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As self-injurious thoughts and behaviors (SITB) remain a pressing public health concern, research continues to focus on risk factors, such as posttraumatic stress disorder (PTSD). Network analysis provides a novel approach to examining the PTSD-SITB relationship. This study utilized the network approach to elucidate how individual PTSD symptoms may drive and maintain SITB.
We estimated cross-sectional networks in two samples of trauma-exposed adults (Sample 1: N = 349 adults; Sample 2: N = 1307 Veterans) to identify PTSD symptoms that may act as bridges to SITB. Additionally, we conducted a cross-lagged panel network in Sample 2 to further clarify the temporal relationship between PTSD symptoms and SITB during a 2-year follow-up. Finally, in both samples, we conducted logistic regressions to examine the utility of PTSD symptoms in prospectively predicting SITB, over a 15-day period (Sample 1) and over a 2-year period (Sample 2), allowing us to examine both short- and long-term prediction.
Two PTSD symptoms (i.e. negative beliefs and risky behaviors) emerged as highly influential on SITB in both cross-sectional networks. In the cross-lagged panel network, distorted blame emerged as highly influential on SITB over time. Finally, risky behaviors, unwanted memories, and psychological distress served as the strongest predictors of SITB across the two samples.
Overall, our results suggest that treatments targeting negative beliefs and risky behaviors may prevent SITB in community and Veteran populations, whereas treatments targeting distorted blame and unwanted memories may help reduce SITB for individuals with a history of combat trauma.
Vascular cognitive impairment (VCI) post-stroke is frequent but may go undetected, which highlights the need to better screen cognitive functioning following a stroke.
We examined the clinical utility of the Montreal Cognitive Assessment (MoCA) in detecting cognitive impairment against a gold-standard neuropsychological battery.
We assessed cognitive status with a comprehensive battery of neuropsychological tests in 161 individuals who were at least 3-months post-stroke. We used receiver operating characteristic (ROC) curves to identify two cut points for the MoCA to maximize sensitivity and specificity at a minimum 90% threshold. We examined the utility of the Symbol Digit Modalities Test, a processing speed measure, to determine whether this additional metric would improve classification relative to the MoCA total score alone.
Using two cut points, 27% of participants scored ≤ 23 and were classified as high probability of cognitive impairment (sensitivity 92%), and 24% of participants scored ≥ 28 and were classified as low probability of cognitive impairment (specificity 91%). The remaining 48% of participants scored from 24 to 27 and were classified as indeterminate probability of cognitive impairment. The addition of a processing speed measure improved classification for the indeterminate group by correctly identifying 65% of these individuals, for an overall classification accuracy of 79%.
The utility of the MoCA in detecting cognitive impairment post-stroke is improved when using a three-category approach. The addition of a processing speed measure provides a practical and efficient method to increase confidence in the determined outcome while minimally extending the screening routine for VCI.
The mechanism through which developmental programming of offspring overweight/obesity following in utero exposure to maternal overweight/obesity operates is unknown but may operate through biologic pathways involving offspring anthropometry at birth. Thus, we sought to examine to what extent the association between in utero exposure to maternal overweight/obesity and childhood overweight/obesity is mediated by birth anthropometry. Analyses were conducted on a retrospective cohort with data obtained from one hospital system. A natural effects model framework was used to estimate the natural direct effect and natural indirect effect of birth anthropometry (weight, length, head circumference, ponderal index, and small-for-gestational age [SGA] or large-for-gestational age [LGA]) for the association between pre-pregnancy maternal body mass index (BMI) category (overweight/obese vs normal weight) and offspring overweight/obesity in childhood. Models were adjusted for maternal and child socio-demographics. Three thousand nine hundred and fifty mother–child dyads were included in analyses (1467 [57.8%] of mothers and 913 [34.4%] of children were overweight/obese). Results suggest that a small percentage of the effect of maternal pre-pregnancy BMI overweight/obesity on offspring overweight/obesity operated through offspring anthropometry at birth (weight: 15.5%, length: 5.2%, head circumference: 8.5%, ponderal index: 2.2%, SGA: 2.9%, and LGA: 4.2%). There was a small increase in the percentage mediated when gestational diabetes or hypertensive disorders were added to the models. Our study suggests that some measures of birth anthropometry mediate the association between maternal pre-pregnancy overweight/obesity and offspring overweight/obesity in childhood and that the size of this mediated effect is small.
The debate regarding euthanasia and physician-assisted suicide (E/PAS) raises key issues about the role of the doctor, and the professional, ethical, and clinical dimensions of the doctor-patient relationship. This review aimed to examine the published evidence regarding the response of doctors who have participated in E/PAS.
Original research papers were identified reporting either qualitative or qualitative data published in peer-reviewed literature between 1980 and March 2018, with a specific focus on the impact on, or response from, physicians to their participation in E/PAS. PRISMA and CASP guidelines were followed.
Nine relevant papers met selection criteria. Given the limited published data, a descriptive synthesis of quantitative and qualitative findings was performed. Quantitative surveys were limited in scope but identified a mixed set of responses. Where studies measured psychological impact, 30–50% of doctors described emotional burden or discomfort about participation, while findings also identified a comfort or satisfaction in believing the request of the patient was met. Significant, ongoing adverse personal impact was reported between 15% to 20%. A minority of doctors sought personal support, generally from family or friends, rather than colleagues. The themes identified from the qualitative studies were summarized as: 1) coping with a request; 2) understanding the patient; 3) the doctor's role and agency in the death of a patient; 4) the personal impact on the doctor; and 5) professional guidance and support.
Significance of results
Participation in E/PAS can have a significant emotional impact on participating clinicians. For some doctors, participation can contrast with perception of professional roles, responsibilities, and personal expectations. Despite the importance of this issue to medical practice, this is a largely neglected area of empirical research. The limited studies to date highlight the need to address the responses and impact on clinicians, and the support for clinicians as they navigate this challenging area.
Residency education delivery in the United States has migrated from conventional lectures to alternative educational models that include mini-lectures, small group, and learner lead discussions. As training programs struggle with mandated hours of content, prehospital (EMS) and disaster medicine are given limited focus. While the need for prehospital and disaster medicine education in emergency training is understood, no standard curriculum delivery has been proposed and little research has been done to evaluate the effectiveness of any particular model.
To demonstrate a four-hour multi-modal curriculum that includes lecture based discussions and small group exercises, culminating in an interactive multidisciplinary competition that integrates the previously taught information.
EMS and disaster faculty were surveyed on the previous disaster and prehospital educational day experiences to evaluate course content, level of engagement, and participation by faculty. Based on this feedback, the EMS/Disaster divisions developed a schedule for the four hour EMS and Disaster Day that incorporated vital concepts while addressing the pitfalls previously identified. Sessions included traditional lectures, question and answer sessions, small group exercises, and a tabletop competition. Structured similarly to a strategy board game, the tabletop exercise challenged residents to take into account both medical and ethical considerations during a traditional triage exercise.
Compared to past reviews by emergency medical faculty, residents, and medical students, there was a precipitous increase in satisfaction scores on the part of all participants.
This curriculum deviates from the conventional education model and has been successfully implemented at our 3-year residency program of 66 residents. This EMS and Disaster Day promotes active learning, resident and faculty participation, and retention of important concepts while also fostering relationships between disaster managers and the Department of Emergency Medicine.
OBJECTIVES/SPECIFIC AIMS: To examine rural-urban disparities in prevalence of diagnosed diabetes in veterans receiving care at the VA and to determine the extent to which demographic factors and obesity levels contribute to identified disparities. METHODS/STUDY POPULATION: A retrospective serial cross-sectional analysis was employed. A stratified weighted random sample of veterans who received care at a VA facility was selected each year for 2007 through 2012. Rural Urban Commuting Area (RUCA) codes were based on resident zip code. Diabetes was defined by two or more primary or secondary ICD-9 codes for diabetes (250.xx) within a 12 month period. Data were analyzed using complex survey-specific procedures. RESULTS/ANTICIPATED RESULTS: Diabetes prevalence 2007-2012 was lowest in urban (20.5%-21.0%), followed by highly rural (21.1%-22.1%) and rural (22.3%-23.0%) areas with the prevalence being significantly higher on the insular islands (31.0%-32.4%). In 2012, 41% of urban, 43% of rural and highly rural and 30% of insular island veterans were obese. Relative to urban areas, the odds ratio for prevalent diabetes was 1.10 (95% CI: 1.08, 1.12) for rural veterans, 1.19 (95% CI: 1.16, 1.23) for insular island veterans, and 1.00 (95% CI: 0.98, 1.02) for highly rural veterans. DISCUSSION/SIGNIFICANCE OF IMPACT: Prevalence of diagnosed diabetes is high in veterans residing in rural, highly rural and urban areas, but markedly higher on the insular islands. Understanding the burden of disease and factors driving disparities provides information required to develop targeted interventions.
Epilepsy and mental illness have a bidirectional association. Psychiatrists are likely to encounter epilepsy as comorbidity. Seizures may present as mental illness. Equally, the management of psychiatric conditions has the potential to destabilise epilepsy. There is a need for structured epilepsy awareness and training amongst psychiatrists. This paper outlines key considerations around diagnosis, treatment and risk while suggesting practical recommendations.
Abstract presentations of scientific information at meetings are important for broadcasting new information. Publication of these studies should be the final goal, but minimal data exist documenting publication rates, especially for paediatric sub-speciality meetings. The goal of this study was to document the manuscript publication rate for paediatric cardiac echocardiography abstracts and to determine whether there were differences between abstracts that were published versus not published.
Paediatric cardiac echocardiography abstracts presented from 2007 to 2011 at the American Society of Echocardiography Meetings were reviewed. Characteristics of the abstracts were noted. A Medline/Pubmed search was performed using keywords, first author, and senior author criteria to determine publication. Fisher’s exact tests or χ2 tests were used for analysis.
A total of 194 abstracts were reviewed. In all, 27 abstracts were oral presentations and 167 were poster presentations. A total of 124 abstracts were prospective studies and 70 were retrospective studies; 11 abstracts were basic science studies and 183 were clinical studies. Altogether, 25 abstracts dealt with three-dimensional echocardiography, 15 with fetal echocardiography, 56 with deformation analysis, 79 with standard transthoracic echocardiography, and 19 were in the other category. A total of 73 abstracts were subsequently published – with a 37.6% publication rate – 2.1±1.7 years after initial presentation. There were no significant differences in publication rates based on the above-noted variables.
A paediatric cardiac echocardiography abstract publication rate of 37.6% is comparable to previous published publication rates for other meetings. No differences in variables analysed were noted between published versus unpublished abstracts.
On August 25, 2017, Hurricane Harvey made landfall near Corpus Christi, Texas. The ensuing unprecedented flooding throughout the Texas coastal region affected millions of individuals.1 The statewide response in Texas included the sheltering of thousands of individuals at considerable distances from their homes. The Dallas area established large-scale general population sheltering as the number of evacuees to the area began to amass. Historically, the Dallas area is one familiar with “mega-sheltering,” beginning with the response to Hurricane Katrina in 2005.2 Through continued efforts and development, the Dallas area had been readying a plan for the largest general population shelter in Texas. (Disaster Med Public Health Preparedness. 2019;13:33–37)
Background: Measurement of cognitive behavioural therapy (CBT) competency is often resource intensive. A popular emerging alternative to independent observers’ ratings is using other perspectives for rating competency. Aims: This pilot study compared ratings of CBT competency from four perspectives – patient, therapist, supervisor and independent observer using the Cognitive Therapy Scale (CTS). Method: Patients (n = 12, 75% female, mean age 30.5 years) and therapists (n = 5, female, mean age 26.6 years) completed the CTS after therapy sessions, and clinical supervisor and independent observers rated recordings of the same session. Results: Analyses of variance revealed that therapist average CTS competency ratings were not different from supervisor ratings, and supervisor ratings were not different from independent observer ratings; however, therapist ratings were higher than independent observer ratings and patient ratings were higher than all other raters. Conclusions: Raters differed in competency ratings. Implications for potential use and adaptation of CBT competency measurement methods to enhance training and implementation are discussed.
To establish if the relatively low rate of involuntary psychiatric admission in a suburban area between 2007 and 2011 was maintained in 2014/2015, and explore key correlates of involuntary status.
We used existing hospital records and data sources to extract rates and selected potential correlates of voluntary and involuntary admission in south west Dublin (catchment area: 273 419 people) over 18 months in 2014/2015 and compared these with published national data from the census and Health Research Board.
The rate of involuntary admission in the suburban area studied between 2007 and 2011 was 33.8 involuntary admissions per 100 000 population annually, which was lower than the national rate (48.6). By 2014/2015, the rate of involuntary admission in this area had risen to 46.8 involuntary admissions per 100 000 population annually, similar to the national rate (44.9). Nevertheless, the overall (voluntary and involuntary) admission rate in the suburban area (346.7 admissions per 100 000 population annually) was still lower the national rate (387.9), owing to a lower rate of voluntary admission in the suburban area (299.9) compared to Ireland as a whole (342.9). Multi-variable testing demonstrated that diagnosis was the strongest driver of involuntary admission in the suburban area: this area had 28.5 involuntary admissions per 100 000 population annually with schizophrenia or related disorders, compared to 18.9 nationally. Schizophrenia and related disorders accounted for 60.9% of involuntary admissions in the suburban area compared to 42.1% nationally.
Schizophrenia is the strongest driver of involuntary admission in the suburban area in this study.
To examine variation in antibiotic coverage and detection of resistant pathogens in community-onset pneumonia.
A total of 128 hospitals in the Veterans Affairs health system.
Hospitalizations with a principal diagnosis of pneumonia from 2009 through 2010.
We examined proportions of hospitalizations with empiric antibiotic coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PAER) and with initial detection in blood or respiratory cultures. We compared lowest- versus highest-decile hospitals, and we estimated adjusted probabilities (AP) for patient- and hospital-level factors predicting coverage and detection using hierarchical regression modeling.
Among 38,473 hospitalizations, empiric coverage varied widely across hospitals (MRSA lowest vs highest, 8.2% vs 42.0%; PAER lowest vs highest, 13.9% vs 44.4%). Detection rates also varied (MRSA lowest vs highest, 0.5% vs 3.6%; PAER lowest vs highest, 0.6% vs 3.7%). Whereas coverage was greatest among patients with recent hospitalizations (AP for anti-MRSA, 54%; AP for anti-PAER, 59%) and long-term care (AP for anti-MRSA, 60%; AP for anti-PAER, 66%), detection was greatest in patients with a previous history of a positive culture (AP for MRSA, 7.9%; AP for PAER, 11.9%) and in hospitals with a high prevalence of the organism in pneumonia (AP for MRSA, 3.9%; AP for PAER, 3.2%). Low hospital complexity and rural setting were strong negative predictors of coverage but not of detection.
Hospitals demonstrated widespread variation in both coverage and detection of MRSA and PAER, but probability of coverage correlated poorly with probability of detection. Factors associated with empiric coverage (eg, healthcare exposure) were different from those associated with detection (eg, microbiology history). Providing microbiology data during empiric antibiotic decision making could better align coverage to risk for resistant pathogens and could promote more judicious use of broad-spectrum antibiotics.
Background: Although negative beliefs have been found to be associated with worry symptoms and depressive rumination, negative beliefs have yet to be examined in relation to post-event processing and social anxiety symptoms. Aims: The purpose of the current study was to examine the psychometric properties of the Negative Beliefs about Post-Event Processing Questionnaire (NB-PEPQ). Method: A large, non-referred undergraduate sample completed the NB-PEPQ along with validation measures, including a measure of post-event processing and social anxiety symptoms. Results: Based on factor analysis, a single-factor model was obtained, and the NB-PEPQ was found to exhibit good validity, including positive associations with measures of post-event processing and social anxiety symptoms. Conclusions: These findings add to the literature on the metacognitive variables that may lead to the development and maintenance of post-event processing and social anxiety symptoms, and have relevant clinical applications.
Objectives: To summarize the clinical characteristics and outcomes of pediatric sports-related concussion (SRC) patients who were evaluated and managed at a multidisciplinary pediatric concussion program and examine the healthcare resources and personnel required to meet the needs of this patient population. Methods: We conducted a retrospective review of all pediatric SRC patients referred to the Pan Am Concussion Program from September 1st, 2013 to May 25th, 2015. Initial assessments and diagnoses were carried out by a single neurosurgeon. Return-to-Play decision-making was carried out by the multidisciplinary team. Results: 604 patients, including 423 pediatric SRC patients were evaluated at the Pan Am Concussion Program during the study period. The mean age of study patients was 14.30 years (SD: 2.32, range 7-19 years); 252 (59.57%) were males. Hockey (182; 43.03%) and soccer (60; 14.18%) were the most commonly played sports at the time of injury. Overall, 294 (69.50%) of SRC patients met the clinical criteria for concussion recovery, while 75 (17.73%) were lost to follow-up, and 53 (12.53%) remained in active treatment at the end of the study period. The median duration of symptoms among the 261 acute SRC patients with complete follow-up was 23 days (IQR: 15, 36). Overall, 25.30% of pediatric SRC patients underwent at least one diagnostic imaging test and 32.62% received referral to another member of our multidisciplinary clinical team. Conclusion: Comprehensive care of pediatric SRC patients requires access to appropriate diagnostic resources and the multidisciplinary collaboration of experts with national and provincially-recognized training in TBI.
People with a life-limiting physical illness experience high rates of significant psychological and psychiatric morbidity. Nevertheless, psychiatrists often report feeling ill-equipped to respond to the psychiatric needs of this population. Our aim was to explore psychiatry trainees’ views and educational needs regarding the care of patients with a life-limiting physical illness.
Using semistructured interviews, participants’ opinions were sought on the role of psychiatrists in the care of patients with a life-limiting illness and their caregivers, the challenges faced within the role, and the educational needs involved in providing care for these patients. Interviews were audiotaped, fully transcribed, and then subjected to thematic analysis.
A total of 17 psychiatry trainees were recruited through two large psychiatry training networks in New South Wales, Australia. There were contrasting views on the role of psychiatry in life-limiting illness. Some reported that a humanistic, supportive approach including elements of psychotherapy was helpful, even in the absence of a recognizable mental disorder. Those who reported a more biological and clinical stance (with a reliance on pharmacotherapy) tended to have a nihilistic view of psychiatric intervention in this setting. Trainees generally felt ill-prepared to talk to dying patients and felt there was an educational “famine” in this area of psychiatry. They expressed a desire for more training and thought that increased mentorship and case-based learning, including input from palliative care clinicians, would be most helpful.
Significance of Results:
Participants generally feel unprepared to care for patients with a life-limiting physical illness and have contrasting views on the role of psychiatry in this setting. Targeted education is required for psychiatry trainees in order to equip them to care for these patients.