Browsing by Author "Jaworska, Natalia"
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Item Open Access A Preliminary Study of the Influence of Age of Onset and Childhood Trauma on Cortical Thickness in Major Depressive Disorder(2014-03-06) Jaworska, Natalia; MacMaster, Frank P.; Gaxiola, Ismael; Cortese, Filomeno; Goodyear, Bradley; Ramasubbu, RajamannarBackground. Major depressive disorder (MDD) neural underpinnings may differ based on onset age and childhood trauma. We assessed cortical thickness in patients who differed in age of MDD onset and examined trauma history influence. Methods. Adults with MDD () and controls (HC; ) underwent magnetic resonance imaging. Twenty patients had MDD onset 24 years of age (pediatric onset) and 16 had onset 25 years of age (adult onset). The MDD group was also subdivided into those with () and without () physical and/or sexual abuse as assessed by the Childhood Trauma Questionnaire (CTQ). Cortical thickness was analyzed with FreeSurfer software. Results. Thicker frontal pole and a tendency for thinner transverse temporal cortices existed in MDD. The former was driven by the pediatric onset group and abuse history (independently), particularly in the right frontal pole. Inverse correlations existed between CTQ scores and frontal pole cortex thickness. A similar inverse relation existed with left inferior and right superior parietal cortex thickness. The superior temporal cortex tended to be thinner in pediatric versus adult onset groups with childhood abuse. Conclusions. This preliminary work suggests neural differences between pediatric and adult MDD onset. Trauma history also contributes to cytoarchitectural modulation. Thickened frontal pole cortices as a compensatory mechanism in MDD warrant evaluation.Item Open Access A randomized, crossover comparison of ketamine and electroconvulsive therapy for treatment of major depressive episodes: a Canadian biomarker integration network in depression (CAN-BIND) study protocol(2020-06-02) Phillips, Jennifer L; Jaworska, Natalia; Kamler, Elizabeth; Bhat, Venkat; Blier, Jean; Foster, Jane A; Hassel, Stefanie; Ho, Keith; McMurray, Lisa; Milev, Roumen; Moazamigoudarzi, Zahra; Placenza, Franca M; Richard-Devantoy, Stéphane; Rotzinger, Susan; Turecki, Gustavo; Vazquez, Gustavo H; Kennedy, Sidney H; Blier, PierreAbstract Background Recent evidence underscores the utility of rapid-acting antidepressant interventions, such as ketamine, in alleviating symptoms of major depressive episodes (MDE). However, to date, there have been limited head-to-head comparisons of intravenous (IV) ketamine infusions with other antidepressant treatment strategies in large randomized trials. This study protocol describes an ongoing multi-centre, prospective, randomized, crossover, non-inferiority trial comparing acute treatment of individuals meeting diagnostic criteria for a major depressive episode (MDE) with ketamine and electroconvulsive therapy (ECT) on efficacy, speed of therapeutic effects, side effects, and health care resource utilization. A secondary aim is to compare a 6-month maintenance strategy for ketamine responders to standard of care ECT maintenance. Finally, through the measurement of clinical, cognitive, neuroimaging, and molecular markers we aim to establish predictors and moderators of treatment response as well as treatment-elicited effects on these outcomes. Methods Across four participating Canadian institutions, 240 patients with major depressive disorder or bipolar disorder experiencing a MDE are randomized (1:1) to a course of ECT or racemic IV ketamine (0.5 mg/kg) administered 3 times/week for 3 or 4 weeks. Non-responders (< 50% improvement in Montgomery-Åsberg Depression Rating Scale [MADRS] scores) crossover to receive the alternate treatment. Responders during the randomization or crossover phases then enter the 6-month maintenance phase during which time they receive clinical assessments at identical intervals regardless of treatment arm. ECT maintenance follows standard of care while ketamine maintenance involves: weekly infusions for 1 month, then bi-weekly infusions for 2 months, and finally monthly infusions for 3 months (returning to bi-weekly in case of relapse). The primary outcome measure is change in MADRS scores after randomized treatment as assessed by raters blind to treatment modality. Discussion This multi-centre study will help identify molecular, imaging, and clinical characteristics of patients with treatment-resistant and/or severe MDEs who would benefit most from either type of therapeutic strategy. In addition to informing clinical practice and influencing health care delivery, this trial will add to the robust platform and database of CAN-BIND studies for future research and biomarker discovery. Trial registration ClinicalTrials.gov identifier NCT03674671. Registered September 17, 2018.Item Open Access A scoping review of perceptions from healthcare professionals on antipsychotic prescribing practices in acute care settings(2022-10-21) Jaworska, Natalia; Moss, Stephana J.; Krewulak, Karla D.; Stelfox, Zara; Niven, Daniel J.; Ismail, Zahinoor; Burry, Lisa D.; Fiest, Kirsten M.Abstract Background Antipsychotic medications are frequently prescribed in acute care for clinical indications other than primary psychiatric disorders such as delirium. Unfortunately, they are commonly continued at hospital discharge and at follow-ups thereafter. The objective of this scoping review was to characterize antipsychotic medication prescribing practices, to describe healthcare professional perceptions on antipsychotic prescribing and deprescribing practices, and to report on antipsychotic deprescribing strategies within acute care. Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases from inception date to July 3, 2021 for published primary research studies reporting on antipsychotic medication prescribing and deprescribing practices, and perceptions on those practices within acute care. We included all study designs excluding protocols, editorials, opinion pieces, and systematic or scoping reviews. Two reviewers screened and abstracted data independently and in duplicate. The protocol was registered on Open Science Framework prior to data abstraction (10.17605/OSF.IO/W635Z). Results Of 4528 studies screened, we included 80 studies. Healthcare professionals across all acute care settings (intensive care, inpatient, emergency department) perceived prescribing haloperidol (n = 36/36, 100%) most frequently, while measured prescribing practices reported common quetiapine prescribing (n = 26/36, 76%). Indications for antipsychotic prescribing were delirium (n = 48/69, 70%) and agitation (n = 20/69, 29%). Quetiapine (n = 18/18, 100%) was most frequently prescribed at hospital discharge. Three studies reported in-hospital antipsychotic deprescribing strategies focused on pharmacist-driven deprescribing authority, handoff tools, and educational sessions. Conclusions Perceived antipsychotic prescribing practices differed from measured prescribing practices in acute care settings. Few in-hospital deprescribing strategies were described. Ongoing evaluation of antipsychotic deprescribing strategies are needed to evaluate their efficacy and risk.Item Open Access Clinical practice guideline recommendations for diagnosis and management of anxiety and depression in hospitalized adults with delirium: a systematic review(2023-09-25) Poulin, Therese G.; Jaworska, Natalia; Stelfox, Henry T.; Fiest, Kirsten M.; Moss, Stephana J.Abstract Background Delirium commonly occurs in hospitalized adults. Psychiatric disorders such as anxiety, depression, and post-traumatic stress disorder (PTSD) can co-occur with delirium, and can be recognized and managed by clinicians using recommendations found in methodological guiding statements called Clinical Practice Guidelines (CPGs). The specific aims of this review were to: [1] synthesize CPG recommendations for the diagnosis and management of anxiety, depression, and PTSD in adults with delirium in acute care; and [2] identify recent published literature in addition to those identified and reported in a 2017 review on delirium CPG recommendations and quality. Methods MEDLINE, EMBASE, CINAHL, PsycINFO, and 21 sites on the Canadian Agency for Drugs and Technologies listed in the Health Grey Matters Lite tool were searched from inception to February 12, 2021. Selected CPGs focused on delirium in acute care, were endorsed by an international scientific society or governmental organization, and contained at least one recommendation for the diagnosis or management of delirium. Two reviewers independently extracted data in duplicate and independently assessed CPG quality using the AGREE-II tool. Narrative synthesis of CPG recommendations was conducted. Results Title and abstract screening was completed on 7611 records. Full-text review was performed on 197 CPGs. The final review included 27 CPGs of which 7 (26%) provided recommendations for anxiety (4/7, 57%), depression (5/7, 71%), and PTSD (1/7, 14%) in delirium. Twenty CPGs provided recommendations for delirium only (e.g., assess patient regularly, avoid use of benzodiazepines). Recommendations for the diagnosis of psychiatric disorders with delirium included using evidence-based diagnostic criteria and standardized screening tools. Recommendations for the management of psychiatric disorders with delirium included pharmacological (e.g., anxiolytics, antidepressants) and non-pharmacological interventions (e.g., promoting patient orientation using clocks). Guideline quality varied: the lowest was Applicability (mean = 36%); the highest Clarity of Presentation (mean = 76%). Conclusions There are few available evidence-based CPGs to facilitate appropriate diagnosis and management of anxiety, depression, and PTSD in patients with delirium in acute care. Future guideline developers should incorporate evidence-based recommendations on the diagnosis and management of these psychiatric disorders in delirium. Systematic review registration Registration number: PROSPERO (CRD42021237056)Item Open Access Corrigendum to “Massive Acetaminophen Overdose Treated Successfully with N-Acetylcysteine, Fomepizole, and Hemodialysis”(2021-11-17) Chiu, Michael H.; Jaworska, Natalia; Li, Nicholas L.; Yarema, MarkItem Open Access Cortical thickness in youth with major depressive disorder(BioMed Central, 2014-03-20) Reynolds, Stephanie; Carrey, Normand; Jaworska, Natalia; Langevin, Lisa Marie; Yang, Xiao-Ru; MacMaster, Frank P.Item Open Access Facilitators and barriers to deprescribing antipsychotic medications in critically ill adult patients at transitions of care(2022-07-09) Jaworska, Natalia; Fiest, Kirsten; Niven, Daniel; Ismail, ZahinoorAntipsychotic medications are prescribed to critically ill adult patients in the intensive care unit (ICU) for clinical indications including delirium, agitation, and sleep disturbances. While there is some evidence for their use in managing agitation, antipsychotic medications have not convincingly shown efficacy for the management of delirium or sleep and are often continued at transitions of care in critically ill patients when they may no longer be necessary or appropriate. The current literature on antipsychotic minimization and deprescribing in critically ill patients is sparse lacking evaluation of underlying facilitators and barriers informing current antipsychotic prescribing practices that may be important in the development of effective minimization and deprescribing strategies. The studies presented in this thesis address knowledge gaps regarding antipsychotic prescribing and deprescribing practices among inpatient healthcare professionals who care for patients with and following critical illness. Based on a qualitative study with semi-structured interviews of 21 healthcare professionals, seven relevant domains from the Theoretical Domains Framework (TDF) contributing to antipsychotic prescribing and deprescribing were identified. A subsequent scoping review of the literature identified differences between healthcare professional perceived and actual prescribing practices, with few in-hospital deprescribing strategies available to guide practice. Thereafter, a nationwide modified Delphi consensus process informed by the qualitative study and scoping review identified consensus statements for antipsychotic minimization activities and antipsychotic deprescribing strategies for patients with and following critical illness. The results of these studies characterize and catalogue relevant priority facilitators and barriers to antipsychotic minimization and deprescribing in critically ill adult patients during their hospitalization to support best clinical prescribing practices.Item Open Access Impact of restricted family presence during the COVID-19 pandemic on critically ill patients, families, and critical care clinicians: a qualitative systematic review(2024-08-15) Krewulak, Karla D.; Jaworska, Natalia; Lee, Laurie; Louis, Julia S.; Dmitrieva, Olesya; Leia, Madison P.; Doig, Christopher; Niven, Daniel J.; Parhar, Ken K. S.; Rochwerg, Bram; West, Andrew; Stelfox, Henry T.; Leigh, Jeanna P.; Fiest, Kirsten M.Abstract Background We aimed to synthesize the qualitative evidence on the impacts of COVID-19-related restricted family presence policies from the perspective of patients, families, and healthcare professionals from neonatal (NICU), pediatric (PICU), or adult ICUs. Methods We searched MEDLINE, EMBASE, Cochrane Databases of Reviews and Clinical Trials, CINAHL, Scopus, PsycINFO, and Web of Science. Two researchers independently reviewed titles/abstracts and full-text articles for inclusion. Thematic analysis was completed following appraising article quality and assessing confidence in the individual review findings using standardized tools. Results We synthesized 54 findings from 184 studies, revealing the impacts of these policies in children and adults on: (1) Family integrated care and patient and family-centered care (e.g., disruption to breastfeeding/kangaroo care, dehumanizing of patients); (2) Patients, families, and healthcare professionals (e.g., negative mental health consequences, moral distress); (3) Support systems (e.g., loss of support from friends/families); and (4) Relationships (e.g., loss of essential bonding with infant, struggle to develop trust). Strategies to mitigate these impacts are reported. Conclusion This review highlights the multifaceted impacts of restricted visitation policies across distinct care settings and strategies to mitigate the harmful effects of these policies and guide the creation of compassionate family presence policies in future health crises. Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=290263 .Item Open Access Massive Acetaminophen Overdose Treated Successfully with N-Acetylcysteine, Fomepizole, and Hemodialysis(2021-07-12) Chiu, Michael H.; Jaworska, Natalia; Li, Nicholas L.; Yarema, MarkAcetaminophen overdose is one of the most common causes of acute hepatic failure in the developed world. There is strong evidence for N-acetylcysteine (NAC) as a safe and effective antidote for acetaminophen toxicity. However, there is less clarity in the management of massive overdoses (acute, single mg/kg with 4-hour equivalent concentrations ~6000 μmol/L) which are often associated with metabolic acidosis and multiorgan dysfunction. In such ingestions, the role of adjuvant treatments such as fomepizole and extracorporeal removal is unclear. We present a case of a 20-year-old female presenting with an acute ingestion of over 120 grams (1764.7 mg/kg) and an acetaminophen concentration of 5880 μmol/L who developed refractory shock, decreased level of consciousness, and metabolic acidosis requiring mechanical ventilation and vasopressor support. She was treated with gastric decontamination with activated charcoal, IV NAC, fomepizole, and hemodialysis. The patient had complete clearance of acetaminophen by 32 hours after presentation and normalization of her acid base and hemodynamic status without any organ failure. This case highlights the potential benefit of a triple strategy of NAC, fomepizole, and early hemodialysis in massive acetaminophen overdose, potentially sparing complications of prolonged intubation and ICU hospitalization.