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The author identifies one type of expressions found in Greek drama and Plato that are often regarded as line fillers and argues that they are illocutionary clauses, explicitly identifying specific speech acts. Often such clauses clearly identify unmarked questions or facilitate transitions.

Objectives: Koolen-de Vries Syndrome (KdVS) is a rare multisystem neurodevelopmental disorder. Ocular manifestations, including strabismus, ptosis, and hyperopia, have been reported in KdVS patients, but detailed clinical data are limited. This study aims to investigate the already known ocular malformations and their frequency while uncovering novel ocular associations., Methods: This was an international cross-sectional study. An anonymous questionnaire was sent to 237 KdVS patients registered in the GenIDA database. The questionnaire inquired about demographic data, ocular symptoms, findings reported by ophthalmologists, and ophthalmologic surgical interventions. The main outcome measures included ocular findings and surgical interventions., Results: Sixty-seven respondents worldwide completed the questionnaire, most (n = 53; 79%) under 18 years of age. Ophthalmologic abnormalities, noted in 79% of patients, included refractive errors (n = 35; 52.2%), strabismus (n = 23; 34.3%), amblyopia (n = 13; 19.5%), and eyelid ptosis (n = 9; 13.4%). Lacrimal disorders were present (n = 6; 9.0%), as were retinal findings (n = 7; 10.4%), including retinal hyperpigmentation or hypopigmentation (n = 4; 7.5%), Sjögren's pigment epithelial reticular dystrophy (n = 1; 1.5%), and macular chorioretinal coloboma (n = 1; 1.5%). Other manifestations included ocular surface disorders (n = 5; 7.5%), cataracts (n = 3; 4.5%), Brown syndrome (n = 1; 1.5%), glaucoma (n = 1; 1.5%), cerebral visual impairment (n = 1; 1.5%), and optic atrophy (n = 1; 1.5%). Fourteen patients (20.8%) had undergone surgical interventions., Conclusions: KdVS is associated with various ophthalmic findings, such as amblyopia, refractive errors, strabismus, and eyelid ptosis. We describe, for the first time, a high rate of nasolacrimal disorders and retinal abnormalities consisting mainly of pigmentary findings, including a rare case of Sjögren's pigment epithelial reticular dystrophy. A comprehensive ophthalmic evaluation is therefore recommended for all KdVS patients at initial diagnosis or at 4-6 months of age for diagnosed newborns., Competing Interests: Footnotes and Disclosure The authors have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Patient sexuality and intimacy comprise important dimensions of quality of life (QOL), making them essential topics for palliative care (PC) clinicians to address. Created with interprofessional input from PC, urology, gynecology, sexual health, oncology, psychiatry, psychology, nursing, and social work, this article offers 10 high-yield, evidence-based tips to better equip PC clinicians to address sexuality and intimacy for patients with serious illness. These tips highlight skills such as opening discussions, assessing concerns through a biopsychosocial model, and thinking through appropriate interventions to improve QOL.

A fundamental principle of clinical reasoning is that assessment precedes plan; clinicians are taught to base interventions on the presumed etiology of a presentation. A notable exception is in the domain of communication education, where training is focused heavily on tools and interventions, with minimal focus on the assessment that informs which tools or strategies to select with a given patient. The concept of formulation (foundational in psychotherapy education) provides a framework with which to address this gap, enhancing a clinician's ability to be more therapeutically effective with the communication tools at their disposal. Our formulation serves as the compass that guides our decisions around communication, allowing us to conceptualize communication as a therapeutic intervention and align our approach to communication with the broader philosophy of clinical reasoning. This manuscript explores the concept of formulation, the direct relevance and applicability to palliative care, sample cases to underscore the impact of this framework, and high-yield tips for use of formulation in general palliative care practice. Palliative care clinicians and IDTs can readily apply formulation in synergy with the communication tools they already possess, elevating their ability to address patients' psychological needs., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Addressing the psychiatric aspects of serious illness in palliative care (PC) is crucial to both care delivery and outcomes. Psychiatric comorbidities are common among patients with PC needs and can significantly impact their total burden of symptomatic distress, overall quality of life, functional independence, and healthcare utilization. Yet, these aspects of care are often deferred to mental health consultant teams in the context of busy PC services and often limited human resources. To provide comprehensive and person-centered care, PC clinicians must understand the interplay between medical conditions and psychiatric presentations within a biopsychosocial framework to respond empathically, efficiently, and effectively. This article is the first of a two-part series developed in collaboration with a group of psychiatric-palliative care specialists. This article explores ten common physical manifestations of psychiatric illness and treatment among patients facing serious illnesses. The second article will provide pragmatic tips PC clinicians should know about the psychiatric manifestations of nonpsychiatric serious illness and treatment. Combined, these two articles support a holistic approach that PC clinicians can use to prioritize and integrate both mental and emotional well-being throughout the continuum of serious illness.

Introduction: Little is known about the interdependence of psychological distress among patients with decompensated cirrhosis and their caregivers., Methods: In this cross-sectional study, we examined the interdependence of psychological distress (Hospital Anxiety and Depression Scale) among 127 patient-caregiver dyads using Actor-Partner Interdependence Modeling., Results: Among dyads, 26% had both partners reporting clinically significant anxiety and 18% reporting clinically significant depression. Caregiver anxiety significantly predicted patient depression (standardized β = 0.18, P = 0.03)., Discussion: Psychological distress was prevalent and interdependent among dyads. These results underscore the need to develop interventions to reduce psychological distress in both patients with decompensated cirrhosis and their caregivers., (Copyright © 2024 by The American College of Gastroenterology.)

Purpose: To determine the role of diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) in differentiating the inflammatory process and malignant lymphoma of the lacrimal gland., Methods: A retrospective analysis of all subjects who underwent lacrimal gland biopsy and magnetic resonance (MR) imaging with DWI sequences during a 10-year period at the Sheba Medical Center, Israel. The lacrimal glands' ADC values were documented bilaterally by blinded observers and correlated with the final histology verified diagnoses., Results: Twenty-eight patients were included, with 19 females (68%) with a mean ± SD age of 48.1 ± 25.7 years. The right orbit was involved in 14 cases (50%) and the left in 13 (46%); one patient (4%) had bilateral involvement. Seventeen cases (61%) had a final diagnosis of idiopathic inflammation or dacryoadenitis, and six cases (21%) were diagnosed with lymphoma. Additional diagnoses included pleomorphic adenoma in 3 (11%), adenoid cystic carcinoma, and solitary fibrous tumor. Lower mean ADC values were observed in the lymphoma versus inflammatory group (1.03 × 10-3 Vs. 1.45 × 10-3, P = 0.02)., Conclusion: Restricted diffusion on MR imaging can serve as a diagnostic tool in the differentiation between inflammatory processes of the lacrimal gland and lymphoma., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Psychological symptoms are notably prevalent in palliative care (PC) settings, significantly impacting quality of life for patients and their families. Given the inherent multidimensionality of suffering in PC, addressing these psychological aspects is essential. This article aims to introduce and integrate discrete concepts from various schools of psychotherapy, which are directly applicable to PC practices, thereby providing clinicians with a rich toolkit to manage psychological distress. The article focuses on 10 key concepts from different psychotherapeutic traditions. They are a small sample from the vast and deep pool of wisdom contained in psychotherapeutic theory, and they were selected due to their direct applicability to PC practice. Adopting psychotherapeutic principles, along with leveraging the interdisciplinary wisdom inherent in PC practice, enhances our therapeutic relationships in PC and empowers patients to navigate their illness with greater resilience and adaptive coping.

Objectives: Approximately 5.5% of the population live with serious mental illnesses (SMI). Older adults with SMI experience a high burden of serious medical illnesses and disparities in advance care planning, symptom management, and caregiver support. The objectives of this study are to explore interdisciplinary clinician perspectives on the palliative care needs of older adults with SMI and serious medical illnesses., Design, Setting, and Participants: This qualitative study utilized thematic analysis of semi-structured interviews of interdisciplinary clinicians practicing palliative care, geriatrics, or geriatric/consultation-liaison psychiatry at four hospitals within an urban health system., Measurements: Themes related to care of older adults with serious mental illness and serious medical illness with respect to clinician experiences, challenges in care, and opportunities to improve care., Results: The authors interviewed 45 clinicians. Major themes identified were: (1) Current paradigms of palliative care do not meet the needs of patients with SMI; (2) Clinicians are motivated to care for this population but require more training and interdisciplinary practice; (3) There is a need for structural integration of psychiatric and palliative care services., Conclusions: The study underscores the inadequacy of current palliative care models in meeting the unique needs of older adults with SMI. Models of integrated psychiatric and serious illness care and enhanced training are needed to improve the delivery of palliative care. Integrated care models and workforce development at the interface of serious illness care and psychiatric have the potential to improve outcomes for this vulnerable population., (Copyright © 2024 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: As the concept of a clinician-educator (CE) evolves and the multiple competencies of the role become better defined, there seems to be a growing need for targeted training for clinicians pursuing a career in medical education. This study aims to describe the current state of CE tracks in adult neurology residency programs and to identify the barriers to implementation, potential solutions, and program goals and outcomes., Methods: We characterized CE tracks using 2 methods. First, we reviewed the websites of all US adult neurology residency programs to determine the availability of a CE track and its characteristics. Second, we administered a 20-item survey to program directors (PDs) of all US neurology residency programs, with questions focused on track availability, characteristics, perceived benefits of CE tracks on resident career development, barriers to implementation, and ideas for national initiatives that may facilitate track development or improvement., Results: Fifty-eight of 177 (33%) PDs responded to the survey. Combining the results of the website reviews and surveys, we found that 34 of 179 (19%) programs have CE tracks. Seventy percent of PDs felt that CE tracks are very impactful or impactful for participating residents' careers, a perception more common among PDs of programs with tracks. The greatest perceived benefit was in preparing residents for educational leadership roles. The greatest barriers to implementation were a lack of teaching faculty, a lack of resources, and limited resident time. The highest ranked idea for a national initiative that can facilitate track development was live and recorded lectures on medical education topics., Discussion: Although most PDs surveyed agreed that CE tracks are impactful for preparing residents as teachers and education leaders, such tracks are available in only 19% of adult neurology residency programs. PDs report that the benefits of CE tracks extend beyond the participants, with implications for the health of the residency program and the neurology department. While some programs have significant barriers to implementation, national initiatives may help reduce the resource burden on individual programs. Future areas of study include assessing the development and outcomes of national initiatives and analyzing the outcomes associated with CE tracks., Competing Interests: N. Jacoby served on an advisory board for Argenx in 2023. The other authors report no relevant disclosures. Go to Neurology.org/NE for full disclosures., (© 2024 American Academy of Neurology.)

Objective: To investigate the incidence of intraoperative floppy iris syndrome (IFIS) in patients with pseudoexfoliation syndrome (PXF) and analyze preoperative ocular predicting factors., Design: A retrospective case-control study METHODS: The study included 224 eyes with PXF and 287 control eyes without PXF. One eye per patient, who underwent cataract surgery at the Wolfson Medical Center between January 2020 to December 2021, was included. Medical records of the patients were reviewed. Data collected included demographic characteristics, medical history, preoperative comprehensive ophthalmic examination, biometry, surgical procedure details, and IFIS occurrence. The association of IFIS with preoperative ocular parameters was analyzed through both univariant and multivariant analyses., Results: Patients with PXF were older and had a higher prevalence of glaucoma (77.6 ± 6.4 years vs 74.2±7.6 years; p < 0.001, and 20.1 % vs 9.8 %, p < 0.001, respectively). Prevalence of α-blockers treatment was similar in both groups. IFIS rate among the PXF group was 12.5% (n = 28) compared to 7.3% (n = 21) in the control group (p < 0.05). When omitting patients exposed to α-blockers, the PXF group exhibited a significantly higher IFIS rate (9.9% vs 4.8%; p < 0.05). Pupil dilation diameter was significantly lower among PXF patients (5.8 ± 1.1 mm vs 6.9 ± 0.99 mm; p < 0.001). Biometric evaluation revealed significant differences in anterior segment depth (ACD) and lens thickness (LT). Multivariate analysis indicated that PXF and decreased mydriatic pupil size remained significant predictors of IFIS., Conclusion: This study establishes an association between PXF and an increased risk of IFIS during cataract surgery, independent of α-blockers treatment., (Copyright © 2024 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: Behavioral health disorders are common among patients and caregivers in the hospice setting. Yet, limited data exist regarding what hospice providers perceive as the most common and challenging behavioral health disorders they encounter and how they manage these issues in practice., Objective: To characterize the perspectives of hospice medical directors (HMDs) on addressing the behavioral health challenges when caring for patients enrolled in home hospice care and their family caregivers., Methods: Semistructured interviews with seventeen certified HMDs were conducted. Data were analyzed using thematic analysis., Results: Many HMDs agreed that delivering high-quality behavioral health care is a tenet for good end-of-life (EoL) care. HMDs shared that depression and anxiety were the most common behavioral health challenges they encountered, while among caregivers, substance use disorder was the most challenging. Participants mentioned that nurses and social workers played a vital role in detecting and managing behavioral health problems. HMDs also stated that providing additional training for frontline staff and incorporating behavioral health experts are potential solutions to help address current challenges., Conclusion: HMDs emphasized the importance of addressing behavioral health challenges among patients and caregivers to provide effective end-of-life care. Future studies should examine the viewpoints of additional key stakeholder groups (e.g., hospice interdisciplinary team members, family caregivers) and confirm them in quantitative studies. Designing and implementing evidence-based assessments and interventions to improve behavioral health care by addressing anxiety, depression, and caregiver substance use disorders is essential to improving care and care outcomes in the hospice setting., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: To compare retention times of various ophthalmic viscosurgical devices (OVDs) and soft-shell combinations., Methods: Experimental study. Eighteen rabbit eyes were divided into six groups of three eyes, based on OVDs tested. A: Endocoat, B: HealonPro, C: Viscoat, D: Provisc, E: Endocoat and HealonPro and F: Viscoat and Provisc. OVDs were stained with 10% fluorescein dye before being injected into the anterior chamber. Phacoemulsification, using fixed parameters, was performed. If OVD persisted after 60 s, a standardised irrigation and aspiration technique replaced phacoemulsification. The time until central and complete clearance of the OVD were video-recorded and measured., Results: Mean central retention times (CRT) were found to be: HealonPro-5.33 ± 2.56 s, Provisc-3.33 ± 1.11 s, Endocoat-75.0 ± 3.26 s, Viscoat-62.33 ± 5.19 s, combining HealonPro with Endocoat-22.67 ± 4.75 s and Provisc with Viscoat-11.0 ± 0.82 s. The mean total retention time (TRT) was: Endocoat-80.0 ± 8.17 s, Viscoat-81.67 ± 2.09 s, HealonPro with Endocoat-81.33 ± 3.35 s, and Provisc with Viscoat-71.0 ± 2.94 s. For HealonPro and Provisc, CRT and TRT remained identical across all trials., Conclusions: Retention times varied, with cohesive OVDs exhibiting shorter durations than dispersive OVDs. Among dispersive OVDs, TRTs were comparable; however, Endocoat displayed an extended CRT. In soft shell trials, the combination of HealonPro and Endocoat exhibited prolonged CRT and TRT, suggesting enhanced corneal protection., (© 2024 The Author(s). Clinical & Experimental Ophthalmology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Ophthalmologists.)

Background: Surrogate Decision-Makers (surrogates) are frequently employed in decision-making for critically ill adults. There are insufficient data considering the surrogate experience, stress, and potential for mitigation., Methods: An anonymous online survey queried (1) medical situation (2) total stress (3) demographics (4) potential factors, including sources of information about patient wishes, external sources of support or competing stressors, and their interactions with the medical team through the experience., Results: 108 respondents were included; 91 completed all items. Most respondents ranked their experience as a surrogate as one of the most stressful experiences of their lives; this was associated with whether it was an end-of-life decision ( P = .003), Respondent Religion ( P = .015), or religious or spiritual beliefs ( P = .024), and having their own health problems (P = .008). On individual Likert responses, surrogates reported significant stress mitigation when they felt they had been helpful ( P < .001), knew the patient's wishes ( P = .0011), specifically discussed patient wishes ( P < .001), or patient's wishes were documented ( P < .001). Items about surrogate-team interaction also met significance, including the physician being communicative and available (P < .001), respectful ( P = .007), honest ( P < .001), and validating ( P = .001)., Conclusions: Surrogate stress is an evolving area for research. Significant factors included relationship with the medical team, making this an important area for HPM to play a key role in mitigating surrogate stress., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Fatigue is a multifactorial symptom that is commonly faced by patients with cancer, chronic disease, and other serious illnesses. Fatigue causes suffering across biopsychosocial domains and affects patients and their loved ones. In this article, a consortium of professionals across cancer care, physical therapy, exercise, pharmacy, psychiatry, and palliative medicine offers tips and insights on evaluating, categorizing, and addressing fatigue in the setting of serious illness. The comprehensive approach to managing fatigue underscores the importance of collaborative efforts characteristic of interdisciplinary palliative care. Prioritizing screening, diagnosing, and treating fatigue is crucial for enhancing patients' and families' overall quality of life.

Background: Palliative care (PC) clinicians provide mental healthcare to individuals with serious illnesses. Despite this, there is limited knowledge regarding their mental health training opportunities. Methods: To identify predictors of satisfaction with mental health training opportunities and assess the relationship between training opportunities and clinician comfort in managing mental health comorbidities, we conducted a secondary analysis of a nationwide survey involving 708 PC clinicians. Results: Satisfaction with mental health training was moderate (M = 2.75/5, SD = .915). Access to lectures/webinars was the most common training opportunity (54%). Significant predictors of satisfaction with training included access to lectures/webinars (β = .328, P <.001) and case discussions (β = .231, P = .007). Academic practice settings and satisfactory mental health referrals were associated with a greater number of different training opportunities. Clinicians in academic settings had higher odds of accessing various training opportunities, such as lectures/webinars (OR = 2.58, P <.001) and longitudinal training pathways (OR = 4.51, P <.001). A moderate, positive correlation was found between training satisfaction and comfort in managing mental health comorbidities (r = .30, P <.001). Discussion: This study is among the first to elucidate factors influencing PC clinicians' satisfaction with mental health training. Low-resource training opportunities, such as webinars and lectures, significantly predict satisfaction, suggesting the potential of these scalable solutions to enhance training. The findings underscore the importance of expanding evidence-based mental health training for PC clinicians to improve patient care., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: Home health aides and attendants (HHAs) provide essential care to older adults and those with chronic conditions in the home. However, some HHAs struggle with poor mood and stress, which may have been exacerbated by the COVID-19 pandemic., Objective: To elicit HHAs' perspectives toward mental health and well-being, including how their job influences both and how to better support the workforce in the future., Design, Setting, and Participants: For this qualitative study, focus groups and interviews with HHAs were facilitated in English and Spanish from August 17, 2022, to February 9, 2023, in partnership with the 1199SEIU Training and Employment Fund, a benefit fund of the 1199SEIU United Healthcare Workers East and the largest health care union in the US. Included were HHAs at risk for poor mental health and well-being, which were defined as having at least mild or more symptoms on either the 8-item Personal Health Questionnaire depression scale, the 4-item Cohen Perceived Stress Scale, or the University of California, Los Angeles Loneliness Scale., Exposure: Mental health and well-being of HHAs., Main Outcomes and Measures: Focus groups and interviews were audio recorded, professionally transcribed, and translated. A thematic analysis was performed that was informed by Pender's Health Promotion Model and the National Institute for Occupational Safety and Health's Total Worker Health model., Results: A total of 28 HHAs from 14 different agencies participated (mean [SD] age, 54.3 [10.8] years; 26 female [93%]). Seventeen participants (61%) spoke Spanish at home. Five key themes emerged: (1) HHAs' attitudes toward mental health and well-being were influenced by a variety of personal and cultural factors; (2) HHAs' relationships with their patients impacted their mood in both positive and negative ways; (3) structural and organizational aspects of the job, alongside the COVID-19 pandemic, impacted HHAs' mood and stress levels; (4) HHAs used a variety of strategies to cope with their emotions; and (5) HHAs were eager for interventions that can improve their mood, particularly those that bring them closer to their colleagues., Conclusions and Relevance: These findings suggest that HHAs' mental health and well-being may be influenced by both personal and occupational factors. Interventions and policies to better support their emotional well-being on the job are warranted.

Mental health issues are widespread and significant among individuals with serious illness. Among patients receiving palliative care (PC), psychiatric comorbidities are common and impact patient quality of life. Despite their prevalence, PC clinicians face challenges in effectively addressing the intricate relationship between medical and psychiatric disorders due to their complex, intertwined and bidirectionally influential nature. This article, created collaboratively with a team of psychiatric-palliative care experts, is the second in a two-part series examining the bidirectional relationship between medical and psychiatric illness in PC. This article explores 10 prevalent psychiatric manifestations associated with severe illness and its treatment. Building upon the first article, which focused on 10 common physical manifestations of psychiatric illness among patients receiving PC, these two articles advocate for an integrated approach to PC that prioritizes mental and emotional wellbeing across the continuum of serious illness.

Background: Behavioral health (BH) comorbidities in hospice patients are widespread and impact important outcomes, including symptom burden, quality of life, and caregiver wellbeing. However, evidence-based BH interventions tailored for the hospice setting remain understudied., Methods: We conducted a scoping review with the objective of mapping studies of interventions for BH comorbidities in the hospice setting. We included empirical studies among hospice patients of interventions with BH outcomes. We abstracted data on study design, intervention type, and patient characteristics., Results: Our search generated 7,672 unique results, of which 37 were ultimately included in our analysis. Studies represented 16 regions, with the United Kingdom (n=13) most represented. The most frequent intervention type was complementary and alternative interventions (n=13), followed by psychotherapeutic interventions (n=12). Most of the studies were either pilot or feasibility investigations. Fifteen studies employed a randomized controlled trial design. The most frequently utilized measurement tools for BH outcomes included the Hospital Anxiety and Depression Scale and the Edmonton Symptom Assessment Scale. Seventeen studies demonstrated statistically significant results in a BH outcome measure. BH conditions prevalent among hospice patients that were the focus of intervention efforts included depression symptoms, anxiety symptoms, and general psychological distress. No study focused on trauma-related disorders or substance use disorders., Conclusions: This scoping review reveals a concerning gap in research regarding evidence-based BH interventions in hospice settings, especially in the U.S. Despite extensive utilization of hospice care services and the high prevalence of BH conditions among hospice patients, randomized controlled trials focused on improving BH outcomes remain scant. The current BH practices, like the widespread use of benzodiazepines and antipsychotics, may not be rooted in robust evidence, underscoring an urgent need for investment in hospice research infrastructure and tailored clinical trials to test behavioral approaches to mitigate mental health outcomes at the end of life.

Objectives: Present analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH)., Design: Review and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH-Serious Illness Care (SIC) model domains., Setting and Participants: The 155 PACE organizations operating in 32 states and the District of Columbia., Methods: A multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals., Results: According to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions., Conclusions and Implications: Regarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities., Competing Interests: Disclosure The authors declare no conflicts of interest., (Published by Elsevier Inc.)

Purpose of Review: Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry., Recent Findings: PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Unmet mental health needs are associated with a range of negative consequences for individuals at the end of life. Despite the high prevalence of mental health needs among individuals enrolled in hospice, there is a paucity of data describing mental health service integration in hospices in the United States. Objectives: 1. To identify patterns of mental health service integration in hospice organizations nationally; 2. To characterize gaps in mental health service delivery in hospice settings as perceived by hospice clinicians and medical leadership. Methods: A cross-sectional survey querying hospice clinicians and hospice medical leadership nationally. Results: A total of 279 surveys were included. Clinically significant mental health symptoms were common among hospice patients; the most frequently encountered symptom groups were depression, anxiety, dementia, and delirium. A minority of hospices maintained relationships with psychiatrists (23%, n = 60), psychiatric nurse practitioners (22%, n = 56), or psychologists (19%, n = 49). Only 38% (n = 99) of respondents were satisfied with their patients' access to services and only 45% (n = 118) were satisfied with the quality of these services. Common limitations to providing adequate mental health services included lack of specialist services, short length of stay for patients, and reluctance of patients to engage in these services. Conclusions: Significant mental health symptoms are common among hospice patients, and hospice organizations perceive these needs are not being met. Further research is needed to better understand the current treatment landscape and design interventions to address these needs., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: To evaluate residents' perceptions and attitudes toward the various aspects of a comprehensive ophthalmic examination, and to determine if these factors correlate with their choices for fellowship and future career plans., Methods: This is a cross-sectional study. A questionnaire on the perception of the ophthalmic exam was sent via SurveyMonkey to ophthalmology residents throughout Israel. Eighty of them (one-half of all ophthalmology residents in 2019) completed it. The first part related to how they perceived each component of the ophthalmic evaluation. The second part related to their future fellowship plans. The Chi-squared test was used to compare categorical variables and Student's t -test and One-way ANOVA were used to compare continuous variables. Multivariate logistic regression analysis was applied as needed to detect interactions between variables and to exclude confounder effects., Results: Slit-lamp examination of the anterior and posterior segments ranked as the most likeable aspects, whereas gonioscopy, ocular motility examination and visual acuity assessment were least likeable. Anterior segment and retina subspecialties were the ones most sought after. Forty-nine respondents (61.3%) noted a direct correlation between their preferred parts of comprehensive ophthalmic evaluations and their choice of subspecialty. Perceptions of selected components of those evaluations were significantly associated with responders' intentions to pursue anterior segment, retina, or oculoplastic fellowships ( P <0.05)., Conclusion: Perspectives of residents toward the ophthalmic examination, and most specifically its individual components, play an important role in their choice of subspecialty training., Competing Interests: Conflicts of Interest: Leshno A, None; Shalev D, None; Landau Prat D, None., (International Journal of Ophthalmology Press.)

Palliative care clinicians enhance the illness experiences of patients and their families through building therapeutic relationships. Many psychological concepts underlie a clinician's approach to a specific patient. Through high-yield tips, this article highlights ten selected psychological elements that palliative care clinicians often use to support patients. As we all (both clinicians and patients) bring our own histories and unique biographies to the work of palliative care, a more explicit focus on the psychological aspects of this work can enhance our own experience and efficacy as providers. With a thoughtful focus on the psychological aspects of how we engage with patients, palliative care clinicians can offer a more meaningful therapeutic encounter.

Objectives: Older adults with psychiatric illnesses often have medical comorbidities that require symptom management and impact prognosis. Geriatric psychiatrists are uniquely positioned to meet the palliative care needs of such patients. This study aims to characterize palliative care needs of geriatric psychiatry patients and utilization of primary palliative care skills and subspecialty referral among geriatric psychiatrists., Methods: National, cross-sectional survey study of geriatrics psychiatrists in the United States., Results: Respondents (n = 397) reported high palliative care needs among their patients (46-73% of patients). Respondents reported using all domains of palliative care in their clinical practice with varied comfort. In multivariate modeling, only frequency of skill use predicted comfort with skills. Respondents identified that a third of patients would benefit from referral to specialty palliative care., Conclusions: Geriatric psychiatrists identify high palliative care needs in their patients. They meet these needs by utilizing primary palliative care skills and when available referral to subspecialty palliative care., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Context: Mental health comorbidities among individuals with serious illness are prevalent and negatively impact outcomes. Mental healthcare is a core domain of palliative care, but little is known about the experiences of palliative care clinicians delivering such care., Objectives: This national survey aimed to characterize the frequency with which palliative care providers encounter and manage common psychiatric comorbidities, evaluate the degree of mental health integration in their practice settings, and prioritize strategies to meet the mental health needs of palliative care patients., Methods: A e-survey distributed to the American Academy of Hospice and Palliative Medicine membership., Results: Seven hundred eight palliative care clinicians (predominantly physicians) were included in the analysis. Mood, anxiety, and neurocognitive disorders were frequently encountered comorbidities that many respondents felt comfortable managing. Respondents felt less comfortable with other psychiatric comorbidities. Eighty percent of respondents noted that patients' mental health status impacted their comfort delivering general palliative care at least some of the time. Mental health screening tool use varied and access to specialist referral or to integrated psychiatrists/psychologists was low. Respondents were unsatisfied with mental health training opportunities., Conclusion: Palliative care clinicians play a crucial role in addressing mental health comorbidities, but gaps exist in care. Integrated mental health care models, streamlined referral systems, and increased training opportunities can improve mental healthcare for patients with serious illness., Competing Interests: Disclosures and Acknowledgments This work was supported by the National Institute on Aging [grant number T32AG049666] and by the Weill Cornell JumpStart Research Program. The authors declare no conflicts of interest., (Copyright © 2023 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Context: Psychological and psychiatric care is a core domain of palliative care. Despite a high burden of mental health comorbidity among individuals with serious illness, the Accreditation Council of Graduate Medical Education gives little guidance about training hospice and palliative medicine (HPM) fellows in this domain of care. Currently, there is a lack of empiric data on HPM physician fellowship training in mental health topics., Objectives: To characterize HPM physician fellowship training practices in the psychological and psychiatric aspects of palliative care., Methods: A cross-sectional survey study querying HPM fellowship training directors nationally., Results: A total of 95 programs participated (51% response rate). A total of 98% programs offered didactics on mental health topics. Topics universally deemed as important by program directors were commonly taught, but there was variability in both the perceived importance and the didactic coverage of several topics. Only 15% of programs offered core rotations in psychiatry. Most programs offered psychiatry electives, but such electives were only rarely utilized by fellows. Interdisciplinary team (IDT) rounds infrequently included doctoral mental health clinicians., Conclusions: Beyond a few commonly identified and taught key topics, there is variability in clinical and didactic exposure to mental health training among HPM fellowships. Standardizing key learning objectives and guiding educators in how to achieve these objectives could improve the preparedness of the physician workforce in HPM to meet the mental health needs of patients with serious illness., (Copyright © 2023 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The Program of All-inclusive Care for the Elderly (PACE) is a community-based care model that delivers collaborative care via an interdisciplinary team to meet the medical and social needs of older adults eligible for nursing home placement. Fifty-nine percent of PACE participants are reported to have at least one psychiatric disorder. PACE organizations (POs) function through an interdisciplinary model of care, but a behavioral health (BH) provider is not a mandated role on the interdisciplinary team. Published literature regarding how POs integrate and provide BH services is limited; however, the National PACE Association (NPA) and select POs have made significant contributions to behavioral health integration (BHI) efforts in PACE., Methods: PubMED, EMBASE, and PsycINFO were searched for articles published between January 2000 and June 2022; hand-searching was also conducted. Research articles and items involving BH components or programming in POs were included. Evidence of BH programming and initiatives at the organization and national level was summarized., Results: This review reported on nine primary items addressing BH in POs from 2004 to 2022. It found evidence of successful BH initiatives in PACE and identified a gap of published information given an evident need for BH services in the PACE participant population. Findings also indicate the NPA works to advance BH integration in POs with a dedicated workgroup that has produced the NPA BH Toolkit, BH training webinar series, and a site coaching program., Conclusions: In the absence of PACE-specific BH delivery guidelines and guidance from the federal or state level for PACE programs, BH service inclusion has been developed unevenly across POs. Assessing the landscape of BH inclusion across POs is a step toward evidence-based and standardized inclusion of BH within the all-inclusive care model., (© 2023 The American Geriatrics Society.)

Background: Although psychiatric comorbidities are common among individuals at end of life, their impact on outcomes is poorly understood., Methods: We conducted a systematic literature review of six databases following preferred reporting items for systematic reviews and meta-analyses guidelines and aimed at assessing the relationship between psychiatric comorbidities and outcomes in palliative and end-of-life care. Six databases were included in our search. This review is registered on PROSPERO (CRD42022335922)., Results: Our search generated 7472 unique records. Eighty-eight full texts were reviewed for eligibility and 43 studies were included in the review. Clinically, psychiatric comorbidity was associated with poor quality of life, increased physical symptom burden, and low function. The impact of psychiatric comorbidity on health utilization varied, though many studies suggested that psychiatric comorbidity increased utilization of palliative care services. Quality of evidence was limited by lack of consistent approach to confounding variables as well as heterogeneity of the included studies., Conclusion: Psychiatric comorbidity is associated with significant differences in care utilization and clinical outcome among patients at end of life. In particular, patients with psychiatric comorbidity and serious illness are at high risk of poor quality of life and high symptom burden. Our finding that psychiatric comorbidity is associated with increased utilization of palliative care likely reflects the complexity and clinical needs of patients with serious illness and mental health needs. These data suggest that greater integration of mental health and palliative care services may enhance quality-of-life among patients at end of life., (Copyright © 2023 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Psychiatric comorbidities are common among patients approaching the end of life, often necessitating the involvement of consultation-liaison psychiatrists. We present the case of a patient with advanced metastatic prostate cancer and a complicated hospital course who made suicidal remarks and requested a hastened death. This common and challenging clinical scenario requires a multidisciplinary approach. In this article, experts in consultation psychiatry, palliative care, and psycho-oncology describe helpful diagnostic and therapeutic strategies for such cases. The key learning points are the differential diagnoses in end-of-life patients endorsing suicidal ideation, the psychiatric management of oncological and palliative care patients, the implementation of a safe discharge plan, and the role of the consultation-liaison psychiatrist in hospice care., (Copyright © 2022 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: This article describes the development, implementation, and piloting of an e-learning neuropsychiatry curriculum for psychiatry residents. The primary outcome of interest was feasibility. Secondary outcomes were interest and confidence caring for patients with neuropsychiatric disorders, and knowledge about neuropsychiatry., Methods: The curriculum was designed utilizing Kern's six-step framework. A ten-module, interactive, primarily vignette-based e-learning curriculum was developed focusing on the neurocognitive exam and neurocognitive disorders. The curriculum was piloted in two psychiatry residencies in Brooklyn, NY (n = 80 residents). The curriculum was evaluated using a survey adapted from the General Practitioner Attitudes and Confidence Scale for Dementia (GPACS-D) and a 24-item neuropsychiatry examination prior to the intervention and 1-month post-intervention. Qualitative feedback was acquired through four open-ended items in the post-curriculum survey, which underwent a thematic analysis., Results: Seventy-eight of eighty residents completed the full curriculum. Three of nine attitude items demonstrated significant differences, with residents feeling less frustrated managing dementia (pre-mean = 2.32, post = 2.68, t(2,59) = 2.00, p = 0.004), less frustrated due to not knowing how to effectively treat dementia (pre-mean = 2.05, post = 2.95, t(2,59) = 6.27, p = 0.000), and demonstrating less interest in pursuing further training in neuropsychiatry (pre-mean = 1.95, post = 2.18, t(2,59) = 1.70, p = 0.047), though still overall showing interest. There was no change in confidence ratings. There was a small but significant improvement in total number of knowledge items answered correctly., Conclusions: This study demonstrated the feasibility of implementing an e-learning neuropsychiatry curriculum. It also demonstrated an improvement in resident responses to two attitude items and an increase in neuropsychiatry knowledge., (© 2023. The Author(s), under exclusive licence to American Association of Chairs of Departments of Psychiatry, American Association of Directors of Psychiatric Residency Training, Association for Academic Psychiatry and Association of Directors of Medical Student Education in Psychiatry.)

Opinion Statement: Patients with hematologic malignancies and their families are among the most distressed of all those with cancer. Despite high palliative care-related needs, the integration of palliative care in hematology is underdeveloped. The evidence is clear that the way forward includes standard-of-care PC integration into routine hematologic malignancy care to improve patient and caregiver outcomes. As the PC needs for patients with blood cancer vary significantly by disease, a disease-specific PC integration strategy is needed, allowing for serious illness care interventions to be individualized to the specific needs of each patient and situation., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Machine learning algorithms have shown groundbreaking results in neuroimaging. The authors herein evaluated the performance of a newly developed convolutional neural network (CNN) to detect and analyze intracranial aneurysms (IAs) on CTA., Methods: Consecutive patients with CTA studies between January 2015 and July 2021 at a single center were identified. The ground truth determination of cerebral aneurysm presence or absence was made from the neuroradiology report. The primary outcome was the performance of the CNN in detecting IAs in an external validation set, measured using area under the receiver operating characteristic curve statistics. Secondary outcomes included accuracy for location and size measurement., Results: The independent validation imaging data set consisted of 400 patients with CTA studies, median age 40 years (IQR 34 years) and 141 (35.3%) of whom were male; 193 patients (48.3%) had a diagnosis of IA on neuroradiologist evaluation. The median maximum IA diameter was 3.7 mm (IQR 2.5 mm). In the independent validation imaging data set, the CNN performed well with 93.8% sensitivity (95% CI 0.87-0.98), 94.2% specificity (95% CI 0.90-0.97), and a positive predictive value of 88.2% (95% CI 0.80-0.94) in the subgroup with an IA diameter ≥ 4 mm., Conclusions: The described Viz.ai Aneurysm CNN performed well in identifying the presence or absence of IAs in an independent validation imaging set. Further studies are necessary to investigate the impact of the software on detection rates in a real-world setting.

Background: Depression is common in the palliative care setting and impacts outcomes. Operationalized screening is unusual in palliative care., Local Problem: Lack of operationalized depression screening at two ambulatory palliative care sites., Methods: A fellow-driven quality improvement initiative to implement operationalized depression screening using the patient health questionnaire-2 (PHQ-2). The primary measure was rate of EMR-documented depression screening. Secondary measures were clinician perspectives on the feasibility and acceptability of implementing the PHQ-2., Intervention: The intervention is a clinic-wide implementation of PHQ-2 screening supported by note templates, brief clinician training, referral resources for clinicians, and opportunities for indirect psychiatric consultation., Results: Operationalized depression screening rates increased from 2% to 38%. All clinicians felt incorporation of depression screening was useful and feasible., Conclusions: Operationalized depression screening is feasible in ambulatory palliative care workflow, though optimization through having screening be completed prior to clinician visit might improve uptake., Competing Interests: Disclosures and Acknowledgments None of the authors have conflicts of interest to declare., (Copyright © 2022 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)