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Coronavirus disease (COVID-19) is a “disaster of uncertainty” with ambiguity about its nature and trajectory. These features amplify its psychological toxicity and increase the number of psychological casualties it inflicts. Uncertainty was fueled by lack of knowledge about the lethality of a disaster, its duration, and ambiguity in messaging from leaders and health care authorities. Human resilience can have a buffering effect on the psychological impact. Experts have advocated “flattening the curve” to slow the spread of the infection. Our strategy for crisis leadership is focused on flattening the rise in psychological casualties by increasing resilience among health care workers. This paper describes an approach employed at Johns Hopkins to promote and enhance crisis leadership. The approach is based on 4 factors: vision for the future, decisiveness, effective communication, and following a moral compass. We make specific actionable recommendations for implementing these factors that are being disseminated to frontline leaders and managers. The COVID-19 pandemic is destined to have a strong psychological impact that extends far beyond the end of quarantine. Following these guidelines has the potential to build resilience and thus reduce the number of psychological casualties and speed the return to normal – or at least the new normal in the post-COVID world.
Enterotoxigenic Escherichia coli (ETEC) is a well-established cause of traveller's diarrhoea and occasional domestic foodborne illness outbreaks in the USA. Although ETEC are not detected by conventional stool culture methods used in clinical laboratories, syndromic culture-independent diagnostic tests (CIDTs) capable of detecting ETEC have become increasingly prevalent in the last decade. This study describes the epidemiology of ETEC infections reported to the Minnesota Department of Health (MDH) during 2016–2017. ETEC-positive stool specimens were submitted to MDH to confirm the presence of ETEC DNA by polymerase chain reaction (PCR). Cases were interviewed to ascertain illness and exposures. Contemporaneous Salmonella cases were used as a comparison group in a case-case comparison analysis of risk factors. Of 222 ETEC-positive specimens received by MDH, 108 (49%) were concordant by PCR. ETEC was the sixth most frequently reported bacterial enteric pathogen among a subset of CIDT-positive specimens. Sixty-nine (64%) laboratory-confirmed cases had an additional pathogen codetected with ETEC, including enteroaggregative E. coli (n = 40) and enteropathogenic E. coli (n = 39). Although travel is a risk factor for ETEC infection, only 43% of cases travelled internationally, providing evidence for ETEC as an underestimated source of domestically acquired enteric illness in the USA.
In cognitive models of adult psychosis, schematic beliefs about the self and others are important vulnerability and maintaining factors, and are therefore targets for psychological interventions. Schematic beliefs have not previously been investigated in children with distressing unusual, or psychotic-like, experiences (UEDs). The aim of this study was firstly to investigate whether a measure of schematic beliefs, originally designed for adults with psychosis, was suitable for children; and secondly, to examine the association of childhood schematic beliefs with internalising and externalising problems and with UEDs.
Sixty-seven children aged 8–14 years, with emotional and behavioural difficulties, completed measures of UEDs, internalising (depression and anxiety), and externalising (conduct and hyperactivity-inattention) problems, together with the Brief Core Schema Scales (BCSS).
The BCSS was readily completed by participants, and scale psychometric properties were good. Children tended to view themselves and others positively. Internalising and externalising problems and UEDs were all associated with negative schematic beliefs; effect sizes were small to medium.
Schematic beliefs in young people can be measured using the BCSS, and negative schematic beliefs are associated with childhood psychopathology and with UEDs. Schematic beliefs may therefore form a useful target in psychological interventions for young people with UEDs.
The number of psychiatrists continues to grow in Canada. Patient psychiatry utilization statistics, including reasons for termination of such services, are important factors that have the potential to impact future Canadian and international psychiatry service policies and practices. In addition, understanding the reasons for psychiatry service termination is necessary to improve service quality and effectiveness.
This study focused on utilization trends, perceived effectiveness of psychiatry services, and reasons for termination of psychiatry services in Canada.
Prevalence of psychiatry service use, perceived effectiveness, and reasons for termination of such services were investigated in a Canadian sample (n = 25,113). Prevalence rates were investigated by geography, sex, and age. Data were self-reported and collected through a national Canadian phone survey focused on mental and physical health.
Results highlight that a small percentage of participants reported utilizing psychiatry services. The majority of participants using such services perceived them as useful. Across geographical regions, reasons for discontinuing services were most often related to completing treatment, feeling better, or not seeing the treatment as helpful.
This study explored psychiatry utilization trends, perceived psychiatry effectiveness, and reasons for patient termination of such services. Results are explored through a geographical region breakdown, sex differences, and age stratification. Implications for policy, practice, and training are discussed from a Canadian and international perspective.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Introduction: Given the current opioid crisis, caregivers have mounting fears regarding use of opioid medication in their children. Since caregivers are often the gatekeepers to their children's pain management, understanding their perspectives on analgesics is essential. For caregivers of children with acute injury presenting to the pediatric emergency department (PED), we aimed to determine caregivers’: a) willingness to accept opioids from emergency care providers, b) reasons for refusing opioids, and c) past experiences with opioids. Methods: A novel 31-item electronic survey was offered, via tablet device, to caregivers of children aged 4-16 years who had a musculoskeletal injury <7 days old and presented to one of two Canadian PEDs between March and November 2017. Primary outcome was caregiver willingness to accept opioids for moderate pain for their children. Results: 517 caregivers completed the survey; mean age was 40.9 +/−7 years with 70.0% (362/517) being mothers. Children included 62.2% (321/516) males with an overall mean age of 10 +/−3.6 years. 49.6% of caregivers (254/512) reported willingness to accept opioids for moderate pain that persisted after non-opioid analgesia, while 37.1% (190/512) were unsure what they would do. Only 33.2% (170/512) of caregivers stated they would accept opioid analgesia upon discharge while 45.5% (233/512) were unsure about at-home use. Caregivers were primarily concerned about side effects, overdose, addiction, and masking of diagnosis. Caregiver fear of addiction (OR 1.12, 95% CI 1.01-1.25) and side effects (OR 1.25, 95% CI 1.11-1.42) increased the odds of rejecting opioids in the emergency department, while fears of addiction (OR 1.19, 95% CI 1.07-1.32) and overdose (OR 1.15, 95% CI 1.04-1.27) increased the odds of rejecting opioids for at-home use. Conclusion: Only half of caregivers reported that they would accept opioids for moderate pain, despite ongoing pain following non-opioid analgesics. Caregiver fears of addiction, side effects, overdose, and masking their child's diagnosis influence their behaviours. These findings are a first step in understanding caregiver decision-making and can guide healthcare providers in their conversations about acute pain treatment with families.
To investigate the relative importance of 10 attributes identified in prior studies as essential for effective disaster medical responders and leaders.
Emergency and disaster medical response personnel (N=220) ranked 10 categories of disaster worker attributes in order of their importance in contributing to the effectiveness of disaster responders and leaders.
Attributes of disaster medical leaders and responders were rank ordered, and the rankings differed for leaders and responders. For leaders, problem-solving/decision-making and communication skills were the highest ranked, whereas teamwork/interpersonal skills and calm/cool were the highest ranked for responders.
The 10 previously identified attributes of effective disaster medical responders and leaders include personal characteristics and general skills in addition to knowledge of incident command and disaster medicine. The differences in rank orders of attributes for leaders and responders suggest that when applying these attributes in personnel recruitment, selection, and training, the proper emphasis and priority given to each attribute may vary by role. (Disaster Med Public Health Preparedness. 2019;13:700–703)
We consider the instability properties of dense granular flow in inclined plane and plane shear geometries as tests for the compressible inertial-dependent rheology. The model, which is a recent generalisation of the incompressible
rheology, constitutes a hydrodynamical description of dense granular flow which allows for variability in the solids volume fraction. We perform a full linear stability analysis of the model and compare its predictions to existing experimental data for glass beads on an inclined plane and discrete element simulations of plane shear in the absence of gravity. In the case of the former, we demonstrate that the compressible model can quantitatively predict the instability properties observed experimentally, and, in particular, we find that it performs better than its incompressible counterpart. For the latter, the qualitative behaviour of the plane shear instability is also well captured by the compressible model.
Introduction: Inadequate pain management in children is ubiquitous in the emergency department (ED). As the current national opioid crisis has highlighted, physicians are caught between balancing pain management and the risk of long term opioid dependence. This study aimed to describe pediatric emergency physicians (PEPs) willingness to prescribe opioids to children in the ED and at discharge. Methods: A unique survey tool was created using published methodology guidelines. Information regarding practices, knowledge, attitudes, perceived barriers, facilitators and demographics were collected. The survey was distributed to all physician members of Pediatric Emergency Research Canada (PERC), using a modified Dillmans Tailored Design method, from October to December 2017. Results: The response rate was 49.7% (124/242); 53% (57/107) were female, mean age was 43.6 years (+/− 8.7), and 58% (72/124) had pediatric emergency subspecialty training. The most common first line ED pain medication was ibuprofen for mild, moderate and severe musculoskeletal injury (MSK-I)-related pain (94.4% (117/124), 89.5% (111/124), and 62.9% (78/124), respectively). For moderate and severe MSK-I, intranasal fentanyl was the most common opioid for first (35.5% (44/124) and 61.3% (76/124), respectively) and second line pain management (41.1% (51/124) and 20.2% (25/124), respectively). 74.8% (89/119) of PEPs reported that an opioid protocol would be helpful, specifically for morphine, fentanyl, and hydromorphone. Using a 0-100 scale, physicians minimally worried about physical dependence (13.3 +/−19.3), addiction (16.6 +/−19.8), and diversion of opioids (32.8+/−26.4) when prescribing short-term opioids to children. They reported that the current opioid crisis minimally influenced their willingness to prescribe opioids (30.0 +/−26.2). Physicians reported rarely (36%; 45/125) or never (28%; 35/125) completing a screening risk assessment prior to prescribing opioids. Conclusion: Ibuprofen remains the most common medication recommended for MSK-I pain in the ED and at discharge. Intranasal fentanyl was the top opioid for all pain intensities. PEPs are minimally concerned regarding dependence, addiction, and the current opioid crisis when prescribing short-term opioids to children. There is an urgent need for robust evidence regarding the dependence and addiction risk for children receiving short term opioids in order to create knowledge translation tools for ED physicians. Opioid specific protocols for both in the ED and at discharge would likely improve physician comfort in responsible and adequate pain management for children.
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)
To determine whether antimicrobial-impregnated textiles decrease the acquisition of pathogens by healthcare provider (HCP) clothing.
We completed a 3-arm randomized controlled trial to test the efficacy of 2 types of antimicrobial-impregnated clothing compared to standard HCP clothing. Cultures were obtained from each nurse participant, the healthcare environment, and patients during each shift. The primary outcome was the change in total contamination on nurse scrubs, measured as the sum of colony-forming units (CFU) of bacteria.
PARTICIPANTS AND SETTING
Nurses working in medical and surgical ICUs in a 936-bed tertiary-care hospital.
Nurse subjects wore standard cotton-polyester surgical scrubs (control), scrubs that contained a complex element compound with a silver-alloy embedded in its fibers (Scrub 1), or scrubs impregnated with an organosilane-based quaternary ammonium and a hydrophobic fluoroacrylate copolymer emulsion (Scrub 2). Nurse participants were blinded to scrub type and randomly participated in all 3 arms during 3 consecutive 12-hour shifts in the intensive care unit.
In total, 40 nurses were enrolled and completed 3 shifts. Analyses of 2,919 cultures from the environment and 2,185 from HCP clothing showed that scrub type was not associated with a change in HCP clothing contamination (P=.70). Mean difference estimates were 0.118 for the Scrub 1 arm (95% confidence interval [CI], −0.206 to 0.441; P=.48) and 0.009 for the Scrub 2 rm (95% CI, −0.323 to 0.342; P=.96) compared to the control. HCP became newly contaminated with important pathogens during 19 of the 120 shifts (16%).
Antimicrobial-impregnated scrubs were not effective at reducing HCP contamination. However, the environment is an important source of HCP clothing contamination.
Although the Great Basin of North America has produced some of the most robust and ancient fiber artifact assemblages in the world, many were recovered with poor chronological controls. Consequently, this class of artifacts has seldom been effectively incorporated into general discussions of early chronological and cultural patterns. In recent years, the Great Basin Textile Dating Project has accumulated direct AMS dates on textiles (bags, sandals, mats, cordage, and basketry) from dry caves in the Great Basin, particularly in the northern and western areas. We focus here on the terminal Pleistocene/early Holocene, to identify chronological patterns in this class of artifacts and to evaluate Adovasio’s characterization of the region’s earliest basketry as simple and undecorated. New AMS dates now suggest that the region’s earliest people had sophisticated textile traditions that incorporated numerous decorative elaborations. Some distinctive structures, including Fort Rock sandals and weft-faced plaited textiles, have limited early temporal ranges and may serve as diagnostic indicators for terminal Pleistocene/early Holocene times. Other basketry forms and structures that appear by about 9000 cal B.P. persist into the historic period, suggesting a stronger thread of continuity (especially in the north) from this time than is apparent in lithic traditions
To identify key attributes of effective disaster/mass casualty first responders and leaders, thereby informing the ongoing development of a capable disaster health workforce.
We surveyed emergency response practitioners attending a conference session, the EMS State of the Science: A Gathering of Eagles. We used open-ended questions to ask participants to describe key characteristics of successful disaster/mass casualty first responders and leaders.
Of the 140 session attendees, 132 (94%) participated in the survey. All responses were categorized by using a previously developed framework. The most frequently mentioned characteristics were related to incident command/disaster knowledge, teamwork/interpersonal skills, performing one’s role, and cognitive abilities. Other identified characteristics were related to communication skills, adaptability/flexibility, problem solving/decision-making, staying calm and cool under stress, personal character, and overall knowledge.
The survey findings support our prior focus group conclusion that important characteristics of disaster responders and leaders are not limited to the knowledge and skills typically included in disaster training. Further research should examine the extent to which these characteristics are consistently associated with actual effective performance of disaster response personnel and determine how best to incorporate these attributes into competency models, processes, and tools for the development of an effective disaster response workforce. (Disaster Med Public Health Preparedness. 2016;page 1 of 4)
Various transmission routes contribute to spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) in hospitalized patients. Patients with readmissions during which CRKP is again isolated (“CRKP readmission”) potentially contribute to transmission of CRKP.
To evaluate CRKP readmissions in the Consortium on Resistance against Carbapenems in K. pneumoniae (CRaCKLe).
Cohort study from December 24, 2011, through July 1, 2013.
Multicenter consortium of acute care hospitals in the Great Lakes region.
All patients who were discharged alive during the study period were included. Each patient was included only once at the time of the first CRKP-positive culture.
All readmissions within 90 days of discharge from the index hospitalization during which CRKP was again found were analyzed. Risk factors for CRKP readmission were evaluated in multivariable models.
Fifty-six (20%) of 287 patients who were discharged alive had a CRKP readmission. History of malignancy was associated with CRKP readmission (adjusted odds ratio [adjusted OR], 3.00 [95% CI, 1.32–6.65], P<.01). During the index hospitalization, 160 patients (56%) received antibiotic treatment against CRKP; the choice of regimen was associated with CRKP readmission (P=.02). Receipt of tigecycline-based therapy (adjusted OR, 5.13 [95% CI, 1.72–17.44], using aminoglycoside-based therapy as a reference in those treated with anti-CRKP antibiotics) was associated with CRKP readmission.
Hospitalized patients with CRKP—specifically those with a history of malignancy—are at high risk of readmission with recurrent CRKP infection or colonization. Treatment during the index hospitalization with a tigecycline-based regimen increases this risk.
Infect. Control Hosp. Epidemiol. 2016;37(3):281–288
Paranoia is one of the commonest symptoms of psychosis but has rarely been studied in a population at risk of developing psychosis. Based on existing theoretical models, including the proposed distinction between ‘poor me’ and ‘bad me’ paranoia, we aimed to test specific predictions about associations between negative cognition, metacognitive beliefs and negative emotions and paranoid ideation and the belief that persecution is deserved (deservedness).
We used data from 117 participants from the Early Detection and Intervention Evaluation for people at risk of psychosis (EDIE-2) trial of cognitive–behaviour therapy, comparing them with samples of psychiatric in-patients and healthy students from a previous study. Multi-level modelling was utilized to examine predictors of both paranoia and deservedness, with post-hoc planned comparisons conducted to test whether person-level predictor variables were associated differentially with paranoia or with deservedness.
Our sample of at-risk mental state participants was not as paranoid, but reported higher levels of ‘bad-me’ deservedness, compared with psychiatric in-patients. We found several predictors of paranoia and deservedness. Negative beliefs about self were related to deservedness but not paranoia, whereas negative beliefs about others were positively related to paranoia but negatively with deservedness. Both depression and negative metacognitive beliefs about paranoid thinking were specifically related to paranoia but not deservedness.
This study provides evidence for the role of negative cognition, metacognition and negative affect in the development of paranoid beliefs, which has implications for psychological interventions and our understanding of psychosis.
Large numbers of evacuees arrived in Dallas, Texas, from Hurricanes Katrina and Rita just 3 weeks apart in 2005 and from Hurricanes Gustav and Ike just 3 weeks apart again in 2008. The Dallas community needed to locate, organize, and manage the response to provide shelter and health care with locally available resources. With each successive hurricane, disaster response leaders applied many lessons learned from prior operations to become more efficient and effective in the provision of services. Mental health services proved to be an essential component. From these experiences, a set of operating guidelines for large evacuee shelter mental health services in Dallas was developed, with involvement of key stakeholders. A generic description of the processes and procedures used in Dallas that highlights the important concepts, key considerations, and organizational steps was then created for potential adaptation by other communities. (Disaster Med Public Health Preparedness. 2015;9:423–429)
To determine the rates of and risk factors for tigecycline nonsusceptibility among carbapenem-resistant Klebsiella pneumoniae (CRKPs) isolated from hospitalized patients
Multicenter prospective observational study
Acute care hospitals participating in the Consortium on Resistance against Carbapenems in Klebsiella pneumoniae (CRaCKle)
A cohort of 287 patients who had CRKPs isolated from clinical cultures during hospitalization
For the period from December 24, 2011 to October 1, 2013, the first hospitalization of each patient with a CRKP during which tigecycline susceptibility for the CRKP isolate was determined was included. Clinical data were entered into a centralized database, including data regarding pre-hospital origin. Breakpoints established by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) were used to interpret tigecycline susceptibility testing.
Of 287 patients included in the final cohort, 155 (54%) had tigecycline-susceptible CRKPs. Of all index isolates, 81 (28%) were tigecycline-intermediate and 51 (18%) were tigecycline resistant. In multivariate modeling, independent risk factors for tigecycline nonsusceptibility were (1) admission from a skilled nursing facility (OR, 2.51; 95% CI, 1.51–4.21; P=.0004), (2) positive culture within 2 days of admission (OR, 1.82; 95% CI, 1.06–3.15; P=.03), and (3) receipt of tigecycline within 14 days (OR, 4.38, 95% CI, 1.37–17.01, P=.02).
In hospitalized patients with CRKPs, tigecycline nonsusceptibility was more frequently observed in those admitted from skilled nursing facilities and occurred earlier during hospitalization. Skilled nursing facilities are an important target for interventions to decrease antibacterial resistance to antibiotics of last resort for treatment of CRKPs.
(See the commentary by Pfeiffer and Beldavs, on pages 984–986.)
Describe the epidemiology of carbapenem-resistant Enterobacteriaceae (CRE) and examine the effect of lower carbapenem breakpoints on CRE detection.
Inpatient care at community hospitals.
All patients with CRE-positive cultures were included.
CRE isolated from 25 community hospitals were prospectively entered into a centralized database from January 2008 through December 2012. Microbiology laboratory practices were assessed using questionnaires.
A total of 305 CRE isolates were detected at 16 hospitals (64%). Patients with CRE had symptomatic infection in 180 cases (59%) and asymptomatic colonization in the remainder (125 cases; 41%). Klebsiella pneumoniae (277 isolates; 91%) was the most prevalent species. The majority of cases were healthcare associated (288 cases; 94%). The rate of CRE detection increased more than fivefold from 2008 (0.26 cases per 100,000 patient-days) to 2012 (1.4 cases per 100,000 patient-days; incidence rate ratio (IRR), 5.3 [95% confidence interval (CI), 1.22–22.7]; P = .01). Only 5 hospitals (20%) had adopted the 2010 Clinical and Laboratory Standards Institute (CLSI) carbapenem breakpoints. The 5 hospitals that adopted the lower carbapenem breakpoints were more likely to detect CRE after implementation of breakpoints than before (4.1 vs 0.5 cases per 100,000 patient-days; P < .001; IRR, 8.1 [95% CI, 2.7–24.6]). Hospitals that implemented the lower carbapenem breakpoints were more likely to detect CRE than were hospitals that did not (3.3 vs 1.1 cases per 100,000 patient-days; P = .01).
The rate of CRE detection increased fivefold in community hospitals in the southeastern United States from 2008 to 2012. Despite this, our estimates are likely underestimates of the true rate of CRE detection, given the low adoption of the carbapenem breakpoints recommended in the 2010 CLSI guidelines.
Dopamine D3 receptor (D3R) antagonists may be effective medications for multiple substance use disorders (SUDs). However, no selective D3R antagonists are currently available for clinical testing. Buspirone, originally characterized as a 5-HT1A partial agonist and used as an anxiolytic, also binds to D3R and D4R with high affinity, with lower affinity to D2R, and interferes with cocaine reward. Here we used PET with [11C]PHNO (D3R-preferring radioligand), [11C]raclopride (D2R/D3R radioligand) and [11C]NNC-112 (D1R radioligand) to measure occupancy of oral and parenteral buspirone in the primate brain. Intramuscular buspirone (0.19 and 0.5 mg/kg) blocked both [11C]PHNO and [11C]raclopride binding to striatum, exhibiting high occupancy (50–85%) at 15 min and rapid wash-out over 2–6 h. In contrast, oral buspirone (3 mg/kg) significantly blocked [11C]PHNO binding in D3-rich regions (globus pallidum and midbrain) at 3 h, but had minimal effects on [11C]raclopride binding (28–37% at 1 h and 10% at 3 h). Buspirone did not block [11C]NNC-112. Our findings provide evidence that i.m. buspirone blocks D3R and D2R, whereas oral buspirone is more selective towards D3R blockade in vivo, consistent with extensive first pass metabolism and supporting the hypothesis that its metabolites (5- and 6′-hydroxybuspirone) merit evaluation for treating SUDs. They also indicate that for oral buspirone to achieve greater than 80% sustained D3R occupancy, as might be needed to treat addiction, higher doses (at least three-fold) than those used to treat anxiety (maximal 60 mg) will be required. Nonetheless, based on previous clinical studies, these doses would be safe and well tolerated.
For people with psychosis, contact with informal caregivers is an important source of social support, associated with recovery, and with better outcomes following individual cognitive therapy (CBTp). In this study, we tested whether increased flexibility in delusional thinking, an established predictor of positive outcome following CBTp, was a possible mechanism underlying this effect.
219 participants with delusions (mean age 38 years; 71% male; 75% White) were grouped according to the presence of a caregiver (37% with a caregiver) and caregiver level of expressed emotion (High/Low EE, 64% Low). Delusional belief flexibility was compared between groups, controlling for interpersonal functioning, severity of psychotic symptoms, and other hypothesised outcome predictors.
Participants with caregivers were nearly three times more likely than those without to show flexibility (OR = 2.7, 95% CI 1.5 to 5.0, p = 0.001), and five times more likely if the caregiving relationship was Low EE (OR = 5.0, 95% CI 2.0–13.0, p = 0.001). ORs remained consistent irrespective of controlling for interpersonal functioning and other predictors of outcome.
This is the first evidence that having supportive caregiving relationships is associated with a specific cognitive attribute in people with psychosis, suggesting a potential cognitive mechanism by which outcomes following CBTp, and perhaps more generally, are improved by social support.