents/caregivers frequently have different expectations for post-discharge functioning. This may be the result of inadequate or unclear communication on the part of nursing home staff and/or residents and caregivers being unable or unwilling to internalize the information. The lack of shared expectations can leave residents and caregivers unprepared, creating unanticipated caregiving burdens for the social network and unwanted outcomes for the resident. We conducted interviews with 14 resident/caregiver dyads who experienced care transitions from VA nursing homes to examine expected and actual functioning and activities post-discharge. Using a qualitative content analysis approach, we identified several themes including marital strain related to mismatched expectations, impact of physical changes on Veterans’ social functioning, and differences between planned and actual post-discharge activities. We will discuss the importance of clear communication about expectations throughout the nursing home stay. We will also provide suggestions for improving discharge care planning to ensure creation of shared expectations and timely communication to allow residents and their social networks to adequately prepare for nursing home discharge.

SOCIAL FUNCTIONING AS AN IMPORTANT CLINICAL TARGET DURING CARE TRANSITIONS FROM SKILLED NURSING FACILITIES

Care transitions from skilled nursing facilities (SNF) to home signify a period of medical risk for older adults. They also present opportunities for clinical interventions to reduce these risks and to enhance or maintain patients’ quality of life. A substantial body of research has been published on improving late life care transitions (CTs), including the development of standardized CT models for acute care. However, such models typically focus on improved coordination of medical services; overlook the need to address psychosocial well-being and social connectedness; and have rarely been implemented in SNFs. This poster will present a conceptual model of social functioning in older adults that draws on constructs from the World Health Organization’s World Report on Ageing and Health (2015). We propose that social functioning is a key part of overall functioning among older adults who use SNFs and is simultaneously influenced by physical, psychological, and cognitive functioning. To illustrate our model, we will present results of a qualitative study (n= 21) that describes declines in social functioning following care transitions to the community from VA SNFs. Implications for clinical practice include the need to better integrate social functioning in clinical assessments, goal setting, discharge planning, and coordination of care activities. The need for additional research on this topic will also be addressed. Our project is highly relevant to the overall conference theme “Harnessing the Power of Networks” as it presents a conceptual model and study findings related to social connectedness and social functioning in older adults who use SNFs.

ADDRESSING AN UNMET NEED FOR MENTAL HEALTH SUPPORT DURING CARE TRANSITIONS FROM NURSING FACILITIES

Mental health (MH) disorders are common among skilled nursing facility (SNF) residents and may inhibit rehabilitation goals. Moreover, discharges to the community from SNFs are periods of heightened suicide risk within the Veterans Health Administration (VHA), suggesting an urgent need for improved continuity of MH care. This paper presents results of medical records reviews indicating a potential gap in MH services at discharge from VHA SNFs. A quality improvement project (”Suicide Awareness for Veterans Exiting Community Living Centers” – SAVE-CLC), designed to address this gap, will also be discussed. Piloted in 3 sites (N = 66) in 2018, SAVE-CLC clinicians administered depression screens by phone to 47 Veterans (71%) after SNF discharge and helped connect Veterans to MH services. 24 Veterans (26%) received a second such call. Patients and caregivers expressed high satisfaction with SAVE-CLC (n = 35, 97%). Implications for quality improvements in SNF care transitions will be discussed.

PHYSICAL CONDITIONS ASSOCIATED WITH SUICIDE ATTEMPTS: DO RISKS DIFFER AMONG OUR OLDER VETERANS?

Physical illness confers risk for late-life suicide, yet few studies report whether risks differ with older age and among Veterans. We examined age-stratified associations between physical illness and suicide attempt among Veterans 65+ years (n=8452, 97% male) from a larger retrospective case-control study that utilized secondary data from the Veterans Affairs Corporate Data Warehouse and Suicide Prevention Applications Network. Controls were matched by age, sex, and mental health treatment utilization. Risk estimates for 15 conditions and a combined comorbidity score were stratified by young-old (65-74), middle-old (75-84), and oldest-old (85+), adjusting for age and sex within strata. Neurodegenerative disorder (ORs=4.5, 6.0, 6.5) or dementia (ORs=5.0, 5.7, 4.4) diagnosis within 180 days conferred the highest risks across young-, middle-, and oldest-old. Cerebrovascular disorder was associated with higher risk among the oldest-old versus young-old (ORs=6.1 vs 2.2). Findings differ from reported risks for suicide death. Illness may be experienced differently across later-life.

P4377Use of LV Deformation Imaging to predict long term Heart Failure Risk in high risk patients

Background

The increasing prevalence of heart failure (HF), due to hypertension, ischaemic heart disease, diabetes, obesity, and ageing population demands identification of at-risk subgroup whom we could target on prevention strategies. In a same cohort of patients at risk of HF (70% with CAD), 13% developed new HF hospitalization or death over 4.3 years of follow-up, however, disease management program did not confer any benefit to outcome and LV ejection fraction (EF) was not predictive of progression to HF. Better risk stratification strategies are needed. In this study, we sought whether advanced echo measure on deformation, global longitudinal strain (GLS) would predict HF admission over a long term follow up and thereby define an at-risk group. Aim: To determine which of the LV morphology, function and deformation parameters, best predict new HF admission or HF death in pts at risk but without prior dx of HF.

Method

Echocardiograms (including measurement of LV, size, function, morphology and deformation) were obtained in 431 inpatients (mean age 65±11, 72% male) at risk of HF. LV global longitudinal strain (GLS) and strain rate (GLSR) were measured offline (EchoPac, GE). Long term (9 years) follow up data were obtained via data linkage.

Results

63 pts (15%) reached the end-point of HF admission or HF death. LV deformation showed a univariable association with outcome (Table). In multivariable analysis, including known significant predictors of outcome (age, sex, BMI, diabetes, hypertension), GLS less than 18 remained an independent predictor (Table), in addition to age and DM at baseline. EF and LV mass were not predictors of heart failure.

HR (95% CI) P value HR (95% CI) P value HR (95% CI) P value Age 1.1 (1–1.1) <0.01 1.1 (1–1.1) 0.04 1 (1–1.1) 0.04 Sex 1.0 (0.6–1.7) 0.9 0.8 (0.4–1.8) 0.6 0.8 (0.4–1.8) 0.6 BMI 1.0 (1–1.1) 0.05 1 (0.9–1.1) 0.7 1 (0.9–1.1) 0.7 DM 2.6 (1.6–4.3) <0.01 2.7 (1.4–5.3) <0.01 2.7 (1.4–5.2) 0.04 LVMI 1.0 (1.0–1.0) <0.01 1 (0.9–1.0) 0.7 1 (0.99–1.0) 0.7 Impaired EF, % 1.0 (0.9–1.0) <0.01 1 (0.9–1.0) 0.16 0.97 (0.94–1.0) 0.04 Diastolic dysfunction 2.3 (1.4–3.7) <0.01 0.8 (0.3–1.7) 0.5 0.7 (0.3–1.7) 0.5 GLS 1.3 (1.4–1.2) <0.01 1.1 (1–1.2) 0.07 GLS <18 5.3 (2.8–10.2) <0.01 2.3 (1.1–5.1) 0.04

Conclusion

GLS <18 is independently associated with increasing new onset heart failure admission and HF mortality in patients at risk of HF.

Circulating tumor DNA as a potential marker of adjuvant chemotherapy benefit following surgery for localized pancreatic cancer

BACKGROUND

In early-stage pancreatic cancer, there are currently no biomarkers to guide selection of therapeutic options. This prospective biomarker trial evaluated the feasibility and potential clinical utility of circulating tumor DNA (ctDNA) analysis to inform adjuvant therapy decision making.

MATERIALS AND METHODS

Patients considered by the multidisciplinary team to have resectable pancreatic adenocarcinoma were enrolled. Pre- and post-operative samples for ctDNA analysis were collected. PCR-based-SafeSeqS assays were used to identify mutations at codon 12, 13 and 61 of KRAS in the primary pancreatic tumor and to detect ctDNA. Results of ctDNA analysis were correlated with CA19-9, recurrence-free and overall survival (OS). Patient management was per standard of care, blinded to ctDNA data.

RESULTS

Of 112 patients consented pre-operatively, 81 (72%) underwent resection. KRAS mutations were identified in 91% (38/42) of available tumor samples. Of available plasma samples (N = 42), KRAS mutated ctDNA was detected in 62% (23/37) pre-operative and 37% (13/35) post-operative cases. At a median follow-up of 38.4 months, ctDNA detection in the pre-operative setting was associated with inferior recurrence-free survival (RFS) [hazard ratio (HR) 4.1; P = 0.002)] and OS (HR 4.1; P = 0.015). Detectable ctDNA following curative intent resection was associated with inferior RFS (HR 5.4; P < 0.0001) and OS (HR 4.0; P = 0.003). Recurrence occurred in 13/13 (100%) patients with detectable ctDNA post-operatively, including in seven that received gemcitabine-based adjuvant chemotherapy.

CONCLUSION

ctDNA studies in localized pancreatic cancer are challenging, with a substantial number of patients not able to undergo resection, not having sufficient tumor tissue for analysis or not completing per protocol sample collection. ctDNA analysis, pre- and/or post-surgery, is a promising prognostic marker. Studies of ctDNA guided therapy are justified, including of treatment intensification strategies for patients with detectable ctDNA post-operatively who appear at very high risk of recurrence despite gemcitabine-based adjuvant therapy.

A feasibility study to investigate post-operative oxygen consumption (POpOC) after colorectal surgery requiring bowel resection

Background

Oxygen consumption after surgery is increased in response to the tissue trauma sustained intra-operatively and the subsequent systemic inflammatory response that ensues. The cardio-respiratory system must match the tissue oxygen and metabolic requirements; otherwise, peri-operative complications may occur. Existing data is several decades old. The primary objective of this feasibility study was to determine the ease of recruiting participants and collecting relevant data to assess the extent and duration of increased oxygen consumption and post-operative complications after major abdominal surgery in contemporaneous times.

Methods

One hundred patients scheduled for elective colorectal surgery requiring a bowel resection were screened to test specific feasibility criteria relating to ease of recruitment, duration of post-operative stay, ease of data collection, and drop-out rates. A calibrated metabolic cart was used to obtain unblinded pre-operative resting oxygen consumption recordings. The metabolic cart was then used to obtain post-operative oxygen consumption readings on days 1 to 5 as long as the participant remained as an inpatient. At the time of the oxygen consumption reading, a Post-Operative Morbidity Survey score (POMS) was calculated. Feasibility outcomes chosen a priori were that at least one participant would be recruited every 2 weeks from the pre-admission colorectal clinic, at least 10% of potential subjects screened would be enrolled, at least 80% of recruited participants would have a minimum post-operative stay of 2 nights, a minimum of 3 consecutive days of oxygen consumption data would be collected for each subject, at least 8 of 9 POMS score domains would be completed per participant per day and the drop-out rate would be no greater than 10%. We deemed that screening 100 patients would be sufficient to test our feasibility outcomes.

Results

Twelve participants completed the protocol. All pre-specified feasibility criteria were met. No increase in post-operative oxygen consumption was observed in this feasibility cohort.

Conclusions

The protocol and experiences gained from this feasibility study could be used to plan a larger study to better define changes in post-operative oxygen consumption after major abdominal surgery utilizing current surgical techniques.

Age Differences in Suicide Risk Screening and Management Prior to Suicide Attempts

OBJECTIVE

This study examined differences by age in suicide risk screening and clinical actions to reduce suicide risk among patients with visits to Veterans Health Administration (VHA) medical facilities in the year prior to an attempt.

METHODS

Ninety-three VHA patient records were reviewed specific to the last visit before an attempt. Information was extracted regarding documentation of individual suicide risk factors and provider actions to reduce risk.

RESULTS

The authors examined differences by patient age (≥50 versus 18-49). Older patients' medical records were less likely to have evidence of 1) screening for impulsivity and firearms access and 2) engagement in safety planning, referrals for mental health services, and consideration of psychiatric hospitalization. General medical providers were less likely to document these risk factors and action steps in comparison with mental health clinicians.

CONCLUSION

Lethal means education and collaborative care are universal strategies that may improve identification of and lower suicide risk in older veterans.

Short-term health effects in the general population following a major train accident with acrylonitrile in Belgium

BACKGROUND

Following a train derailment, several tons of acrylonitrile (ACN) exploded, inflamed and part of the ACN ended up in the sewage system of the village of Wetteren. More than 2000 residents living in the close vicinity of the accident and along the sewage system were evacuated. A human biomonitoring study of the adduct N-2-cyanoethylvaline (CEV) was carried out days 14-21 after the accident.

OBJECTIVES

(1) To describe the short-term health effects that were reported by the evacuated residents following the train accident, and (2) to explore the association between the CEV concentrations, extrapolated at the time of the accident, and the self-reported short-term health effects.

METHODS

Short-term health effects were reported in a questionnaire (n=191). An omnibus test of independence was used to investigate the association between the CEV concentrations and the symptoms. Dose-response relationships were quantified by Generalized Additive Models (GAMs).

RESULTS

The most frequently reported symptoms were local symptoms of irritation. In non-smokers, dose-dependency was observed between the CEV levels and the self-reporting of irritation (p=0.007) and nausea (p=0.007). Almost all non-smokers with CEV concentrations above 100pmol/g globin reported irritation symptoms. Both absence and presence of symptoms was reported by non-smokers with CEV concentrations below the reference value and up to 10 times the reference value. Residents who visited the emergency services reported more symptoms. This trend was seen for the whole range of CEV concentrations, and thus independently of the dose.

DISCUSSION AND CONCLUSION

The present study is one of the first to relate exposure levels to a chemical released during a chemical incident to short-term (self-reported) health effects. A dose-response relation was observed between the CEV concentrations and the reporting of short-term health effects in the non-smokers. Overall, the value of self-reported symptoms to assess exposure showed to be limited. The results of this study confirm that a critical view should be taken when considering self-reported health complaints and that ideally biomarkers are monitored to allow an objective assessment of exposure.

Professional and practice characteristics associated with self-efficacy in assessment and intervention among social workers in aging

This study examined professional and practice characteristics associated with assessment and intervention self-efficacy among gerontological social workers in Ontario, Canada who participated in online surveys. Results from multivariate analyses indicated that higher client acuity, longer duration of practice experience, smaller caseloads, and a greater proportion of clients 85 and over were significantly associated with greater assessment self-efficacy. Greater client acuity and smaller caseloads were also significantly associated with greater intervention self-efficacy. Implications for education include the importance of providing practical experience with the oldest old and with clients with greater biopsychosocial complexity. Also recommended is the need for manageable caseloads, especially when older adults with complex needs are part of the practice milieu.

Physiologic Changes in the Heart Following Cessation of Mechanical Ventilation in a Porcine Model of Donation After Circulatory Death: Implications for Cardiac Transplantation

Hearts donated following circulatory death (DCD) may represent an additional source of organs for transplantation; however, the impact of donor extubation on the DCD heart has not been well characterized. We sought to describe the physiologic changes that occur following withdrawal of life-sustaining therapy (WLST) in a porcine model of DCD. Physiologic changes were monitored continuously for 20 min following WLST. Ventricular pressure, volume, and function were recorded using a conductance catheter placed into the right (N = 8) and left (N = 8) ventricles, and using magnetic resonance imaging (MRI, N = 3). Hypoxic pulmonary vasoconstriction occurred following WLST, and was associated with distension of the right ventricle (RV) and reduced cardiac output. A 120-fold increase in epinephrine was subsequently observed that produced a transient hyperdynamic phase; however, progressive RV distension developed during this time. Circulatory arrest occurred 7.6±0.3 min following WLST, at which time MRI demonstrated an 18±7% increase in RV volume and a 12±9% decrease in left ventricular volume compared to baseline. We conclude that hypoxic pulmonary vasoconstriction and a profound catecholamine surge occur following WLST that result in distension of the RV. These changes have important implications on the resuscitation, preservation, and evaluation of DCD hearts prior to transplantation.

Job Satisfaction Among Gerontological Social Workers in Ontario, Canada

Little is known about job satisfaction among Canada's social work workforce in aging, although social workers remain a key component of interdisciplinary care in health and social service settings. This study begins to address this gap in knowledge by examining individual, interpersonal, and job-design factors influencing the job satisfaction of gerontological social workers in Ontario. Data were collected via two online surveys with a sample drawn from the Ontario Association of Social Workers' membership list (N = 104). A multiple regression model explained 37% of the variance in job satisfaction, F = 5.47[10, 93], p < .001). Three independent variables were significant (positive affect, β = .21; promotional chances, β = .21; and client acuity, β = -.18). The results suggest the importance of promoting strategies for enhancing job satisfaction, advancing promotional opportunities for social work clinicians, and providing educational and clinical supports to clinicians.

State of innovation in suicide intervention research with military populations

A systematic search was performed to identify active, externally funded randomized controlled trials (RCTs) that target suicidal ideation or behavior as a primary or secondary outcome among U.S. military service members, guard-reservists, and veterans. Twenty-three studies were identified, most funded by the U.S. Department of Defense or U.S. Department of Veterans Affairs. Several innovations were identified based on departures from or modernizations of usual practices and included the targeting of suicide deaths or attempts as primary outcome, delivery of interventions through technology and/or outside clinical settings, and examinations of rarely studied treatments.

Aging and place in long-term care settings: influences on social relationships

OBJECTIVE

This article presents results of a qualitative research study that examined how living in a long-term care (LTC) home influences the quality of residents' relationships with peers, family members, and outside friends.

METHOD

Semistructured interviews using a phenomenological approach were conducted with 23 residents of a LTC home. Thematic analysis was employed to illuminate residents' perspectives on the nature of social relationships in this setting.

RESULTS

Four key themes were identified that highlight the role of place in social relationships. Residing in a LTC home influences the context of social interactions, impacts their quality and process, clusters individuals with health and functional declines that hinder socialization, and poses structural and cultural barriers that impede social interactions. Health and functional limitations posed the greatest challenge to socialization relative to characteristics of the facility itself.

DISCUSSION

Residents' insights emphasize how personal characteristics influence community culture and the experience of place.

Psychosocial assessment of nursing home residents via MDS 3.0: recommendations for social service training, staffing, and roles in interdisciplinary care

The Minimum Data Set 3.0 has introduced a higher set of expectations for assessment of residents' psychosocial needs, including new interviewing requirements, new measures of depression and resident choice, and new discharge screening procedures. Social service staff are primary providers of psychosocial assessment and care in nursing homes; yet, research demonstrates that many do not possess the minimum qualifications, as specified in federal regulations, to effectively provide these services given the clinical complexity of this client population. Likewise, social service caseloads generally exceed manageable levels. This article addresses the need for enhanced training and support of social service and interdisciplinary staff in long term care facilities in light of the new Minimum Data Set 3.0 assessment procedures as well as new survey and certification guidelines emphasizing quality of life. A set of recommendations will be made with regard to training, appropriate role functions within the context of interdisciplinary care, and needs for more realistic staffing ratios.

Gerontological social workers' perceived efficacy for influencing client outcomes

Using a sample of practitioners (n = 269) from the 2004 National Study of Licensed Social Workers, this article employs a quality assurance structure-process-outcome model to examine factors at the practitioner, workplace, and service delivery levels that influence the perceived efficacy of licensed gerontological social workers to affect client outcomes in the context of a highly challenging health care environment. A regression model accounted for 33.9% of the variance (adjusted R (2) = .291) in perceived efficacy with 3 aspects of service delivery satisfaction having significant effects: ability to address complex/chronic care, to influence the design of services, and to help clients navigate the system.

Commitment of licensed social workers to aging practice

This study sought to identify client, professional, and employment characteristics that enhance licensed social workers' commitment to aging practice. A series of binary logistic regressions were performed using data from 181 licensed, full-time social workers who reported aging as their primary specialty area as part of the 2004 NASW's national study of licensed social workers. Several variables were identified as being significant predictors of commitment to aging, including clients' source of insurance, practitioners' years of experience in social work and gerontology, perceived adequacy of training, number of social work colleagues in the work environment, perceived appropriateness of delegated tasks, and annual income. This study illuminates critical areas of need to promote professional commitment to aging practice. Promotion of training and competency-based education and the need for sufficient job challenge and appropriate assignment of roles (that is, those that are consistent with practitioners' skills and abilities) will encourage commitment to working in the field ofgerontology.

Molecular structures and interactions in the yeast kinetochore

Kinetochores are the elaborate protein assemblies that attach chromosomes to spindle microtubules in mitosis and meiosis. The kinetochores of point-centromere yeast appear to represent an elementary module, which repeats a number of times in kinetochores assembled on regional centromeres. Structural analyses of the discrete protein subcomplexes that make up the budding-yeast kinetochore have begun to reveal principles of kinetochore architecture and to uncover molecular mechanisms underlying functions such as transmission of tension and establishment and maintenance of bipolar attachment. The centromeric DNA is probably wrapped into a compact organization, not only by a conserved, centromeric nucleosome, but also by interactions among various other DNA-bound kinetochore components. The rod-like, heterotetrameric Ndc80 complex, roughly 600 Å long, appears to extend from the DNA-proximal assembly to the plus end of a microtubule, to which one end of the complex is known to bind. Ongoing structural studies will clarify the roles of a number of other well-defined complexes.

Social work student interest in nursing home employment: a North American study

Nursing homes (NHs) are a primary setting for gerontological social work; yet, little is known about social workers' career interest relative to this setting. This article reports the findings of an online survey of social work students (177 U.S. and 91 Canadian) that sought to identify personal characteristics and beliefs that influence NH employment intentions. Students who were enrolled in bachelors programs, lacked previous practice experience, and had already had a NH field placement or wanted this experience were more likely to express employment intent. The implications of these findings for social work education and research are discussed.

Advancing the evidence base for social work in long-term care: the disconnect between practice and research

This article reviews the research literature relative to social work practice in geriatric long-term care (LTC) settings with the aim of determining the state of the evidence base for practice. Overall, this body of research supports the efficacy of social work services within the context of community-based case management and interdisciplinary models of geriatric intervention; however, there is less evidence of a discipline-specific contribution, particularly in institutional health care settings (e.g., nursing homes and hospitals) where a great number of gerontological social workers are employed. Implications of this review include the need to prioritize research within gerontological social work in order to enhance best practice knowledge and skills in settings where it is most needed.

The role of uvomorulin in the formation of epithelial occluding junctions

We have used an assay for the recovery of transepithelial resistance to identify proteins involved in the formation of the epithelial occluding barrier. The occluding junctions of high resistance monolayers of strain I MDCK cells (greater than 2500 ohm X cm2) were opened briefly and reversibly by removal of Ca2+ from the bathing medium. We screened for monoclonal antibodies which could inhibit the recovery of resistance upon Ca2+ readdition. One such monoclonal antibody, rrl, was obtained which recognizes a uvomorulin-like (or L-CAM-like) polypeptide in MDCK cells. Uvomorulin may be primarily, if not entirely, responsible for the Ca2+ dependence of occluding junction integrity. The maintenance of transmonolayer resistance had the same divalent cation selectivity as the conformational change shown by the uvomorulin molecule. In contrast to its exclusive localization to the zonula adherens of small intestinal cells, we found uvomorulin to be distributed over much of the lateral plasma membrane of MDCK cells and dog hepatocytes. The role of extrajunctional uvomorulin in these cells is not understood. Treatment of intact, high resistance monolayers of MDCK cells with antibody rr1 failed to induce a loss of resistance even though the antibody had access to uvomorulin at the lateral surfaces. Thus, cell junctions must be partially disrupted to perturb the function of uvomorulin. We present a working model for the function of uvomorulin in the establishment of the epithelial occluding barrier.