Predictors and Correlates of Positive Urine Drug Screening in a Retrospective Cohort Analysis of Child and Adolescent Psychiatry Inpatients Throughout the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Youth substance use is associated with significant psychological, neurological, and medical complications. Risk factors for substance use among children and adolescents in the general population include peer and/or parental substance use, certain psychiatric illnesses (eg, Attention-Deficit/Hyperactivity Disorder, depression), and history of maltreatment. Co-occurring substance use and psychiatric illness have been associated with increased suicidality, but few prior studies have characterized substance use among child/adolescent inpatients. As such, it remains unclear how substance use contributing to acute psychiatric presentations has changed since the start of the COVID-19 pandemic.

METHODS

This is a retrospective cohort study of 816 unique child/adolescent psychiatry inpatients with urine drug screening (UDS) results from a diverse urban setting. Charts of patients hospitalized between June 1, 2018 and November 30, 2021 were reviewed for sociodemographic characteristics, indication for admission, psychiatric history, hospital course, treatment plan, and discharge diagnosis. Differences in sociodemographic and clinical characteristics, such as age, race, and diagnoses, between patients with and without positive UDS were explored throughout various periods of the COVID-19 pandemic. Descriptive and comparative statistics were performed, as well as a logistic regression model to identify the predictors of positive UDS.

RESULTS

Of the study sample, 18% had a positive UDS. Older age, diagnosis of impulsive or behavioral disorder, and a history of violence were found to be predictors of positive UDS. Asian/South Asian or Hispanic/LatinX race and history of a developmental or intellectual disability were found to be negative predictors. The frequency of positive UDS in this population did not change based on COVID-19.

DISCUSSION AND CONCLUSIONS

Multiple factors may predispose children and adolescents to substance use. Though no impact of COVID-19 was found in this sample, longer-term studies are needed.

SCIENTIFIC SIGNIFICANCE

This study identifies independent predictors of active substance use in the child and adolescent psychiatric inpatient population.

Precarious Manhood Beliefs Are Positively Associated with Erectile Dysfunction in Cisgender Men

The notions that manhood is hard to attain, easy to lose, and needs to be proven via public action constitute precarious manhood beliefs (PMB). PMB is a new concept and it remains unclear whether and how PMB relate to erectile dysfunction (ED) in cisgender men. The ability to achieve an erection remains considered as a cornerstone of masculinity and sexual performance can be conceived as a proof of one's masculinity. In this context, ED can be received as sexual failure and a threat to a man's masculinity and sense of adequacy. For these reasons, the hypothesis that PMB are associated with ED warranted empirical testing. In an anonymous online survey focusing on men's mental health conducted in German-speaking countries of Europe, 507 cisgender men (Mage = 44.2, SDage = 15.2) completed measures on PMB, sexual function, self-stigma, social desirability, and conformity to traditional masculinity ideology (TMI). Multilinear regression analysis with stepwise introduction of relevant covariates evaluated potential associations between PMB and ED. Of a 507 cisgendered male sample, 63.1% reported an increased risk for ED based on previously established cutoff points. Elevated levels of PMB endorsement among the men predicted reduced sexual and erectile function in all models, even when accounting for relevant control variables such as age, education, self-stigma, social desirability, or conformity to TMI. Group comparisons revealed that the men suffering from ED showed higher levels of PMB endorsement but not self-stigma nor TMI relative to men without ED. PMB are significantly associated with ED. While determining causality will require further study, our results may support the hypothesis that higher levels of PMB endorsement may lead to increased tension to perform sexually, resulting in increased psychological pressure and a higher risk to develop ED.

Using Technology to Limit the Impacts of Isolation on Youth in Inpatient Psychiatry Units

The COVID-19 pandemic has been identified as a mental health crisis for children and adolescents in America.1 Social isolation and loneliness during the pandemic present a significant challenge. A rapid systematic review published in this journal found that social isolation correlates with depression and anxiety and may heighten the risk of disorder onset.2 Specifically in an infectious disease context, research on the H1N1 influenza pandemic showed that children in North America required to quarantine were 5 to 30 times more likely to meet criteria for posttraumatic stress disorder than children not under these restrictions.2.

Difference in Psychiatric Hospital Admissions Between Cisgender and Transgender and Gender Nonconforming Youth, Before and During the Start of the COVID-19 Pandemic

This retrospective study of 1101 children and adolescents examines differences in psychiatric admissions between cisgender and transgender/gender nonconforming (TGNC) youth between June 2018 and November 2021. Sociodemographic and clinical characteristics for each admission were extracted from medical records. We compared proportion of total admissions and clinical characteristics between cisgender and TGNC youth, during specified time frames of pre-COVID-19, during quarantine, and post-quarantine. During quarantine, 294 (89.9%) youth identified as cisgender and 33 (10.1%) youth identified as TGNC. Post-quarantine, 205 (88.4%) youth identified as cisgender and 27 (11.6%) identified as TGNC. TGNC patients had more history of mood disorders (p < 0.001), self-injurious behavior (p < 0.001), and suicide attempt (p = 0.007), whereas cisgender patients had more history of Attention-deficit/Hyperactivity Disorder (ADHD) (p = 0.011) and violence (p < 0.001) across each time frame of the study. TGNC patients were more likely to be admitted due to suicidal ideation (p = 0.003), whereas cisgender patients were more often admitted for aggression (p < 0.001). There was no change across COVID-19 time periods in terms of any psychiatric history variable among patients identifying as TGNC. The proportion of admitted youth identifying as TGNC increased by 8.1% from pre-COVID-19 to post-quarantine (p < 0.001). These findings suggest that TGNC youth might be particularly vulnerable to mental health crises when faced with pandemic-related stressors. Further research on the vulnerabilities of TGNC youth during sudden and extreme social changes and how this can impact their mental health is necessary, as global pandemics could and are anticipated to repeat.

Evaluation of a male-specific psychotherapeutic program for major depressive disorder compared to cognitive behavioral therapy and waitlist: study protocol for a six-arm randomized clinical superiority trial examining depressed eugonadal and hypogonadal men receiving testosterone

Background

Treatment of major depressive disorder (MDD) in men is complicated by the endorsement of traditional masculinity ideologies (TMI) often leading to reluctance toward psychotherapy, therapy interfering processes, or premature termination. In addition, it has been shown that men with MDD have a significantly increased risk of being hypogonadal (e.g., total testosterone levels <12.1 nmoL/L). Therefore, it is recommended to examine depressed men with regard to their testosterone status and if hypogonadism is present to combine psychotherapy with testosterone treatment (TT).

Aim

This project aims to evaluate a male-specific psychotherapeutic program (MSPP) for MDD in depressed eugonadal and hypogonadal men receiving testosterone in comparison to a standard cognitive behavioral therapy (CBT) for MDD and a Waitlist.

Methods

The study presents a 2×3 factorial study design. In total, 144 men aged between 25 and 50 will be stratified by testosterone status (eugonadal/hypogonadal) and then randomized into one of the three conditions (MSPP, CBT, or Waitlist). Additionally, a healthy control group of 100 men will be recruited, which will undergo only baseline assessments. Both standardized psychotherapy programs will encompass 18 sessions delivered in a weekly manner. Aligned with the TT-related medical visits of the 72 hypogonadal men, all participants will be followed up with clinical assessments and bio sampling at weeks 0, 6, 15, 24, and 36.

Expected results

Compared to Waitlist control groups, treatment groups are expected to be more effective and efficacious (depression score reduction of ≥50%) at week 24 and at the follow-up at week 36. The MSPP is expected to show higher effectiveness and efficacy for depressive symptoms and higher acceptability (lower dropout rate) as compared to CBT.

Discussion

This study represents the first attempt to test a male-specific psychotherapy for MDD in a single-setting compared to standard CBT and a Waitlist control condition using randomized clinical trial methodology. In addition, the potential positive adjunct effect of psychotherapy to TT in reducing depressive burden and improving quality of life in hypogonadal depressed men represents a neglected research area and might introduce new hypogonadism screening procedures in depressed men and combined treatment approaches for depressed men suffering from hypogonadism. Limitations are the rigorous inclusion and exclusion criteria, which limit the generalizability of the study results to first episode treatment naïve depressed men.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT05435222.

The community engagement course and action network: strengthening community and academic research partnerships to advance health equity

Background

Historically Black Colleges and Universities and Minority Serving Institutions are uniquely positioned to implement community-campus research partnerships based on a history of service, the pursuit of community trustworthiness and student demographics often similar to surrounding marginalized communities. The Morehouse School of Medicine Prevention Research Center collaborates with members of Historically Black Colleges and Universities, Minority Serving Institutes, and community organizations on the Community Engaged Course and Action Network. This network is the first of its kind and aims to strengthen members' ability to implement Community-Based Participatory Research (CBPR) principles and partnerships. Projects address public health priorities including mental health among communities of color, zoonotic disease prevention, and urban food deserts.

Materials and methods

To assess the effectiveness of the network, a Participatory Evaluation framework was implemented to conduct process evaluation which included review of partnership structures, operations, project implementation processes, and preliminary outcomes of the research collaborations. A focus group of Community Engagement Course and Action Network members (community and academic) was also conducted to identify benefits and challenges of the network with emphasis on key areas for improvement to further enhance the relationships between partners and to facilitate their subsequent community-campus research.

Results

Network improvements were tied to themes strengthening community-academic partnerships including sharing and fellowship, coalition building and collaboration, and greater connections and awareness of community needs through their current community-academic partnerships. The need to conduct ongoing evaluation during and after implementation, for determining the early adoption of CBPR approaches was also identified.

Conclusion

Evaluation of the network's processes, infrastructure, and operation provides early lessons learned to strengthen the network. Ongoing assessment is also essential for ensuring continuous quality improvement across partnerships such as determining CBPR fidelity, assessing partnership synergy, and dynamics, and for quality improvement of research protocol. The implications and potential for advancing implementation science through this and similar networks are great towards advancing leadership in modeling how foundations in community service can advance to CBPR partnership formation and ultimately, health equity approaches, that are local defined and assessed.

Autism Spectrum Disorders: There Remains a Place for Psychodynamic Psychiatry through Neuroplasticity, Emotion Regulation, Caring Connections, and Hope

There remains a role for psychodynamic psychiatry in the care of individuals with autism spectrum disorders (ASDs). Contemporary psychodynamic models are uniquely positioned to integrate today's neurobiological understandings of ASD with the subjective experience of those with ASD. Historical psychodynamic formulations of ASD struggled to appreciate the interrelatedness of biological, psychological, and social complexities in individuals with this disorder. Emotionally experienced or "illusory" environmental deprivation, early life stress, and allostatic overload, along with biological factors, current stress, and neuroplasticity, drive maladaptive coping and lead to difficulties with relationships. Fears of caring emotional connections are related to self-protective isolation and other maladaptive efforts to regulate emotions, shutting out what the child needs most-parents' love and help. In a nonlinear way, maladaptive emotion regulation further interferes with the development of the social brain. Thus, a psychodynamic defense-oriented focus upon adaptive emotion regulation provides a therapeutic avenue. Helping build the child's capacity for adaptive emotion regulation, which includes letting others help, can lead to a sense of safety and promote caring connections, a positive outcome. The authors offer guidance in the treatment of individuals with ASD in accordance with contemporary understandings of the disorder and care.

The Behavioral Health Needs of Youth With Preexisting Psychiatric Disorders in the Aftermath of COVID-19

Children and adolescents with psychiatric disorders are a sizable population of children and youth with special health care needs. While the capabilities of behavioral health resources to meet these youth's needs were already strained, the Coronavirus Disease 2019 (COVID-19) pandemic extended resource limitations just as this subgroup of children and youth with special health care needs faced new stressors and potential exacerbations of their underlying psychiatric illnesses. In this article, we provide a brief narrative review of the factors' manifestations with an emphasis upon their disproportionate impact upon children of color and their families and particularly those from disadvantaged communities. We proceed to provide policy proposals for addressing these disparities. These include raising reimbursement for behavioral health services, increasing telehealth care delivery, reducing inter-state licensing requirements, increasing community-based services, and addressing social determinants of health. Conclusions and directions for strengthening behavioral health service delivery capabilities and addressing systemic injustices are made.

Depression and Suicidal Behavior in Adolescents

Depression commonly onsets in adolescence, affecting approximately 1 in 4 female adolescents and 1 in 10 males in the United States. Adolescent depression is a significant risk factor for suicide, the cause of over a third of all American adolescent deaths. Adolescent depression is introduced alongside its developmental and gendered considerations with a focus on important risk factors of adolescent depression, including nonsuicidal self-injury, adverse childhood experiences, and substance abuse. Protective factors and contemporary special topics of the COVID-19 pandemic and social media use are reviewed. Therapeutic options and clinical barriers are highlighted before a summary of findings and conclusion.

Femicide and Public Health Ethics: Approaching Gender-based Violence and Death in the Health Professions

Femicide is an ongoing public health and human rights crisis of global proportions. Currently, however, there is a relative vacuum of ethics theory and discussion about femicide amongst the health professions. This article draws from three illustrative case examples along the continuum of femicide to explore contemporary ethical concerns relevant to addressing gender-based violence and death through clinical medicine and public health. Using an epistemic justice framework, we analyze the relative invisibility of femicide in public health discourse today, and renew a conversation about ethical issues inherent to health interventions and policy-making around femicide.

Identifying and Managing Suicidality in Children and Adolescents with Chronic Pain: Evidence-Based Treatment Strategies

Children and adolescents with chronic pain are at an increased risk of suicidality. This narrative review article aims to inform clinical practice in the assessment and management of suicidality in youth with chronic pain. The article begins with a survey of the background and prevalence of youth with chronic pain. A review of the current evidence behind the increased risk of suicidality in youth with chronic pain follows. Contextualization of this data with general tenets of child and adolescent suicide risk and risk assessment is provided. Suicidology theory including the interpersonal theory of suicide is overviewed to help clinicians to conceptualize the reviewed data. Guiding parameters for the suicide risk assessment and management planning is presented. Concluding recommendations are made to guide clinical practice in the assessment and management of suicidality in youth with chronic pain.

Collaborative to Increase Lethal Means Counseling for Caregivers of Youth With Suicidality

BACKGROUND

The number of youth presenting to hospitals with suicidality and/or self-harm has increased substantially in recent years. We implemented a multihospital quality improvement (QI) collaborative from February 1, 2018 to January 31, 2019, aiming for an absolute increase in hospitals' mean rate of caregiver lethal means counseling (LMC) of 10 percentage points (from a baseline mean performance of 68% to 78%) by the end of the collaborative, and to evaluate the effectiveness of the collaborative on LMC, adjusting for secular trends.

METHODS

This 8 hospital collaborative used a structured process of alternating learning sessions and action periods to improve LMC across hospitals. Electronic medical record documentation of caregiver LMC was evaluated during 3 phases: precollaborative, active QI collaborative, and postcollaborative. We used statistical process control to evaluate changes in LMC monthly. Following collaborative completion, interrupted time series analyses were used to evaluate changes in the level and trend and slope of LMC, adjusting for covariates.

RESULTS

In the study, 4208 children and adolescents were included-1314 (31.2%) precollaborative, 1335 (31.7%) during the active QI collaborative, and 1559 (37.0%) postcollaborative. Statistical process control analyses demonstrated that LMC increased from a hospital-level mean of 68% precollaborative to 75% (February 2018) and then 86% (October 2018) during the collaborative. In interrupted time series analyses, there were no significant differences in LMC during and following the collaborative beyond those expected based on pre-collaborative trends.

CONCLUSIONS

LMC increased during the collaborative, but the increase did not exceed expected trends. Interventions developed by participating hospitals may be beneficial to others aiming to improve LMC for caregivers of hospitalized youth with suicidality.

Impact of global feminist film curriculum on medical student engagement in women's health

Film effectvely imparts experiential knowledge of lived experiences especially in cross-cultural settings. Incorporating film into medical education can catalyze awareness of global issues in women's health. Film-based interventions highlighting such topics have not been reported in literature. This study outlines one session of an 8-week elective course for trainees to engage with topics in women's health through global cinema. Quantitative and qualitative data were collected from participants during each session and via post-session surveys. Class discussions and survey data reflected favorable responses and positive engagement with the pre-session film viewings and 75-minute weekly discussions. A feminist, film-based curriculum for medical and graduate students may broaden trainees' knowledge of global women's health. In medical education, film may serve as an effective tool to encourage a life-course and gender equity approach to women's health topics, rather than more traditional sexual-reproductive framings.

Defense-Oriented Psychoanalytic Psychotherapy as a Tailored Treatment for Boys: Neurobiological Underpinnings to Male-Specific Response Tested in Regulation-Focused Psychotherapy for Children

This paper presents defense-oriented psychoanalytic psychotherapy as a tailored treatment for boys through a neurophysiological hypothesis. Male central nervous system development is reviewed, with a focus on the development of the emotion regulation system. The organizational effects of pre- and post-natal androgens delay central nervous system development in males relative to females, following a caudal to rostral phylogenetic framework. Ventromedial prefrontal structures mature at an earlier developmental age than dorsolateral prefrontal structures, creating less of a gender gap in the available underlying neural architecture for responsivity to targeted therapeutic intervention. The hypothesized operation of defense analysis upon ventromedial prefrontal cortical structures and corticolimbic connectivity therefore positions boys to benefit from psychotherapy equally as girls. In this study, we explored gender differences in presentation and response to a short-term, manualized defense-oriented psychoanalytic psychotherapy named regulation-focused psychotherapy for children. In a sample size of 43 school-aged children, consisting of 32 boys and 11 girls, with oppositional defiant disorder, we found no statistically significant differences in participant characteristics upon entry nor in treatment response, as measured by changes in scores on the Oppositional Defiant Disorder Rating Scale, the oppositional defiant problems subscale of the Child Behavior Checklist, the suppression and reappraisal subscales of the Emotion Regulation Questionnaire for Children and Adolescents, and the lability and negativity subscale of the Emotion Regulation Checklist. The findings were comparable with the gendered findings of preexisting studies of play therapy, where boys and girls improve equally, but not of behaviorally predominant psychotherapy, where girls appear to have superior responses. Our findings suggest that the treatment as a general play therapy, but with a focus on the implicit emotion regulation system, was successful in meeting boys’ gendered treatment needs. Conclusions are drawn with implications for further study.

Resuscitative endovascular balloon occlusion of the aorta in Canada: a context-specific position paper from the Canadian Collaborative for Urgent Care Surgery (CANUCS)

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology.

Preparing for the COVID-19 paediatric mental health crisis: A focus on youth reactions to caretaker death

To promote clinician preparedness for working with children and adolescents who lost or will lose a parent or caretaker to COVID-19, findings from a review of the literature concerning youth reactions to parent and caretaker death and incapacitation were integrated with recent and emergent data concerning the COVID-19 pandemic. Children and adolescents who lose a parent or caretaker are at an increased risk of anxiety and depressive reactions and disorders, externalizing and health-risk behaviours, and substance use disorders. Particular aspects of the COVID-19 pandemic may influence these presentations and the risk of complicated grief. Youth with prior histories of adverse childhood experiences as well as boys and young men may require special considerations in formulation and planning. Tailored paediatric care based on the evidence advances accurate formulations and effective interventions for children and adolescents who suffer such a loss.

Randomized controlled trial of Regulation Focused Psychotherapy for children: A manualized psychodynamic treatment for externalizing behaviors

OBJECTIVE

This article examines outcomes of the first randomized controlled trial of Regulation Focused Psychotherapy for Children (RFP-C), a manualized, short-term, psychodynamic intervention for decreasing symptoms of the oppositional defiant disorder (ODD) in school-aged children.

METHOD

Participants (n = 43) were school-aged children who were randomly assigned to RFP-C or a waitlist control group. Symptoms of ODD and explicit emotion regulation capacities were assessed at baseline, end of waitlist, and end of treatment. Multilevel modeling was used to account for patient and therapist factors in outcomes.

RESULTS

At the end of treatment, parents reported significant reductions in children's ODD symptoms on the primary outcome measure. There were no observed changes in explicit emotion regulation. Reliable change index scores indicated that 79.4% of children were recovered or improved after 10 weeks of treatment. There were no identifiable patient or therapist effects. Treatment adherence and completion was high.

CONCLUSION

This study is the first randomized controlled trial of a manualized psychodynamic intervention for children with ODD. Participants demonstrated significant reductions in symptoms of ODD after 10 weeks of treatment. Further investigation is needed to compare RFP-C relative to active treatment, assess changes in implicit emotion, and to determine long-term maintenance of symptom improvement.Clinical trial registration information: Evaluation of Regulation Focused Psychotherapy for Children (RFP-C); https://clinicaltrials.gov/ct2/show/NCT03594253.

Inpatient Child and Adolescent Psychiatry as an Extracurricular Venue for Medical Student and Resident Education and Professional Development: Story Time and Teen Talk

OBJECTIVE

Comparatively little systematic data exists concerning medical student education from the inpatient child and adolescent psychiatry venue. Training in this venue is vulnerable to pressures including increasingly reduced lengths of stay and greater emphasis on clinical productivity. An extracurricular psychosocial opportunity during evening hours may be a productive means through which to provide meaningful patient exposure, training, and mentorship to trainees. We sought to evaluate the impact upon student beliefs and attitudes through participation in an initiative titled "Story Time and Teen Talk."

METHODS

Under the direct supervision of postgraduate resident physicians in psychiatry, students read fairy tales and children's literature to children and conducted group discussions with adolescents during weekly held evening hours. Students were invited to complete a 15-item questionnaire that surveyed the impact of their participation on their beliefs and attitudes concerning general medical education and patient care, the field of psychiatry, and training in child and adolescent psychiatry. A subset of students underwent a semi-structured interview which was evaluated via grounded theory analysis to determine qualitative themes related to impact of program participation.

RESULTS

Thirty students (N = 30) completed the survey and five students (N = 5) completed the interview. The majority of students reported strongly agreeing or agreeing that participation impacted their attitudes and beliefs about general medical education and patient care in twelve of the thirteen assayed items. Themes from qualitative analysis supported these findings.

CONCLUSIONS

Extracurricular opportunities may be a productive venue for graduate medical education and, specifically, child and adolescent psychiatry.

The US health system: on the brink of major change?

The US system has both considerable strengths and notable weaknesses. It has a large and well-trained health workforce, a wide range of high-quality medical specialists as well as secondary and tertiary institutions, a robust health sector research program, and, for selected services, among the best medical outcomes in the world. But it also suffers from incomplete coverage of its citizenry, health expenditures levels per person far exceeding all other countries, poor objective and subjective indicators of quality and outcomes, and an unequal distribution of resources and outcomes across the country and among different population groups. Because of the adoption of the Affordable Care Act in 2010, and subsequent revisions to it, the US is facing a period of enormous change. There is a great need to improve coverage and improve equity, better ensure quality outcomes, and find ways to better control expenditures.

Glycaemic control among patients with type 2 diabetes followed in a rural African primary care setting - A reality check in the Democratic Republic of Congo

AIMS

The aim of this study was to assess diabetes control in adult patients with type II diabetes and to evaluate its association with socio-economic characteristics in rural the Democratic Republic Congo (DRC).

METHODS

We recruited patients ≥18 years in care for type II diabetes in a hospital in rural DRC. Socio-economic status, medical history and diabetes control were assessed through a structured questionnaire, a physical examination and laboratory tests, such as fasting glucose, HbA1c, serum creatinine and urine analysis. Uni- and multivariate logistic regression was used to assess for patient factors associated with diabetes control.

RESULTS

319 diabetic patients (212 men, 107 women) were enrolled. The target threshold of HbA1c level at 7.0% or below was met by 17.8% (19/107) of female and 12.3% (26/212) of male patients. The fasting plasma glucose level was <7.0mmol/l in 28.9% (31/107) and 36.3% (77/212) of women and men, respectively. Among participants with a fasting glucose <7.0mmol/l only 32.4% (35/108) had an HbA1c at 7.0% or below. None of the assessed socio-economic or lifestyle factors were predictive of diabetes control.

CONCLUSIONS

In this study among diabetic patients in care at a rural hospital in DRC, less than one out of five had an HbA1c ≤7.0%. Fasting plasma glucose at study visit had poor correlation with HbA1c, only a third of patients with a fasting glucose level <7mmol/l had an HbA1c ≤7.0%.

A 30-day prospective audit of all inpatient complications following acute care surgery: How well do we really perform?

Background

Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown.

Methods

In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed.

Results

A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively.

Conclusion

Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada.

Bedside Optic Nerve Ultrasonography for Diagnosing Increased Intracranial Pressure: A Systematic Review and Meta-analysis

BACKGROUND

Optic nerve ultrasonography (optic nerve sheath diameter sonography) has been proposed as a noninvasive, quick method for diagnosing increased intracranial pressure.

PURPOSE

To examine the accuracy of optic nerve ultrasonography for diagnosing increased intracranial pressure in children and adults.

DATA SOURCES

13 databases from inception through May 2019, reference lists, and meeting proceedings.

STUDY SELECTION

Prospective optic nerve ultrasonography diagnostic accuracy studies, published in any language, involving any age group or reference standard.

DATA EXTRACTION

3 reviewers independently abstracted data and performed quality assessment.

DATA SYNTHESIS

Of 71 eligible studies involving 4551 patients, 61 included adults, and 35 were rated as having low risk of bias. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of optic nerve ultrasonography in patients with traumatic brain injury were 97% (95% CI, 92% to 99%), 86% (CI, 74% to 93%), 6.93 (CI, 3.55 to 13.54), and 0.04 (CI, 0.02 to 0.10), respectively. Respective estimates in patients with nontraumatic brain injury were 92% (CI, 86% to 96%), 86% (CI, 77% to 92%), 6.39 (CI, 3.77 to 10.84), and 0.09 (CI, 0.05 to 0.17). Accuracy estimates were similar among studies stratified by patient age, operator specialty and training level, reference standard, sonographer blinding status, and cutoff value. The optimal cutoff for optic nerve sheath dilatation on ultrasonography was 5.0 mm.

LIMITATION

Small studies, imprecise summary estimates, possible publication bias, and no evaluation of effect on clinical outcomes.

CONCLUSION

Optic nerve ultrasonography can help diagnose increased intracranial pressure. A normal sheath diameter measurement has high sensitivity and a low negative likelihood ratio that may rule out increased intracranial pressure, whereas an elevated measurement, characterized by a high specificity and positive likelihood ratio, may indicate increased intracranial pressure and the need for additional confirmatory tests.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42017055485).

A randomized controlled trial comparing tapentadol with oxycodone in non-breastfeeding women post elective cesarean section

BACKGROUND

Tapentadol may allow greater pain relief with reduced "opioid load" compared to oxycodone. Its use has not been studied in the obstetric population. The objective of this study was to compare the efficacy and side effect profile of tapentadol with oxycodone in patients who received spinal anesthesia for elective cesarean section. The trial was registered with EU Clinical Trials Register with CT number 2016-001621-33.

METHODS

This was a multicenter, randomized controlled trial. Randomized patients (n = 68) received either 50 mg tapentadol or oxycodone 10 mg 12 hourly postoperatively. The primary endpoint was the sum of pain intensity difference over the first 48 hours of treatment (SPID₄₈). Secondary outcomes included time to rescue medications, SPID₃₆, total pain relief (TOTPAR) scores, patient satisfaction scores, sum of total pain relief and pain intensity difference (SPRID) scores, time to rescue medications and side effects experienced. An analysis of covariance model with baseline pain intensity score as a covariate was used for statistical analysis.

RESULTS

There was no significant difference in the primary endpoint of SPID₄₈ with adjusted mean difference -11.45 (95% CI -35.35, 12.45) p = .34). Oxycodone showed significantly greater SPID₃₆ scores compared to tapentadol with increased time to rescue medication. Side effects experienced were similar between groups.

CONCLUSION

Tapentadol did not provide superior pain control or improved tolerability compared to oxycodone post cesarean section. Results should be interpreted however with consideration of administration of intrathecal opioids to all patients in this study and debate over the optimal dose of tapentadol for acute pain.

Why Is It Easier to Get Mad Than It Is to Feel Sad? Pilot Study of Regulation-Focused Psychotherapy for Children

OBJECTIVE:

This article reports results of a pilot study of three participants receiving regulation-focused psychotherapy for children (RFP-C), a manualized, short-term, psychodynamic treatment for children with oppositional defiant disorder and other externalizing problems. RFP-C targets implicit emotion regulation while using an intensive, psychodynamic, play therapy approach to decrease the child's need for disruptive behaviors.

METHODS:

Three children with oppositional defiant disorder participated in a trial of RFP-C. Externalizing symptoms were assessed with the Oppositional Defiant Disorder Rating Scale, and emotion regulation was assessed with the Emotion Regulation Checklist.

RESULTS:

All three children improved in accordance with expectations. Participants exhibited clinically significant and reliable change, as assessed by the primary symptom measure, and demonstrated improved capacity for emotional regulation.

CONCLUSIONS:

Results suggest that RFP-C has the potential to produce significant improvements in emotion regulation capacity and in symptoms of oppositional defiant disorder. This pilot study provides initial support for RFP-C as an efficacious and cost-effective intervention, with high treatment compliance rates, and lays the groundwork for a randomized controlled trial of the intervention.

The impact of timing of maternal influenza immunization on infant antibody levels at birth

Pregnant women and infants are at an increased risk of severe disease after influenza infection. Maternal immunization is a potent tool to protect both these at-risk groups. While the primary aim of maternal influenza vaccination is to protect the mother, a secondary benefit is the transfer of protective antibodies to the infant. A recent study using the tetanus, diphtheria and acellular pertussis (Tdap) vaccine indicated that children born to mothers immunized in the second trimester of pregnancy had the highest antibody titres compared to children immunized in the third trimester. The aim of the current study was to investigate how the timing of maternal influenza immunization impacts infant antibody levels at birth. Antibody titres were assessed in maternal and cord blood samples by both immunoglobulin (Ig)G-binding enzyme-linked immunosorbent assay (ELISA) and haemagglutination inhibition assay (HAI). Antibody titres to the H1N1 component were significantly higher in infants born to mothers vaccinated in either the second or third trimesters than infants born to unvaccinated mothers. HAI levels in the infant were significantly lower when maternal immunization was performed less than 4 weeks before birth. These studies confirm that immunization during pregnancy increases the antibody titre in infants. Importantly, antibody levels in cord blood were significantly higher when the mother was vaccinated in either trimesters 2 or 3, although titres were significantly lower if the mother was immunized less than 4 weeks before birth. Based on these data, seasonal influenza vaccination should continue to be given in pregnancy as soon as it becomes available.