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Suicide is a complex multifactorial process influenced by a variety of biological, psychological, and social stressors. Many older adults face a characteristic set of challenges that predispose them to suicidal ideation, suicide-related behavior, and death by suicide. This study explored the subjective experience of suicidality through the analysis of suicide notes from older adults.Qualitative study analyzing written suicide notes.Written notes for suicide deaths in Toronto, Canada, between 2003 and 2009 were obtained from the Office of the Chief Coroner for Ontario.The analysis comprised 29 suicide notes (mean words per note: 221; range: 6-1095) written by individuals 65 years and older (mean ± SD age: 76.2 ± 8.3).We employed a constructivist grounded theory framework for the analysis, conducted through line-by-line open coding, axial coding, and theorizing of data to establish themes.Suicide notes elucidated the writers' conception of suicide and their emotional responses to stressors. Expressed narratives contributing to suicide centered on burdensomeness or guilt, experiences of mental illness, loneliness or isolation, and poor physical health or disability. Terms related to pain, poor sleep, apology, and inability to go on were recurrent.Suicide notes enrich our understanding of the thoughts and emotions of those at highest risk of suicide, and they inform potential interventions for reducing suicide risk in older adults.

Granulomatosis with polyangiitis (GPA) is a rare necrotising small vessel vasculitis typically associated with oronasal, pulmonary and renal manifestations. Pancreatic disease is an exceedingly rare initial presentation and is associated with delayed diagnosis and rapid progression. We discuss a 66-year-old woman presenting with epigastric pain, elevated lipase and radiographic evidence of focal pancreatitis. She had no relevant medical history and no lithiasis seen on imaging. Pertinent findings include strawberry gingivitis, positive proteinase-antineutrophil cytoplasm antibody (98% specificity) and focal nodular parenchymal lung lesions on CT chest—all of which are consistent with a diagnosis of GPA. She was promptly started on high-dose steroids which resulted in significant clinical and biochemical improvement. Cyclophosphamide was added once biopsy confirmed the absence of malignancy. In order to optimise the clinical outcomes of GPA, physicians must keep a wide differential and high index of suspicion in the setting of unexplained pancreatitis with systemic features.

The Confusion Assessment Method (CAM) is commonly used to detect delirium but its utility in patients with limited English proficiency (LEP) is not well-established. In the current study, internal medicine nurses at an acute care hospital in Canada were surveyed on the use of the CAM in older adults with LEP. Nurses' perspectives were explored with a focus on barriers to administration. Fifty participants were enrolled (response rate = 47.6%). Twenty-eight (56%) participants stated they could not confidently and accurately assess delirium in patients with LEP. Twenty-nine (58%) participants believed the CAM is not an effective delirium screening tool in the LEP population. Barriers to screening included: challenges with interpretation services, dependence on family members, and fear that the assessment itself may worsen confusion. Our study is the first to describe specific barriers to administering the CAM in patients with LEP. Strategies are required to address these barriers and optimize delirium screening for patients with LEP. [ Journal of Gerontological Nursing, 47 (4), 29–34.]

Background Minimal exposure, misconceptions, and lack of interest have historically driven the shortage of health-care providers for older adults. This study aimed to determine how medical stu­dents’ participation in the National Geriatrics Interest Group (NGIG) and local Geriatrics Interest Groups (GIGs) shapes their career development in the care of older adults. Methods An electronic survey consisting of quantitative and qualita­tive metrics to assess the influence of Interest Groups was distributed to all current and past members of local GIGs at Canadian universities since 2017, as well as current and past executives of the NGIG since 2011. Descriptive statistics and thematic analysis were performed. Results Thirty-one responses (27.7% response rate) were collected from medical students (13), residents (16), and physicians (2). 79% of resident respondents indicated they will likely have a geriatrics-focused medical practice. 45% of respondents indicated GIG/NGIG involvement facilitated the establish­ment of strong mentorship. Several themes emerged on how GIG/NGIG promoted interest in geriatrics: faculty mentor­ship, networking, dispelling stigma, and career advancement. Conclusion The positive associations with the development of geriatrics-focused careers and mentorship compel ongoing support for these organizations as a strategy to increase the number of physicians in geriatrics-related practices.

Background Measurement-based care (MBC) in mental health improves patient outcomes and is a component of many national guidelines for mental healthcare delivery. Nevertheless, MBC is not routinely integrated into clinical practice. Several known reasons for the lack of integration exist but one lesser explored variable is the subjective perspectives of providers and patients about MBC. Such perspectives are critical to understand facilitators and barriers to improve the integration of MBC into routine clinical practice. Aims This study aimed to uncover the perspectives of various stakeholders towards MBC within a single treatment centre. Method Researchers conducted qualitative semi-structured interviews with patients (n = 15), family members (n = 7), case managers (n = 8) and psychiatrists (n = 6) engaged in an early-psychosis intervention programme. Data were analysed using thematic analysis, informed by critical realist theory. Results Analysis converged on several themes. These include (a) implicit negative assumptions; (b) relevance and utility to practice; (c) equity versus flexibility; and (d) shared decision-making. Providers assumed patients’ perspectives of MBC were negative. Patients’ perspectives of MBC were actually favourable, particularly if MBC was used as an instrument to engage patients in shared decision-making and communication rather than as a dogmatic and rigid clinical decision tool. Conclusions This qualitative study presents the views of various stakeholders towards MBC, providing an in-depth examination of the barriers and facilitators to MBC through qualitative investigation. The findings from this study should be used to address the challenges organisations have experienced in implementing MBC.

Alcohol use disorder and gastric bypass surgery are highly comorbid. Alcohol withdrawal syndrome (AWS) is a common and potentially life-threatening event, requiring nuanced and individually tailored management depending on various clinical factors including patient history, alcohol consumption, comorbidities, and timeline of use. Although increasingly common, the literature for managing alcohol withdrawal in the gastric bypass population is quite limited. We present the case of a 45-year-old woman with a past history of Roux-en-Y gastric bypass admitted for alcohol withdrawal at a psychiatric hospital who experienced a complicated withdrawal despite adhering to standard management guidelines. She had been consuming 8 to 12 standard drinks daily, and she was therefore monitored on a Clinical Institute Withdrawal Assessment for Alcohol. She experienced only minimal withdrawal symptoms up to 48 hours following cessation of alcohol consumption. At 70 hours postcessation, she experienced a witnessed tonic-clonic seizure with associated head trauma with internal bleeding, requiring acute medical intervention. This timeline of withdrawal symptoms is atypical, yet perhaps understood in the context of her past medical history which included gastric bypass surgery. We discuss the potential complicating factors inherent in individuals who have received Roux-en-Y gastric bypass in the past with respect to alcohol metabolism. We discuss the similar considerations with respect to altered metabolism of therapeutics commonly used in managing this condition. Lastly, we include a review of the extent literature on this topic and propose possible considerations for managing this unique but increasingly prevalent clinical scenario.

BACKGROUND Diagrams which allow potential unrelated stem cell donors to visualize the stem cell collection process were hypothesized to support the recruitment and education of committed stem cell donors. STUDY DESIGN AND METHODS A series of bone marrow and peripheral blood stem cell collection procedure diagrams were developed, featuring young adult male donors of varied ethnic backgrounds. Post-implementation, surveys were conducted to evaluate stakeholder perspective on the diagrams' utility. A quality improvement project was conducted at five stem cell drives from 2017 to 2018 at which recruiters did or did not show the diagrams to potential donors. Following the drives, registrants were invited to complete a survey exploring their experience, knowledge and attitude towards donation. RESULTS The diagrams were implemented in Canada in 07/2016. Of 293 participating registrants (24·7% non-Caucasian males) recruited at five drives between 2017 and 2018, 76% (n = 197) were shown the diagrams. Participants who were shown the diagrams were significantly more likely to report that the recruiters appeared very knowledgeable (89% vs. 76%, P = 0·019) and to report improved self-reported knowledge of stem cell donation (P = 0·010) compared to participants not shown the diagram. Data are also shown demonstrating that stakeholders in donor recruitment used and valued the diagrams and that use of the diagrams was associated with improved donor recruitment outcomes in Canada. CONCLUSION This report is the first evaluation of stem cell collection diagrams in the literature. The diagrams are relevant to donor registries, recruitment organizations and transplant centres worldwide, and their use may support efforts to educate and recruit committed, ethnically diverse donors.

BACKGROUND: The genetic risk factors of schizophrenia (SCZ), a severe psychiatric disorder, are not yet fully understood. Multiple lines of evidence suggest mitochondrial dysfunction may play a role in SCZ, but comprehensive association studies are lacking. We hypothesized that variants in nuclear-encoded mitochondrial genes influence susceptibility to SCZ. METHODS: We conducted gene-based and gene-set analyses using summary association results from the Schizophrenia Psychiatric Genomics Consortium GWAS (PGC-SCZ2) comprising 35,476 cases and 46,839 controls. We applied the MAGMA method to three sets of nuclear-encoded mitochondrial genes: oxidative phosphorylation genes, other nuclear-encoded mitochondrial genes, and genes involved in nucleus-mitochondria crosstalk. Furthermore, we conducted a replication study using the iPSYCH SCZ sample of 2,290 cases and 21,621 controls. RESULTS: In the PGC-SCZ2 sample, 1,186 mitochondrial genes were analyzed among which 159 had p-values

BACKGROUND Patients with blood, immune, or metabolic diseases may require a stem cell transplant as part of their treatment. However, 70% of patients do not have a suitable human leukocyte antigen match in their family, and need an unrelated donor. Individuals can register as potential donors at stem cell drives, where they provide consent and a tissue sample for human leukocyte antigen typing. The ideal donors are young, male, and from a diversity of ethnic backgrounds. However, in Canada, non-Caucasian males ages 17 to 35 years represent only 8.8% of listed donors. STUDY DESIGN AND METHODS The Stem Cell Club is a non-profit organization founded in 2011 in Canada that aims to augment recruitment of the most needed donors. The initiative published a recruitment toolkit online (www.stemcellclub.ca). Currently, there are 12 chapters at universities across Canada. RESULTS To date, the Stem Cell Club has recruited 6585 potential registrants, representing 1.63% of donors on Canada's donor-database. Of the recruited registrants, 58.3% were male; 60.3% of males self-reported as non-Caucasian, and 78.5% were ages 17 to 25 years. From 2015 to 2016, the initiative recruited 13.7% of all ethnically diverse males ages 17 to 35 years listed in Canada's donor database. Data from this initiative demonstrate sustainability and performance on key indicators of stem cell drive quality. CONCLUSION The Stem Cell Club has developed a capacity to recruit 2600 donors annually, with the majority being males with a high degree of ethnic diversity. The initiative enhances the quality of Canada's unrelated donor-database, improving the chances that patients in need of an unrelated donor will find a match for transplant. The Stem Cell Club is a model relevant to recruitment organizations around the world.

Cognitive impairment is highly prevalent in the progression of both diabetes mellitus and bipolar disorder. The relationship between insulin resistance in diabetes and the risk of developing major neurocognitive disorders such as Alzheimer's disease has been well described. Insulin resistance and the associated metabolic deficiencies lead to biochemical alteration which hasten neurodegeneration and subsequent cognitive impairment. For bipolar disorder, some patients experience a cyclical, yet progressive course of illness. These patients are also more likely to have medical comorbidities such as cardiovascular disease and diabetes, and insulin resistance in particular may precede the neuroprogressive course. Diabetes and bipolar disorder share epidemiological, biochemical, and structural signatures, as well as cognitive impairment within similar domains, suggesting a common mechanism between the two conditions. Here we describe the association between insulin resistance and cognitive changes in bipolar disorder, as well as potential implications for therapeutic modulation of neuroprogression.

While accounting for only 2% of the body’s weight, the brain utilizes up to 20% of the body’s total energy. Not surprisingly, metabolic dysfunction and energy supply-and-demand mismatch have been implicated in a variety of neurological and psychiatric disorders. Mitochondria are responsible for providing the brain with most of its energetic demands, and the brain uses glucose as its exclusive energy source. Exploring the role of mitochondrial dysfunction in the etiology of psychiatric disease is a promising avenue to investigate further. Genetic analysis of mitochondrial activity is a cornerstone in understanding disease pathogenesis related to metabolic dysfunction. In concert with neuroimaging and pathological study, genetics provides an important bridge between biochemical findings and clinical correlates in psychiatric disease. Mitochondrial genetics has several unique aspects to its analysis, and corresponding special considerations. Here, we review the components of mitochondrial genetic analysis – nuclear DNA, mitochon­drial DNA, mitochondrial pathways, pseudogenes, nuclear-mitochondrial mismatch, and microRNAs – that could contribute to an observable clinical phenotype. Throughout, we highlight psychiatric diseases that can arise due to dysfunction in these processes, with a focus on schizophrenia and bipolar disorder.

Antipsychotic Induced Weight Gain (AIWG) is a common and severe side effect of many antipsychotic medications. Mitochondria play a vital role for whole-body energy homeostasis and there is increasing evidence that antipsychotics modulate mitochondrial function. This study aimed to examine the role of variants in nuclear-encoded mitochondrial genes and the mitochondrial DNA (mtDNA) in conferring risk for AIWG. We selected 168 European-Caucasian individuals from the CATIE sample based upon meeting criteria of multiple weight measures while taking selected antipsychotics (risperidone, quetiapine or olanzapine). We tested the association of 670 nuclear-encoded mitochondrial genes with weight change (%) using MAGMA software. Thirty of these genes showed nominally significant P-values (

Background Schizophrenia (SCZ) is a severe psychiatric disorder wherein the genetic risk factors are far from being fully understood. Multiple lines of evidence have suggested mitochondrial dysfunction in SCZ, but association of mitochondrial variants with SCZ has not been extensively investigated. Methods We conducted gene-based and gene-set analyses to test the hypothesis that variants in nuclear-encoded mitochondrial genes influence susceptibility to SCZ, using results from the most recent release of the Schizophrenia Psychiatric Genomics Consortium GWAS (35,476 cases and 46,839 controls). We applied the MAGMA statistical tool to three gene sets: oxidative phosphorylation genes, other nuclear-encoded mitochondrial genes, and genes involved in nucleus-mitochondria communication signaling. Results For gene-based analysis, a total of 1,187 mitochondrial genes were analyzed and 19 were significant after correction for multiple testing. We applied the method for an independent sample (iPSYCH study, 2,290 SCZ cases and 21,621 controls) and 12 genes had replication p-values Discussion Overall, our study showed evidence that mitochondria play a role in SCZ. Results from our study, combined with future availability of mitochondrial DNA data, will assist researchers to evaluate the role of mitochondrial genomics, potentially across all complex genetic disorders.