Response of US psychiatric programs to the COVID-19 pandemic and the impact on trainees

BACKGROUND

Medical training program and hospital response to the COVID-19 pandemic has varied greatly and has impacted trainee well-being. Which factors have specifically related to trainee wellness, however, has not yet been examined in depth. The aim of the study was to understand trainee perspectives on the individual psychiatry trainee programs' hospitals' objective COVID-19 preparedness management. We also sought and to gauge how program changes, and general pandemic-related concerns, have been associated with trainee satisfaction and burnout.

METHODS

A cross-sectional survey study of psychiatric trainees was distributed electronically throughout the country via various psychiatry residency program listservs in April 2020. Statistical analyses were performed utilizing simple linear regression.

RESULTS

From 352 respondents (346 complete responses and 6 partial responses), the most frequent program changes were "decreased number of rotations requiring in-person patient care" and "increased call hours or duties." Of pandemic-related concerns surveyed, the two greatest were "spreading COVID-19 to family/friends" and "co-residents' burnout and anxiety." A positive relationship was found between trainee satisfaction with perceived COVID-19 departmental response and comfort level of residents/fellows in expressing concerns with attending clinicians and department leadership.

CONCLUSIONS

Since the start of the COVID-19 pandemic, trainees have experienced a variety of changes to trainee program policies and guidelines. Overall, poor communication and trainee dissatisfaction with departmental response correlated with concern of infection and anxiety/burnout. Insights garnered from this study could provide scaffolding for the best practices to reduce trainee physician anxiety/burnout for the current and future pandemics of this variety and magnitude.

Assessing and Responding to the Trauma of Child Maltreatment

Child maltreatment is a significant risk factor for severe psychiatric outcomes in childhood and contributes to problematic symptoms that direct parents, teachers, or other invested parties to seek psychiatric intervention. With ongoing workforce shortages, much of the pediatric psychiatric care to this population is delivered by generalists. Child maltreatment and trauma can critically alter a child's development trajectory, affecting potential success in school and other important life pursuits. In addition, child maltreatment and resultant traumatic stress can dramatically disrupt child and adolescent development of healthy emotional regulation, distress tolerance, and the ability to form effective interpersonal relationships. Such disruption can lead to presentations within children and adolescents that mimic other symptoms of psychopathology but that typically respond poorly to traditional psychopharmacology. Ineffective treatment trials can lead to increased risk of polypharmacy and inaccurate expectations for treatment benefits. Such treatment efforts may impede addressing important environmental contributors and delay indicated therapeutic strategies. This article seeks to review child maltreatment-including core features and prevalence, overlap of child maltreatment with adverse childhood experiences, developmental impacts of exposure and resultant traumatic stress, guidance for appropriate assessment, and evidence-based interventions-and provide basic deprescribing guidelines to reduce polypharmacy burden.

Suicide and Psychosis: Results From a Population-Based Cohort of Suicide Death (N = 4380)

Approximately 5% of individuals with schizophrenia die from suicide. However, suicide in psychosis is still poorly characterized, partly due to a lack of adequate population-based clinical or genetic data on suicide death. The Utah Suicide Genetics Research Study (USGRS) provides a large population-based cohort of suicide deaths with medical record and genome-wide data (N = 4380). Examination of this cohort identified medical and genetic risks associated with type of suicide death and investigated the relative contributions of psychotic and affective symptoms to method of suicide. Key differences in method of suicide (common vs. atypical methods) were tested in relation to lifetime psychosis and genome-wide genetic risk for schizophrenia, major depressive disorder, and neuroticism. Consistent with previous studies, psychosis-spectrum disorders were observed to be common in suicide (15% of the cohort). Individuals with psychosis more frequently died from atypical methods, with rates of atypical suicide increasing across the schizophrenia spectrum. Genetic risk for schizophrenia was also associated with atypical suicide, regardless of clinical diagnosis, though this association weakened when filtering individuals with schizophrenia from the analysis. Follow-up examination indicated that high rates of atypical suicide observed in schizophrenia are not likely accounted for by restricted access to firearms. Overall, better accounting for the increased risk of atypical suicide methods in psychosis could lead to improved prevention strategies in a large portion of the suicide risk population.

Genome-Wide Association Study of Suicide Death and Polygenic Prediction of Clinical Antecedents

OBJECTIVE

Death by suicide is a highly preventable yet growing worldwide health crisis. To date, there has been a lack of adequately powered genomic studies of suicide, with no sizable suicide death cohorts available for analysis. To address this limitation, the authors conducted the first comprehensive genomic analysis of suicide death using previously unpublished genotype data from a large population-ascertained cohort.

METHODS

The analysis sample comprised 3,413 population-ascertained case subjects of European ancestry and 14,810 ancestrally matched control subjects. Analytical methods included principal component analysis for ancestral matching and adjusting for population stratification, linear mixed model genome-wide association testing (conditional on genetic-relatedness matrix), gene and gene set-enrichment testing, and polygenic score analyses, as well as single-nucleotide polymorphism (SNP) heritability and genetic correlation estimation using linkage disequilibrium score regression.

RESULTS

Genome-wide association analysis identified two genome-wide significant loci (involving six SNPs: rs34399104, rs35518298, rs34053895, rs66828456, rs35502061, and rs35256367). Gene-based analyses implicated 22 genes on chromosomes 13, 15, 16, 17, and 19 (q<0.05). Suicide death heritability was estimated at an h2SNP value of 0.25 (SE=0.04) and a value of 0.16 (SE=0.02) when converted to a liability scale. Notably, suicide polygenic scores were significantly predictive across training and test sets. Polygenic scores for several other psychiatric disorders and psychological traits were also predictive, particularly scores for behavioral disinhibition and major depressive disorder.

CONCLUSIONS

Multiple genome-wide significant loci and genes were identified and polygenic score prediction of suicide death case-control status was demonstrated, adjusting for ancestry, in independent training and test sets. Additionally, the suicide death sample was found to have increased genetic risk for behavioral disinhibition, major depressive disorder, depressive symptoms, autism spectrum disorder, psychosis, and alcohol use disorder compared with the control sample.

A model for migratory B cell oscillations from receptor down-regulation induced by external chemokine fields

A long-standing paradigm in B cell immunology is that effective somatic hypermutation and affinity maturation require cycling between the dark zone and light zone of the germinal center. The cyclic re-entry hypothesis was first proposed based on considerations of the efficiency of affinity maturation using an ordinary differential equations model for B cell population dynamics. More recently, two-photon microscopy studies of B cell motility within lymph nodes in situ have revealed the complex migration patterns of B lymphocytes both in the preactivation follicle and post-activation germinal center. There is strong evidence that chemokines secreted by stromal cells and the regulation of cognate G-protein coupled receptors by these chemokines are necessary for the observed spatial cell distributions. For example, the distribution of B cells within the light and dark zones of the germinal center appears to be determined by the reciprocal interaction between the level of the CXCR4 and CXCR5 receptors and the spatial distribution of their respective chemokines CXCL12 and CXCL13. Computer simulations of individual-based models have been used to study the complex biophysical and mechanistic processes at the individual cell level, but such simulations can be challenging to parameterize and analyze. In contrast, ordinary differential equations are more tractable, but traditional compartment model formalizations ignore the spatial chemokine distribution that drives B cell redistribution. Motivated by the desire to understand the motility patterns observed in an individual-based simulation of B cell migration in the lymph node, we propose and analyze the dynamics of an ordinary differential equation model incorporating explicit chemokine spatial distributions. While there is experimental evidence that B cell migration patterns in the germinal center are driven by extrinsically regulated differentiation programs, the model shows, perhaps surprisingly, that feedback from receptor down-regulation induced by external chemokine fields can give rise to spontaneous interzonal and intrazonal oscillations in the absence of any extrinsic regulation. While the extent to which such simple feedback mechanisms contributes to B cell migration patterns in the germinal center is unknown, the model provides an alternative hypothesis for how complex B cell migration patterns might arise from very simple mechanisms.

Influence of ZNF804a on brain structure volumes and symptom severity in individuals with schizophrenia

CONTEXT The single-nucleotide polymorphism rs1344706 in the gene ZNF804a has been associated with schizophrenia and with quantitative phenotypic features, including brain structure volume and the core symptoms of schizophrenia. OBJECTIVE To evaluate associations of rs1344706 with brain structure and the core symptoms of schizophrenia. DESIGN Case-control analysis of covariance. SETTING University-based research hospital. PARTICIPANTS Volunteer sample of 335 individuals with schizophrenia spectrum disorders (306 with core schizophrenia) and 198 healthy volunteers. MAIN OUTCOME MEASURES Cerebral cortical gray matter and white matter (WM) volumes (total and frontal, parietal, temporal, and occipital lobes), lateral ventricular cerebrospinal fluid volume, and symptom severity from the Scale for the Assessment of Negative Symptoms and the Scale for the Assessment of Positive Symptoms divided into 3 domains: psychotic, negative, and disorganized. RESULTS The rs1344706 genotype produced significant main effects on total, frontal, and parietal lobe WM volumes (F = 3.98, P = .02; F = 4.95, P = .007; and F = 3.08, P = .05, respectively). In the schizophrenia group, rs1344706 produced significant simple effects on total (F = 3.93, P = .02) and frontal WM volumes (F = 7.16, P < .001) and on psychotic symptom severity (F = 6.07, P = .003); the pattern of effects was concordant with risk allele carriers having larger volumes and more severe symptoms of disease than nonrisk homozygotes. In the healthy volunteer group, risk allele homozygotes had increased total WM volume compared with nonrisk allele carriers (F = 4.61, P = .03), replicating a previously reported association. CONCLUSIONS A growing body of evidence suggests that the risk allele of rs1347706 is associated with a distinctive set of phenotypic features in healthy volunteers and individuals with schizophrenia. Our study supports this assertion by finding that specific genotypes of the polymorphism are associated with brain structure volumes in individuals with schizophrenia and healthy volunteers and with symptom severity in schizophrenia.

Nonclassical kinetics of an elementary A+B-->C reaction-diffusion system showing effects of a speckled initial reactant distribution and eventual self-segregation: experiments

We demonstrate here the implementation of an experimental system suitable for the study of the diffusion limited A+B-->0, nonclassical reaction behavior. Using a combination of a fluorescent calcium indicator and a calcium ion which is initially "caged," a pulse of near-UV light initiates the reaction which is followed as product formation vs time. Sensitive dependence on the initial reactant distribution is observed through patterns in the uncaging UV light profile. In one case, the reaction progress passes through two nonclassical time regimes, one due to roughness originating from laser speckles, followed by one consistent with the three-dimensional Zeldovich rate of (1/rho(A)-1/rho(A0)) approximately t(3/4), with features matching Monte Carlo simulations on this initial distribution. This behavior is contrasted with reactions initiated by a homogeneous source which induces random initial reactant distributions, though both systems seem to approach the asymptotic limit of self-segregation of reactants.

The impact of external beam radiation therapy prior to autologous bone marrow transplantation in patients with non-Hodgkin's lymphoma

External beam radiation therapy (XRT) is frequently used to treat refractory disease sites or consolidate remission in patients with relapsed non-Hodgkin's lymphoma (NHL) prior to autologous bone marrow transplantation (ABMT). We report the long-term outcome and toxicities associated with this therapy. We uniformly treated 552 patients with NHL with total body irradiation, high-dose chemotherapy, and anti-B-cell monoclonal antibody-purged ABMT. Of these patients, 152 received XRT to the mediastinum, abdomen, or pelvis (n = 102) or other sites (n = 50) prior to ABMT. In this nonrandomized series, there was no difference in progression-free survival between patients treated with XRT and those not treated with XRT. For patients with indolent histology, there was no difference in overall survival between patients treated with XRT and those not treated with XRT. For patients with aggressive histology, the median overall survival time was 64 months in the XRT patients and 79 months in the patients not treated with XRT (P= .09). The risk of acute transplantation-related deaths was not influenced by prior XRT (P = .68). Of patients who received XRT, 12.5% developed secondary myelodysplasia compared with 5.8% of patients not receiving XRT (P = .01). Patients receiving XRT to the mediastinum or axilla had a significantly higher risk of late respiratory death (P = .002). In conclusion, XRT allows refractory patients to become eligible for transplantation and experience a disease-free survival interval equivalent to that of patients who do not receive XRT. However, a higher incidence of non-relapse-associated deaths was observed in patients who received XRT. Future work should explore alternative conditioning strategies and altered timing of XRT, in an attempt to limit these late toxicities.

A fluorescent PEBBLE nanosensor for intracellular free zinc

The development and characterisation of a fluorescent optical PEBBLE (Probe Encapsulated By Biologically Localised Embedding) nanosensor for the detection of zinc is detailed. A ratiometric sensor has been fabricated that incorporates two fluorescent dyes; one is sensitive to zinc and the other acts as a reference. The sensing components are entrapped within a polymer matrix by a microemulsion polymerisation process that produces spherical sensors that are in the size region of 20 to 200 nm. Cellular measurements are made possible by the small sensor size and the biocompatibility of the matrix. The effects of reversibility, photobleaching and leaching have been examined, as well as the selectivity towards zinc over other cellular ions such as Na+, Ca2+, K+, and Mg2+. The dynamic range of these sensors was found to be 4 to 50 microM Zn2+ with a linear range from 15 to 40 microM. The response time for the PEBBLE is less than 4 s and the sensor is reversible. In addition, the nanosensors are photostable and leaching from the matrix, determined using a novel method, is minimal. These sensors are capable of real-time inter- and intra-cellular imaging and are insensitive to interference from proteins.

Observation of laser speckle effects and nonclassical kinetics in an elementary chemical reaction

An experimental demonstration is provided for memory-based, nonclassical reaction kinetics in a homogeneous system with an elementary reaction, A+B-->C. A new reaction-kinetics regime is observed which is a direct consequence of speckles in the laser beam. However, in spite of the nonrandom, speckled initial distribution of reactant B, the long-time regime gives the first experimental demonstration of the asymptotic self-segregation ("Zeldovich") effect. Monte Carlo simulation results are consistent with the experiments.

Lifetime enhancement of ultrasmall fluorescent liquid polymeric film based optodes by diffusion-induced self-recovery after photobleaching

The major concern with optodes, especially miniaturized ones, has been their photobleaching limited lifetime. Liquid polymer [highly plasticized poly(vinyl chloride)] films are commonly used to prepare fluorescent optical fiber sensors. A major advantage is the ease of their fabrication. It is demonstrated here that, with proper choice of excitation power and illumination time, the sensor will completely recover itself from photobleaching after each measurement. This self-recovery is demonstrated on single-mode optical fibers with 80 microns diameter (3.1 microns active region) and on near-field scanning optical microscope pulled fiber tips with submicrometer diameter (250 nm active region). The single-mode optode can be used for 30,000 measurements with only a 5% signal loss at a signal/noise of > 66. This opens the way for prolonged ratiometric application of such optodes.

Implementation of an NSOM system for fluorescence microscopy

We describe our progress toward an NSOM system intended for fluorescence imaging of biological samples. This process included integration of shear-force feedback into an existing NSOM system. Topographic images acquired using uncoated tips are presented. We also present our initial effort at simultaneous acquisition of topographic and fluorescence data using an aluminum coated tip.