Comparison of recruitment methodologies for clinical trials: Results from the time for living and caring (TLC) intervention study

BACKGROUND

Recruiting participants for research studies is a critical yet challenging task. Community-engaged recruitment strategies have gained prominence as effective means to engage diverse populations and ensure the representativeness of study samples. This case study aims to investigate the cost and effectiveness of various recruitment methods in enhancing research participation.

METHODS

A comparative approach was employed to assess the outcomes of five different recruitment strategies used in the Time for Living & Caring (TLC) research study. Data on recruitment success, participant demographics, and retention rates were collected and analyzed using descriptive statistics, including ANOVA and Chi-squares, to statistically compare the outcomes associated with 5 different recruitment methodologies. The recruitment methodologies included two community-engaged strategies (community partner referral and community-based recruiters), a clinical database, social media, and word-of-mouth referral.

CONCLUSION

The meta-data used to build this methodological case study describe different recruitment methodologies that may be used for clinical trials. This data-driven evaluation provides examples and considerations for researchers when developing budgets and proposals for future clinical trials. The primary finding is that there are tradeoffs in terms of cost, time, labor, and ultimately the representativeness of the sample, based on the type of recruitment methodology chosen.

Using Digital Inequality Framework to Evaluate a Technology-Delivered Intervention for Caregivers: Age, Education, and Computer Proficiency

Objectives: Using "digital inequality" as a conceptual framework, this study evaluates the feasibility and usability of a technology-delivered intervention (an "app") for Alzheimer's and related dementia family caregivers. Time for Living and Caring (TLC) is an on-line intervention that provides virtual coaching and self-administered education and resources. Methods: A sample of family caregivers (n = 163) used the tool for 16 weeks, which included completing the Computer Proficiency Questionnaire (CPQ-12) at baseline. Analyses investigate the relationship between age, CPQ scores, intervention use, appraisal, and caregiver outcomes. Results: Age was inversely associated with CPQ; however, CPQ scores did not have a significant relationship with participant's self-perceived benefits or intervention appraisal. Computer Proficiency Questionnaire scores provided insight regarding research feasibility, with lower scores associated with greater odds of discontinuing engagement. Discussion: CPQ-12 scores can be used as a screening tool to identify those who may need additional support to engage with and benefit from technology-delivered interventions.

Maximizing the Benefit of Respite for Dementia Caregivers: A Study Protocol Describing the Development & Evaluation of the Time for Living & Caring (TLC) Intervention

Dementia caregivers are susceptible to adverse physical and mental health outcomes, given the often prolonged and challenging care and support they provide to family members with Alzheimer's Disease and Related Dementias (ADRD). This report describes a community-engaged implementation of a novel behavioral intervention - an "app" (interactive website) called TLC (Time for Living and Caring) that coaches caregivers on how to maximize the benefits associated with respite time. The rationale and features of the TLC intervention and the full research protocol used to develop and then evaluate its feasibility, acceptability, and initial efficacy are described here.

Essentials to Improve the Effectiveness of Healthy Aging Programming: Consideration of Social Determinants and Utilization of a Theoretical Model

Older adult health, while partially determined by genetics, is mostly determined by behavioral and lifestyle choices. Researchers and interventionists develop and administer behavioral health interventions with older adults, and interventions are advertised in any number of settings, for example, by providers in healthcare settings and by activity directors in senior centers or assisted living facilities. However, previous studies and metanalyses indicate that many interventions targeting older adults are unsuccessful in recruitment or in retention. While providers and activity directors may assume older adults are unwilling to participate in behavioral change, in reality, low participation may be caused by erroneous design and administration. The objective of this manuscript is to recommend to creators and implementers of behavioral interventions for older adults that they focus on two critical considerations: the contextual perspective pertaining to healthy aging as well as an appropriately employed theoretical model that most effectively informs program design and implementation. In this commentary, we discuss how Prochaska and DiClemente's Transtheoretical Model of Health Behavior Change may lead to more desirable outcomes as it considers that a person may be at any one of six stages of change, from pre-contemplation to maintenance. Currently, many behavioral interventions are targeted at individuals who are poised for action or in maintenance phases, ignoring those in earlier phases, resulting in limited overall success. Regarding viewing healthy aging in a contextual manner, determinants external to the individual may remain unnoted and unconsidered when designing or recruiting for a behavioral intervention. In conclusion, the integration of an intrapersonal health behavior model such as the Transtheoretical Model of Health Behavior Change, coupled with clearer considerations of the interplay of contextual factors operating in the lives of older adults, may allow for more effective design and implementation, as well as resulting in higher participation in behavioral interventions targeted toward older adults.

Live hospice discharge: Experiences of families, and hospice staff

OBJECTIVE

To examine live hospice discharge prevalence and experiences of families and hospice staff. Hospice eligibility is based on a cancer model where decline and death are predicable. Decline is less predictable for diagnoses such as dementia, frequently resulting in involuntary live hospice discharge.

METHODS

A mixed-method integration of hospice 2013-17 admission/discharge data, 5 family interviews, hospice discipline-specific focus groups (3 aides, 2 nurses, 1 administrator interview) and a discipline-combined focus group (all 6 staff; each staff participant engaged in two data collection experiences).

RESULTS

5648 hospice admissions occurred between 2013-17; 795 patients experienced live discharge. The most prevalent admitting diagnosis was cancer, the most prevalent live discharge diagnosis was dementia. Family caregiver themes were Attitude and experience with hospice, Discharge experience, and Continued need/desire for hospice following discharge. Staff themes were Discharge circumstances, Regulatory guidelines, and Changing practice to meet regulatory guidelines.

CONCLUSION

Involuntary live hospice discharge precludes patient-centered care due to policy constraints, especially for those with noncancer diagnoses. Families and staff noted the paradox of beneficial hospice care, yet this care resulted in ineligibility for continued hospice services.

PRACTICE IMPLICATIONS

Transparent, patient-family-staff communication (including CNAs) facilitates hospice live discharge planning. Hospice service eligibility policy changes are needed.

The Positive Legacy of Vision Loss: Pathways to Posttraumatic Growth

This mixed method study describes posttraumatic growth (PTG) accruing form experience with vision loss caused by severe age related macular degeneration (AMD) and explores relationships between depression, social support, and cognitive processing, on the path to PTG. Research describing the psychological and social issues surrounding AMD has focused on negative outcomes. However, learning from highly challenging experiences, such as vision loss, can offer benefits. In this study, these included an increased sense of personal strength, increased spirituality, and empathy for others (all domains of PTG). 89 participants with severe vision loss (mean age = 85.3 years, age range = 74–98 years) completed the interviewer-administered composite questionnaire, which identified elements of Tedeschi and Calhoun’s model of PTG. Relationships between variables were examined using path analysis. Findings were contextualized with data from 15 qualitative interviews. Findings underscored the importance of supportive others and deliberate cognitive processing in the path to PTG.

Dual-Process Bereavement Group Intervention (DPBGI) for Widowed Older Adults

BACKGROUND AND OBJECTIVES

To examine the primary and secondary outcomes of a theory-driven group bereavement intervention for widowed older adults through a cluster-randomized controlled trial.

RESEARCH DESIGNS AND METHODS

Twelve community centers providing health and social services for elderly people were randomly assigned to the experimental condition, the dual-process bereavement group intervention-Chinese (DPBGI-C) and to the control condition, the loss-oriented bereavement group intervention-Chinese (LOBGI-C). Both interventions comprised weekly, 2-hr sessions for 7 weeks followed by a 4-hr outing in the eighth week. Of 215 widowed older adults contacted and assessed, 125 eligible participants were interviewed three times-preintervention, postintervention, and at a 16-week follow-up-to assess complicated grief symptoms, anxiety, depression, loneliness, and social support.

RESULTS

Using intention-to-treat analysis, both interventions produced improvements in grief, depression, and social support, but effect sizes were larger with the DPBGI-C. The participants in the DPBGI-C condition also reported reduced anxiety, emotional loneliness, and social loneliness, whereas those in the LOBGI-C condition did not. There were interactions between intervention type and time with respect to grief, anxiety, emotional loneliness, and social loneliness.

DISCUSSION AND IMPLICATIONS

Although traditional LOBGI-C can help to reduce grief and depression in bereaved older adults, the DPBGI-C was found to be superior as it had a greater and more extensive impact on outcomes. This is the first study of the effectiveness of this evidence-based, theory-driven intervention for widowed Chinese older adults and has implications for theory building and practice.

Cancer Caregivers' Preparedness for Loss and Bereavement Outcomes: Do Preloss Caregiver Attributes Matter?

Past studies examining the relationship between preparedness for loss and bereavement outcomes among caregivers of spouses/partners with life-limiting illness did not adequately account for preloss caregiver attributes that could potentially confound the relationship. Using a sample of spouse/partner cancer caregivers (N = 226), we examined how preloss caregiver attributes were associated with how prepared one felt for loss and their role in the relationship between preparedness and later bereavement outcomes. Nearly half reported they were not emotionally prepared, and 35% were not prepared for the practical challenges associated with the loss. Although attributes such as depression, anxiety, competence in daily activities, and financial adequacy were associated with both preparedness and bereavement outcomes, regression analyses revealed that preparedness remained the strongest predictor in all models. We suggest that early interventions enhancing caregivers' preparedness for loss may hold considerable promise for improved bereavement outcome.

Communication of emotion in home hospice cancer care: Implications for spouse caregiver depression into bereavement

OBJECTIVE

Family caregivers of cancer hospice patients likely benefit from clinician provision of verbal support and from expression of positive emotions. Our aim was to identify the effects of hospice nurse supportive communication as well as caregiver-nurse exchange of positive emotions on family caregiver depression during bereavement.

METHODS

This prospective, observational longitudinal study included hospice nurses (N = 58) and family caregivers of cancer patients (N = 101) recruited from 10 hospice agencies in the United States. Digitally recorded nurse home visit conversations were coded using Roter interaction analysis system to capture emotion-focused caregiver-nurse communication and supportive nurse responses. Caregivers completed the Hospital Anxiety and Depression Scale Anxiety Subscale and Geriatric Depression Scale-Short Form at study enrollment and at 2, 6, and 12 months after patient death.

RESULTS

Caregivers had moderate levels of depression at study enrollment and throughout bereavement. Multilevel modeling revealed that caregiver positive emotion communication and nurse emotional response communication are associated with caregiver depression in bereavement. There was no significant association between caregiver distress communication and depression in bereavement.

CONCLUSIONS

This is the first study to demonstrate that communication demonstrating emotional expression between cancer spouse caregivers and nurses during home hospice may have implications for caregiver depression up to a year after patient death. Our findings may help identify caregivers who may be coping well in the short term but may struggle more over time.

Distress and Supportive Care Needs of Ethnically Diverse Older Adults With Advanced or Recurrent Cancer

OBJECTIVES

To assess the prevalence of supportive care needs (SCNs) and distress and to describe relationships among these and patient characteristics for ethnically diverse older adults with advanced or recurrent cancer.

SAMPLE & SETTING

Cross-sectional survey in five outpatient oncology clinics in an urban academic medical center involving 100 participants receiving cancer care in an economically challenged community.

METHODS & VARIABLES

The supportive care framework for cancer care guided this study, and participants completed the SCN Survey Short Form 34 and the Distress Thermometer. Study variables are cancer diagnosis, gender, helping to raise children, number of comorbid diseases, race or ethnicity, treatment status, and zip code.

RESULTS

Clinically meaningful distress was found in about a third of patients. Distress was not affected by race or ethnicity. Many ethnically diverse older patients with advanced or recurrent cancer report distress and SCNs; those with high distress are more likely to report multiple SCNs.

IMPLICATIONS FOR NURSING

Nursing assessment of patient SCNs and distress is integral to establishing individualized patient-centered care plans and to delivering optimal care.

Emotional disclosure in home hospice cancer care: Implications for spouse caregiver bereavement

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Background: Evidence shows the benefit of positive and negative emotional disclosure for family caregivers (CG), but little is known about the impact of emotional disclosure at end of life. We assessed the effect of CG and hospice nurse disclosure during home visits on CG anxiety and depression in bereavement. Methods: As part of a larger study, nurse visits to 95 spouse CGs of cancer home hospice patients were audio recorded. An adapted Roter Interaction Analysis System was used to identify emotional disclosure: CG and nurse positive emotion (humor, gratitude), CG distress, and nurse emotional response (reassurance, validation). CGs completed demographics at hospice enrollment, and HADS anxiety scale, and Geriatric Depression Scale (GDS) at enrollment, and 2, 6 and 12 months after patient death. Growth curve analysis was conducted to predict HADS and GDS trajectories, controlling for CG gender, total talk, anxiety and depression at enrollment. Results: Average spouse CG age was 65; 60% were female and 98% were white. There were no GDS effects for CG expression of distress or nurse emotional response. Higher CG positive emotion talk predicted higher GDS at 2 months (B = .18, p < .01), but a significant decline of GDS over time (B = -.08, p = .03). There were no effects for CG emotional disclosure on anxiety. However, more nurse emotional response predicted lower anxiety at 2 months (B = -.10, p = .02) which did not significantly change over time. More nurse positive emotion did not impact anxiety at 2 months, but predicted lower anxiety over time (B = -.04, p = .04). Conclusions: Emotional disclosure during cancer hospice visits was associated with spouse CG bereavement trajectories. CG positive emotion talk may signal increased potential for depression early in bereavement, but appears to lessen over time. CGs who express more positive emotion, which includes humor, gratitude and savoring the moment, may be more sensitive to loss, but appear to recover in time. Nurse expression of reassurance and validation, and of positive emotions seems to be effective in addressing and normalizing CG anxiety during bereavement. These findings have potential implications for communication interventions.

Spouse cancer caregivers' burden and distress at entry to home hospice: The role of relationship quality

High-quality relationships may be protective for family caregivers. This study focuses on relationship quality categories (supportive and ambivalent) in spouse caregivers in cancer home hospice. The goals of this article are to, first, describe relationship quality categories among end-of-life caregivers and, second, test the effects of relationship quality categories on caregiver burden and distress within a stress process model. Using questionnaire data collected at entry to home hospice, we found relationship quality categories were proportionally similar to those seen in noncaregiver older adults. Relationship quality significantly predicted caregiver burden, which completely mediated the relationship between caregiver relationship quality and distress. Caregivers whose social contexts place them at risk for greater distress may benefit from increased clinical attention or intervention.

Older Adults' Attitudes, Concerns, and Support for Environmental Issues in the “New West”

The natural environment has been a missing topic from education and public policy forums concerning an aging society. This study examines demographic trends and several socio-demographic influences on attitudes, concerns, and active support for environmental issues among older adults in a retirement “hot spot” in the New West. A sample of 394 older adults in southwestern Utah was obtained from questionnaires mailed to those randomly selected from a larger dataset, and through hand-distributed questionnaires at selected RV parks. We found a high degree of variability among respondents in regard to environmental attitudes and concerns. Despite a personal attitudinal desire to protect the environment, most older adults did not want to become involved in protective actions for the environment. We found that residency status and religious affiliation emerged as the strongest relationships with measures of attitudes and concerns, and willingness to support the environment. The most influential factors associated with willingness to take action in support of the environment were having higher levels of active/social concerns, and higher levels of awareness of environmental consequences. The New West is one of the fastest-growing areas for demographic aging, and the opinions and actions of older adults will play a significant role in the stewardship and sustainability of natural resources, particularly in retirement hot spots.

A phase II study on the efficacy and safety of procedural analgesia with fentanyl buccal tablet in cancer patients for the placement of indwelling central venous access systems

Background

Pain in cancer patients is often related to oncologic therapies and diagnostic procedures. The placement of fully implantable venous access systems is a very common procedure in oncology patients. Local anaesthesia is the method most commonly used to overcome pain related to this surgical procedure, but the local anaesthetic may be unable to completely eradicate all pain. This study investigates the effectiveness and safety of fentanyl buccal tablet (FBT), administered by OraVescent® technology, in reducing procedural pain related to the placement of indwelling central venous access systems (Ports) in opioid-naïve cancer patients.

Methods

Inpatients who required an indwelling vascular access (Port) were preoperatively assessed with a self-assessment questionnaire on anxiety and pain. A 100 μg FBT was administered 10 min before preparation of the operating field. A self-assessment scale for pain experienced during the procedure was administered at the end of the procedure. Vital signs and the presence of any side effects or bothersome symptoms were monitored during the procedure, at the end, and 4 h later.

Results

From October 2012 to June 2014, 65 patients were enrolled in the study. A total of 61 (93.9 %) patients perceived no or a little pain during the procedure. Four patients (6.2 %) reported a lot of pain. No patient reported very severe pain. This data is significant in terms of the lower than expected presence of pain (Fisher test p = 0.0018) as assessed in our previous experience without procedural analgesia. The most common side effects of FBT was drowsiness, experienced by 28 patients at the end of the procedure (43.1 %), significantly reduced (p < 0.01) to 8 patients after 4 h (12.5 %). Nausea was present in 6 cases at the end of the procedure (9.2 %) and in 7 cases 4 h later (10.9 %). Vomiting was present in 3 cases at the end (4.7 %) and in 2 other patients after 4 h (7.8 %). No significant change of vital parameters was observed between the baseline and the subsequent measurements in all patients studied.

Conclusions

The significant improvement in the number of patients experiencing little or no pain, accompanied by a lower number of non-severe side effects, suggests that FBT is a valid, practical and safe method of procedural analgesia. It will be necessary to perform further studies, taking into account the need for standard antiemetic pre-medication to minimise the incidence of nausea and vomiting.

Factors that influence physical function and emotional well-being among Medicare-Medicaid enrollees

Dually enrolled Medicare-Medicaid older adults are a vulnerable population. We tested House's Conceptual Framework for Understanding Social Inequalities in Health and Aging in Medicare-Medicaid enrollees by examining the extent to which disparities indicators, which included race, age, gender, neighborhood poverty, education, income, exercise (e.g., walking), and physical activity (e.g., housework) influence physical function and emotional well-being. This secondary analysis included 337 Black (31%) and White (69%) older Medicare-Medicaid enrollees. Using path analysis, we determined that race, neighborhood poverty, education, and income did not influence physical function or emotional well-being. However, physical activity (e.g., housework) was associated with an increased self-report of physical function and emotional well-being of β = .23, p < .001; β = .17, p < .01, respectively. Future studies of factors that influence physical function and emotional well-being in this population should take into account health status indicators such as allostatic load, comorbidity, and perceived racism/discrimination.

Missed Opportunity: Hospice Care and the Family

A typical mission statement of hospice services is to provide quality, compassionate care to those with terminal illness and to support families through caregiving and bereavement. This study explored the ways that bereavement needs of caregivers, either predeath or postdeath of their spouse/partner, were addressed using qualitative retrospective phone interviews with 19 caregivers whose spouse/partner was enrolled in hospice care for cancer. Overall, participants expressed high satisfaction with hospice care, most often noting a high satisfaction with the quality of care provided to their spouse/partner. During the predeath phase, caregivers recalled being so focused on their spouse/partner's needs that they rarely spoke with hospice staff about their own personal needs and emotions. Participants said that bereavement counseling occurred primarily after the death of the spouse/partner, in the form of generic pamphlets or phone calls from someone they had not met during prior interactions with hospice staff. These findings suggest that caregivers' high satisfaction with hospice may be more associated with the quality of care provided to the spouse/partner than with bereavement support they received. Our findings illustrated a potential missed opportunity for hospices to address the family-oriented goals that are commonly put forward in hospice mission statements.

Concept Analysis: Alzheimer's Caregiver Stress

AIM

The aim of this article was to analyze the concept of caregiver stress in the context of caring for a person with Alzheimer's disease and related dementias.

BACKGROUND

Currently, there are more than 15 million unpaid caregivers for persons suffering from Alzheimer's disease and related dementias. This unpaid care can be stressful for caregivers due to the chronic nature of the disease process, as well as other factors.

METHOD

The paper incorporates the modified method of Wilson's concept analysis procedure to analyze the concept of caregiver stress.

DATA SOURCES

A review of the literature was undertaken using the Cumulative Index to Nursing and Allied Health Literature, Google Scholar, and PubMed.

RESULTS

A theoretical definition of caregiver stress is provided, and the defining attributes, related concepts, antecedents, and consequences of caregiver stress are proposed, and case studies are presented.

CONCLUSIONS

The analysis demonstrates that caregiver stress is the unequal exchange of assistance among people who stand in close relationship to one another, which results in emotional and physical stress on the caregiver. Implications for future nursing research and practice conclude the paper.

Coping processes among bereaved spouses

The authors investigated if an intervention based on the dual process model (vs. traditional bereavement support) enhanced oscillation between loss- (LO) and restoration-oriented (RO) coping of recently bereaved (2-6 months) spouses/partners. Participants were followed over 12 months. The authors found an increased emphasis over time on RO coping, particularly for women and those who were younger; however, no treatment effect was detected. Although patterns in the data are consistent with the model, the authors conclude that it is difficult for interventions to modify LO, RO, and oscillation unless there is sufficient intervention dosage and tailored to those exclusively engaged in one process.

Friend and family contact and support in early widowhood

OBJECTIVES

This study explored the relative contributions of friends and family to the social and emotional well-being of women and men in the first 2-6 months following the death of their spouse or partner.

METHODS

Three hundred and twenty-eight widowed men (39%) and women aged 50 and older completed self-administered questionnaires that included measures of contact and satisfaction with friends and family, as well as measures of affective (i.e., grief and depression) and self-evaluative (i.e., coping self-efficacy, mastery, self-esteem) responses to loss.

RESULTS

Regression analyses supported the positive features of social support and interaction but particularly highlight the role of friends: ease of contact and satisfaction with friendship support were associated with more positive self-evaluative aspects of loss; greater frequency of friendship help was associated with more negative affective reactions, whereas higher satisfaction with friendship support was associated with more positive affective reactions.

DISCUSSION

These analyses support the voluntary and socializing functions of friendship and social support, bolstering individuals during stressful life transitions, advancing our understanding of the underexamined and particularly distinct functions of friendship in the early phases of spousal loss.

Feeling lonely versus being alone: loneliness and social support among recently bereaved persons

OBJECTIVES

Despite increases in social support following widowhood, loneliness is among the most frequently reported challenges of bereavement. This analysis explores the dynamic relationship between social support and loneliness among recently bereaved older adults.

METHODS

Using longitudinal data from "Living After Loss" (n = 328), latent growth curve modeling was used to estimate changes in loneliness and social support during the first year and a half of bereavement among older adults aged 50+.

RESULTS

Both loneliness and social support declined over the first year and a half of bereavement. Greater social support was associated with lower levels of loneliness overall, but the receipt of social support did not modify one's expression of loneliness over time. Loneliness was more highly correlated with support from friends than family. Together, social support from both friends and family accounted for 36% of the total variance in loneliness.

DISCUSSION

There is conceptual and empirical overlap between the concepts of loneliness and social support, but results suggest that loneliness following widowhood cannot be remedied by interventions aimed only at increasing social support. Social support, especially that from friends, appears to be most effective if it is readily accessible and allows the newly bereaved an opportunity to express him/herself.

An Evaluation of the Living After Loss Intervention - Part 1: Do Bereavement-Related Outcomes Vary by the Content of Support Groups?

This article explores whether the substantive content and specific topics addressed during a 14-week support group can alter the bereavement-related outcomes of widowed older adults over time. It draws on data from the Living After Loss study, which developed a novel support group based on the Dual Process Model of bereavement and provides empirical evidence tracking the longitudinal outcomes of older bereaved spouses. Findings suggest that unless the content is universally relevant, the messaging and topics addressed during the support group do not alter the bereavement-related outcomes of widowed persons over time.

An Evaluation of the Living After Loss Intervention - Part 2: Do Bereavement-Related Outcomes Vary by the Dynamics of Support Groups?

Group-based interventions for recently bereaved spouses may provide support and friendship through the commonality of experiences that are shared among the members of the group. This study compares the experiences and characteristics of persons in 35 different support groups from the Living After Loss (LAL) study, with particular emphasis on the question: Does the chemistry of the group affect the longer term adjustment outcomes associated with bereavement? Results suggest that, perhaps, those groups that foster the greatest sense of mutual support and have the most effective group leaders may be associated with more favourable bereavement-related outcome, especially stress related growth. Challenges associated with evaluating the effectiveness of group-based interventions are also discussed.

Challenges, transitions, and healthy aging: introduction to the special issue

Rowe and Kahn's (1987) seminal piece in the journal Science, and the work driven by the MacArthur Foundation that followed (Rowe & Kahn, 1997, 1998), arguably signaled a paradigm shift in how we think about aging and health. Rather than a purely biomedical view of aging and health, Rowe and Kahn postulated a broader perspective suggesting that in addition to the avoidance of disease and disability (and risk factors that predispose one to such consequences), “successful” aging also entails maintaining a high level of function, and being actively engaged with life through social connectedness and productive activity. Healthy aging, therefore, is best viewed contextually, involving an interplay of personal (including behavioral and attitudinal as well as genetic), environmental, social, and cultural factors (House, 2002; Sallis, Owen, & Fisher, 2008; Vaillant, 2002; Vaillant & Mukamal, 2001).

Investigations such as the Nun Study (Snowdon, 2001) and the Landmark Harvard Study of Adult Development (Vaillant, 2002) demonstrated that healthy aging is an outcome of a convergence of multiple influences over one's lifetime. It is, hence, a life course issue, potentially subject to the challenges associated with altered circumstances out of the individual's control (such as spousal loss), or one's deliberate attempt to effect a change within some aspect of his or her own life. Quitting smoking, for instance, not only entails a significant change from an unhealthy behavior to a healthy one, but also precipitates a transformation in one's identity from a lifelong smoker to a nonsmoker. What influences do life transitions have on an individual's journey as they evolve and develop into their “aging self”? To what extent can they age successfully and by what criteria—how they subjectively perceive it based on their own assessment or according to more objective standards akin to Rowe and Kahn's (1997, 1998) aforementioned dimensions (Pruchno, Wilson-Genderson, & Cartwright, 2010; Strawbridge, Wallhagen, & Cohen, 2002)? What distinguishes those experiencing negative versus positive—even resilient—outcomes? And knowing that, how should prevention and intervention efforts be targeted? The following articles in this special issue represent a combined effort to begin to address these questions.

In addition to comparing those who ever smoked with those who did not, Pruchno et al. examine the complex relationships that exist as individuals transition from being a smoker to a nonsmoker, factoring in the age at which one quits. Their findings emphasize that while broadly focused prevention and cessation efforts have value, special efforts need to be targeted to those early points in the life course when smoking behaviors are adopted. They also present some sobering conclusions pertaining to quitting in later life, which, while it should not be discounted, does not easily predict one would age successfully by both objective as well as subjective criteria. This only reinforces the importance of not smoking at any point within the life course.

Grief, depressive symptoms, and physical health among recently bereaved spouses

PURPOSE

 Widowhood is among the most distressing of all life events, resulting in both mental and physical health declines. This paper explores the dynamic relationship between physical health and psychological well-being among recently bereaved spouses. 

DESIGN AND METHODS

 Using a sample of 328 bereaved persons who participated in the "Living After Loss" study, we modeled trends in physical health, somatic symptoms, and psychological well-being over the first year and a half of widowhood. The primary focus is whether physical health at the time of widowhood modifies psychological well-being over time. 

RESULTS

 There were considerable somatic symptoms during the earliest months of bereavement but no major health declines over the first year and half of bereavement. Those in poor health had initially higher levels of grief and depressive symptoms, but the trajectories or changes over time were similar regardless of health status. Those with poor health at the time of widowhood had significantly higher risks of complicated grief and major depression disorder. 

IMPLICATIONS

 Bereavement requires physical and emotional adjustment, but the psychological trajectory of bereavement may be somewhat universal. Bereavement support ought to include a focus on self-care and health promotion in addition to emotional support, especially because those with poor health initially may be most susceptible to prolonged and intense clinical distress.

Experiences and early coping of bereaved spouses/partners in an intervention based on the dual process model (dpm)

This study was designed to test the effectiveness of the Dual Process Model (DPM) of coping with bereavement. The sample consisted of 298 recently widowed women (61%) and men age 50+ who participated in 14 weekly intervention sessions and also completed before (O1) and after (O2) self-administered questionnaires. While the study also includes two additional follow-up assessments (O3 and O4) that cover up to 14-16 months bereaved, this article examines only O1 and O2 assessments. Based on random assignment, 128 persons attended traditional grief groups that focused on loss-orientation (LO) in the model and 170 persons participated in groups receiving both the LO and restoration-orientation (RO) coping (learning daily life skills). As expected, participants in DPM groups showed slightly higher use of RO coping initially, but compared with LO group participants they improved at similar levels and reported similar high degrees of satisfaction with their participation (i.e., having their needs met and 98-100% indicating they were glad they participated. Even though DPM participants had six fewer LO sessions, they showed similar levels of LO improvement. Qualitative data indicate that the RO component of the DPM might be more effective if it is tailored and delivered individually.

A Tale of Two Counties:Bereavement in Socio-Demographically Diverse Places

The "Living After Loss" study was designed to test the effectiveness of the dual process model (DPM) of coping with bereavement. In order to obtain a larger and more diverse sample we studied 328 recently widowed men and women (61%) age 50+ in two counties, Salt Lake (n=197) and San Francisco (n=131) in two states, Utah and California. This paper does not report on the effects of the intervention but focuses on a comparison of the bereaved spouses/partners in these two cites. First, the only socio-demographic differences we found between those in SF and SL were that those in San Francisco were more racially, ethnically and religiously diverse, higher in education, had slightly fewer years in their relationship to the deceased and were two weeks longer in their grief process. Second, there were far more similarities than differences between SF and SL regarding nearly all of the study variables. Third, we found that those in SF had more positive qualitative features in their friendship support networks and that for bereaved in both counties, we found strong associations with having highly supportive friend-based networks and more positive bereavement adjustments (especially experiencing lower levels of loneliness and depression). Limitations and suggestions for future research are described.

Sampling, recruitment, and retention in a bereavement intervention study: experiences from the Living After Loss Project

This article reports on the sampling and recruitment challenges, as well as the strategies used to address them in the Living After Loss (LAL) project, a bereavement intervention study conducted in Salt Lake City and San Francisco comparing two 14-week group conditions with follow-up. We encountered three major challenges: 1) difficulty determining eligibility for some potential participants who were contacted, 2) locating and recruiting nonwhites, and 3) unavailable phone numbers for approximately one-third of those we attempted to contact. Despite these challenges, we achieved a 42% response rate with a sample size of 328 participants comprising 15% nonwhite. Eighty-five percent of the participants completed all of the follow-up data points. Leading factors in participants' decisions to join and remain in the study were 1) opportunities to obtain help and support, 2) to potentially help other bereaved individuals, 3) to contribute to research, and 4) their on-going interactions with a professional, empathetic, and culturally sensitive project staff. Effectively focusing recruitment efforts and carefully and systematically training research staff were among the most effective strategies we employed and therefore suggest for those planning similar investigations.

Stress-related growth among the recently bereaved

Although stress-related growth (SRG), or a personal transformation beyond adaptation, can be an outcome for some individuals after a traumatic life experience like spouse or partner loss, it is often assumed that some time needs to pass before this happens. This study reports on early experiences of SRG relatively soon after the loss of a spouse or partner in mid and later life. Self-administered questionnaires were completed by 292 recently bereaved (2-6 months) partners, aged 50+, as part of the Living After Loss study conducted in Salt Lake City and San Francisco. Substantial variability in SRG was observed where 21% scored > or =1 SD above and approximately 18% scored > or =1 SD below the sample mean of 17.2 (SD = 7.0). Regression analyses revealed that SRG was more likely for those who had expected their partners' deaths, who were more religious and who engaged in loss- and restoration-oriented coping processes, and was independent of grief levels. Findings suggest that some individuals drew upon their religious beliefs as a way to find meaning and make sense of what happened as they rebuilt their 'assumptive world'. Also, those who anticipated their partner's death could have had more opportunity to cognitively process the loss, address the challenges of widowed life and learn new skills and discover previously unrecognized strengths.

Cognitive decline and low blood pressure: the other side of the coin

Low blood pressure has been found to be associated with cognitive decline and dementia in cross-sectional studies. Two mechanisms have been proposed to interpret this association: blood pressure levels decrease during the course of the dementia process, and low blood pressure induces or accelerates cognitive decline by lowering cerebral blood flow. Results of the prospective studies are contradictory. Low blood pressure and orthostatic hypotension have been found to predict cognitive impairment in the elderly population in some studies only. While hypotension may play a protective role in healthy elderly people, low blood pressure levels in frail elderly patients with associated diseases may cause cerebral hypoperfusion and accelerate cognitive decline.

Baroreflex sensitivity is impaired in essential hypertensives with central obesity

Recently, much interest has focussed on the potential interaction between sympathetic nervous system and global cardiovascular risk. We investigated how baroreflex sensitivity (BRS), an index of autonomic function, interacts with central obesity (CO) in an essential hypertensive (EH) population. We selected 170 EHs and 43 normotensives (NT), (median age 47.3+/-11.3 and 49.1+/-13 years, respectively). Anthropometric parameters were measured for each and BRS was evaluated by a non-invasive method using Portapres TNO. The BRS evaluation was made using the sequences method. Systolic blood pressure (SBP) and heart rate were significantly higher in EH (P<0.001 and P=0.007, respectively). BRS was significantly greater in NT (P=0.02), and was associated inversely with waist circumference (WC) (P=0.005), but not with SBP or with other metabolic risk factors. Body mass index, total and high-density lipoprotein cholesterol, age and WC were not significantly different between the two groups. These results were confirmed by age pounded analysis. Finally, a separate analysis of the hypertensive group with CO (n=84) demonstrated a significantly lower BRS compared with the other hypertensive patients (n=86) (P<0.001). BRS is associated with WC but not with arterial pressure values and metabolic risk factors. Hypertensive subjects with CO show an impairment of BRS. Owing to its association with abdominal fat distribution and subsequently insulin resistance, BRS could represent a further and reliable index for evaluation of global cardiovascular risk in hypertensive patients.

Short-term acenocumarine (A) or dalteparine (D) for the prevention of central venous catheter-related thrombosis (CVCrT) in cancer patients. A randomized controlled study based on serial venographies

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Background: Timing and frequency of non occlusive (nO) or occlusive (O) CVCrT in cancer patients (pts) remain unclear. In this randomized controlled trial we studied these points and evaluated the efficacy and safety of short-term prophylaxis with A or D in the prevention of CVCrT. Methods: Consecutive cancer pts without contraindications to short-term anticoagulation, scheduled for chemotherapy via CVC, were randomly assigned to receive: A 1 mg/day for 3 days before and 8 days after CVC insertion; D 5,000 IU 2 hours before and daily for 8 days after CVC insertion; no anticoagulant treatment (NT). All pts underwent venography (V) at day 8 and 30 after CVC insertion and then every two months until CVC removal . The primary endpoint was V detected CVCrT, evaluated as nO or O when it was partially or completely occlusive of the vein lumen, respectively. Bleeding episodes were recorded. Proportions were compared using chi-square test together with odds ratio (OR). Results: 450 pts were randomized, 348 of whom (120/150 A, 114/150 D, and 114/150 NT) underwent V (median number of procedures 4, range 2–8). Both A and D reduced the frequency of V detected CVCrT (21.9% A vs 55.3% NT, OR= 4.35 (95% CI 2.43–7.69), p<0.001; 40% D vs 55.3% NT, OR= 1.85 (95% CI 1.10–3.13), p=0.02). A was more effective than D (OR= 2.37 (CI 1.34–4.22), p= 0.003). The frequency of O CVCrT was not different in the 3 groups (0.9% A, 5.0% D, 4.4% NT; p= 0.18). Overall, 5.1% of pts with CVCrT were symptomatic, all presenting O CVCrT (42% of pts with O CVCrT were not symptomatic). Most CVCrTs (95.6%) were observed at day 8 after CVC insertion. No major bleeding or pulmonary embolism occurred. Conclusions: In this study, acenocumarine was more effective than dalteparine in reducing V detected CVCrT. The doses of prophylactic agents used in this study proved to be safe. Symptomatic CVCrT evaluation alone underestimates the actual CVCrT frequency. The first days following CVC insertion are at highest risk for CVCrT. Short term thrombosis prophylaxis appears to be superior to no treatment without the expenses and inconveniences inherent in long-term prophylaxis.

No significant financial relationships to disclose.

Music thanatology: prescriptive harp music as palliative care for the dying patient

Music thanatology represents an emerging area in which the raw materials of music, usually harp and/or voice, assist and comfort the dying patient. During prescriptive "music vigils, " the clinician-musician carefully observes physiological changes, cues, and breathing patterns, thereby synchronizing the music to reflect or support the patient's physiology and overall condition. Using data collected from 65 patients, this study was designed to assess the effectiveness of prescriptive harp music on selected palliative care outcomes using a sample of de-identified data forms from past music vigils. Patients were administered a 25- to 95-minute intervention of prescriptive harp music. Data collected included vital signs and observational indicators before (Ti) and after (T2) the vigil. Patients were more likely to experience decreased levels of agitation and wakefulness while also breathing more slowly and deeply with less effort at the conclusion of the music vigil. Results from this study suggest that a prescriptive vigil conducted by a trained music thanatologist could provide an effective form of palliative care for dying patients.

Pulse rate in childhood: reference limits

BACKGROUND AND AIM

Systematic quantitative resting pulse rate measurements may represent an additional parameter for the study of cardiovascular risk factors in youth as well as in adulthood. The aim of this study was to evaluate resting pulse rate and its distribution curve in order to define reference limits in a sample of adolescents from Turin, Italy.

METHODS AND RESULTS

The study population consisted of 2230 children aged 12-18 years, who were randomly enrolled from Turin Junior High Schools. All of the participants underwent pulse rate, blood pressure and height measurements. The 5th and 95th percentiles of the pulse rate in boys and girls are reported by age and height. The pulse rate was higher in the girls, but progressively decreased with age and somatic growth in both genders.

CONCLUSIONS

The present study provides reference blood pressure values by age, gender and height in a sample of male and female adolescents.

Two strange cases of hypereosinophilia and child's relapsing angio-oedema

Two patients aged two and four years came to our observation with "angio-oedema" and relapsing hypodermitis. Atopic diseases were present in both family histories. The clinical examination of both children revealed a good nutritional status, the presence of angio-oedema with fleeting (48 hours max length) and localized hypodermic infiltrations. Amongst laboratory investigations, the blood cells count and the total count of Immunoglobulins showed hypereosinophilia and increased IgE levels over ten times the normal values. Prick tests for the most common inhalant and nutritive allergens were negative. A strong positivity of ELISA for Taenia Solium metacestodes on both sera samples suggested a diagnosis of human cysticercosis.

Celiac plexus block: injectate spread and pain relief in patients with regional anatomic distortions

BACKGROUND

The success of the neurolytic celiac plexus block, despite different approaches and methods used, depends on adequate spread of the injectate in the celiac area. This retrospective study was conducted to evaluate the patterns of alcohol spread and pain relief in patients with cancer or therapy-related anatomic distortion of the celiac area.

METHODS

From 177 cancer patients who underwent computed tomography (CT)-guided single-needle neurolytic celiac plexus block via an anterior approach, a radiologist, blind to the aim of the study, retrospectively selected 105 patients with abnormal anatomy of the celiac area as judged by CT images obtained before the block. To evaluate CT patterns of neurolytic (mixed with contrast) spread, the celiac area was divided on the frontal plane into four quadrants: upper right and left and lower right and left, as related to the celiac artery. Results were expressed as the number of quadrants into which contrast spread, ie., four, three, two, or one quadrants with contrast. The patterns of contrast spread according to the number of quadrants with anatomic distortion were analyzed. Patient assessment by visual analog scale was reviewed to evaluate the degree of pain relief. Pain relief 30 days after block was considered long-lasting. Pain relief at 30 days after block was analyzed according to the number of quadrants with contrast.

RESULTS

Overall, four, three, two, and one quadrants with contrast were observed in 9 (8%), 21 (20%), 49 (47%), and 26 (25%) patients, respectively. An inverse correlation was observed between the number of quadrants with anatomic distortion and the number of quadrants with contrast (P < 0.001). Long-lasting pain relief was noticed in nine of nine patients (100%; 95% confidence interval, 66-100) with contrast in four-quadrants, and in 10 of 21 patients (48%; 95% confidence interval, 26-70) with contrast in 3 quadrants (P < 0.01). None of the 75 patients with contrast in two quadrants or one quadrant experienced long-lasting pain relief.

CONCLUSIONS

These findings suggest that, using the single-needle anterior approach, the neurolytic spread in the celiac area is highly hampered by the regional anatomic alterations. It also appears that only a complete (four quadrants) neurolytic spread in the celiac area can guarantee long-lasting analgesia, and that this picture may be obtained in a very limited fraction of patients with regional anatomic alterations.

Two distinct nucleosome alterations characterize chromatin remodeling at the Saccharomyces cerevisiae ADH2 promoter

Glucose depletion derepresses the Saccharomyces cerevisiae ADH2 gene; this metabolic change is accompanied by chromatin structural modifications in the promoter region. We show that the ADR6/SWI1 gene is not necessary for derepression of the wild type chromosomal ADH2, whereas the transcription factor Adr1p, which regulates several S. cerevisiae functions, plays a major role in driving nucleosome reconfiguration and ADH2 expression. When we tested the effect of individual domains of the regulatory protein Adr1p on the chromatin structure of ADH2, a remodeling consisting of at least two steps was observed. Adr1p derivatives were analyzed in derepressing conditions, showing that the Adr1p DNA binding domain alone causes an alteration in chromatin organization in the absence of transcription. This alteration differs from the remodeling observed in the presence of the Adr1p activation domain when the promoter is transcriptionally active.

Coexistence of incontinentia pigmenti and neonatal herpes simplex virus infection

We present a female infant with classic clinical and histologic features of stage I incontinentia pigmenti with coexistent neonatal herpes simplex virus infection. The diagnosis of a heritable cutaneous condition does not exclude the possibility of a coexistent infection and, given the similar clinical presentation of neonatal vesicular eruptions, accurate diagnoses may require skin biopsy and culture.

Factors affecting Saccharomyces cerevisiae ADH2 chromatin remodeling and transcription

The chromatin structure of the Saccharomyces cerevisiae ADH2 gene is modified during the switch from repressing (high glucose) to derepressing (low glucose) conditions of growth. Loss of protection toward micrococcal nuclease cleavage for the nucleosomes covering the TATA box and the RNA initiation sites (-1 and +1, respectively) is the major modification taking place and is strictly dependent on the presence of the transcriptional activator ADR1. To identify separate functions involved in the transition from a repressed to a transcribing promoter, we have analyzed the ADH2 chromatin organization in various genetic backgrounds. Deletion of the CCR4 gene coding for a general transcription factor impaired ADH2 expression without affecting chromatin remodeling. Growing yeast at 37 degrees C also resulted in chromatin remodeling at the ADH2 locus even under glucose repressing conditions. However, although this temperature-induced remodeling was dependent on the ADR1 protein, no ADH2 mRNA was observed. In addition, inactivating RNA polymerase II (and therefore, elongation) was found to have no effect on the ability to reconfigure nucleosomes. Taken together, these data indicate that chromatin remodeling by itself is insufficient to induce transcription at the ADH2 promoter.

Chromatin structure of the Saccharomyces cerevisiae DNA topoisomerase I promoter in different growth phases

We have determined the chromatin organization of the Saccharomyces cerevisiae DNA topoisomerase I promoter. Three nucleosomal core particles have been mapped at nucleotide level over the promoter region, encompassing the presumptive TATA sequence and the two RNA initiation sites; the most upstream nucleosome particle forms on to a 29 bp-long poly(dA-dT) element. This simple organization remains constant throughout both the logarithmic and the linear phase of growth, with the exception of an increased accessibility to micrococcal nuclease of the nucleosome covering the TATA box and the RNA initiation sites during the diauxic shift (the switching from the fermentative to the respiratory metabolism) in parallel with an increase of the DNA topoisomerase I mRNA. In addition, a strong disorganization of the bulk chromatin structure in the late stationary phase is also reported.

The active role of DNA as a chromatin organizer

Histone octamers (hos) and DNA topoisomerase I contribute, along with other proteins, to the higher order structure of chromatin. Here we report on the similar topological requirements of these two protein model systems for their interaction with DNA. Both histone octamers and topoisomerase I positively and consistently respond to DNA supercoiling and curvature, and to the spatial accessibility of the preferential interaction sites. These findings (1) point to the relevance of the topology-related DNA conformation in protein interactions and define the particular role of the helically phased rotational information; and (2) help to solve the apparent paradoxical behaviour of ubiquitous and abundant proteins that interact with defined DNA sites in spite of the lack of clear sequence consensuses. Considering firstly, that the interactions with DNA of both DNA topoisomerase I and histone octamers are topology-sensitive and that upon their interaction the DNA conformation is modified; and secondly, that similar behaviours have also been reported for DNA topoisomerase II and histone H1, a topology-based functional correlation among all these determinants of the higher order structure of chromatin is here suggested.

Chromatin remodeling during Saccharomyces cerevisiae ADH2 gene activation

We have analyzed at both low and high resolution the distribution of nucleosomes over the Saccharomyces cerevisiae ADH2 promoter region in its chromosomal location, both under repressing (high-glucose) conditions and during derepression. Enzymatic treatments (micrococcal nuclease and restriction endonucleases) were used to probe the in vivo chromatin structure during ADH2 gene activation. Under glucose-repressed conditions, the ADH2 promoter was bound by a precise array of nucleosomes, the principal ones positioned at the RNA initiation sites (nucleosome +1), at the TATA box (nucleosome -1), and upstream of the ADR1-binding site (UAS1) (nucleosome -2). The UAS1 sequence and the adjacent UAS2 sequence constituted a nucleosome-free region. Nucleosomes -1 and +1 were destabilized soon after depletion of glucose and had become so before the appearance of ADH2 mRNA. When the transcription rate was high, nucleosomes -2 and +2 also underwent rearrangement. When spheroplasts were prepared from cells grown in minimal medium, detection of this chromatin remodeling required the addition of a small amount of glucose. Cells lacking the ADR1 protein did not display any of these chromatin modifications upon glucose depletion. Since the UAS1 sequence to which Adr1p binds is located immediately upstream of nucleosome -1, Adr1p is presumably required for destabilization of this nucleosome and for aiding the TATA-box accessibility to the transcription machinery.

Understanding depression in bereaved older adults

Depression is a common outcome of spousal bereavement. Concurrent life events may contribute to the intensity of depression following spousal bereavement in older adults and, if not identified, may interfere with therapeutic plans for the management of depression. Taped interviews, conducted six times over two years, were analyzed for ten subjects, five whose depression scores were low, and five whose scores were high. In addition, a detailed case comparison analysis of two subjects was done. Four recurring types of life events, reported by the bereaved spouses, were illness (of self or others), deaths of family or friends, residential relocation, and changes in interpersonal relationships. Significantly depressed spouses were more likely to report these events. Implications for nursing practice and for integrating qualitative and quantitative research methods are addressed.

Conformational information in DNA: its role in the interaction with DNA topoisomerase I and nucleosomes

Information in DNA is not limited to sequence information. Both local and global conformational parameters are pivotal to the interaction with a number of relevant proteins. The function of the major components of the transcription machinery (RNA polymerase II, DNA topoisomerase I, nucleosomes, the TATA-binding factor) is dependent on the topological status of the substrate DNA molecule. The topological requirements and the conformational consensus that dictate the rules for localization of nucleosomes and define the active sites for DNA topoisomerase I have been established; the reaction of DNA topoisomerase I is regulated by a topological feedback mechanism. The integrating function of the free energy of supercoiling in the transcription process and the regulatory role of DNA topoisomerase I are discussed.