A shift towards targeted post-ICU treatment: Multidisciplinary care for cardiac arrest survivors.

Intensive Care Unit (ICU) survivorship comprises a burgeoning area of critical care medicine, largely due to our improved understanding of and concern for patients' recovery trajectory, and efforts to mitigate the post-acute complications of critical illness. Expansion of care beyond hospitalization is necessary, yet evidence for post-ICU clinics remains limited and mixed, as both interventions and target populations studied to date are too heterogenous to meaningfully demonstrate efficacy. Here, we briefly present the existing evidence and limitations related to post-ICU clinics, identify cardiac arrest survivors as a unique ICU subpopulation warranting further investigation and treatment, and propose a clinical framework that addresses the multifaceted needs of this well-defined patient population.

Inpatient obstetric consultation-liaison services: Meeting unmet needs in perinatal mental health.

Obstetric patients are at increased risk for psychological distress and the development or exacerbation of mental illness, particularly in the setting of pregnancy or delivery complications. Inpatient antepartum, labor and delivery, and postpartum hospitalization is an important opportunity for psychiatric support and intervention. The aims of this paper are to review the unmet mental health needs in obstetric inpatient care, examine the current state of obstetric consultation-liaison (OB CL) psychiatry services, present one existing model of such a service at the authors' institution, provide broad recommendations for the structure and implementation of this service, and detail areas of future research within the area of OB CL psychiatry. We argue that the inpatient obstetric setting is a critical space for mental health evaluation, education and intervention, and that dedicated OB CL psychiatry services are a potentially valuable tool in addressing the perinatal mental health crisis.

Palliative Care Training for Geriatric Psychiatry Fellows: A National Survey Project.

OBJECTIVES: Palliative care is an essential part of the standard of care for individuals with serious medical illnesses. Integration of palliative care and mental health is important for elderly patients with medical and psychiatric comorbidities. Geriatric psychiatrists are natural stewards of palliative care-mental health integration, however this is contingent on palliative care training. Currently, palliative care training in geriatric psychiatry fellowship programs is uncharacterized. We surveyed geriatric psychiatry fellowship program directors in the United States to assess current palliative care training practices. METHODS: Web-based anonymous survey of geriatric psychiatry fellowship training directors RESULTS: Forty-six percent (28/61) of program directors responded. Seventy one percent (20/28) of programs provide didactics on palliative care. Seventy-seven percent (20/26) of programs provide clinical experiences in palliative care. Sixty-three percent (15/24) have formalized interactions between geriatric psychiatry and palliative care fellows. CONCLUSIONS: Palliative care training for geriatric psychiatry fellows is robust but unstandardized. Operationalizing palliative care training for geriatric psychiatrists may improve mental health integration into serious illness care.

Standardized Semistructured Psychosocial Evaluation Before Stem Cell Transplantation Predicts Delirium After Transplant.

BACKGROUND: Delirium affects many patients undergoing stem cell transplantation (SCT). Delirium is treatable, but prevention is a better goal, making it desirable to identify patients at heightened risk for delirium. A standardized pretransplant psychosocial assessment rating scale, the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT), has been demonstrated to predict outcomes in solid organ transplant recipients and nonadherence in patients with SCT. OBJECTIVES: In this study, we aimed to evaluate the association of SIPAT score and post-SCT incident delirium. METHODS: We retrospectively reviewed records of SCT recipients who had SIPAT evaluations before SCT, for indications of delirium in the 6 months after transplant. We tested the association between SIPAT score and delirium by logistic regression, controlling for relevant covariates such as transplant type (allogeneic vs autologous). RESULTS: Of 85 patients (median age of 49 years, range 18-74), 56 (66%) were men, and 43 (50.5%) were autologous SCT recipients. The median pretransplant SIPAT score was 8, range 0-40. There were 15 cases (17.6%) of delirium in the 6 months following transplant.  In univariate analyses, transplant type was significantly associated with incident delirium. In multivariate analyses, SIPAT score was significantly associated with incident delirium (odds ratio, 1.090; P = 0.021). CONCLUSIONS: Psychosocial risk as quantified by the SIPAT is associated with development of delirium in SCT recipients. This scale can therefore be integrated into medical risk models to anticipate which patients are at higher risk for delirium in their hospital course, enabling preventative measures tailored to the needs of the individual patient.

Report of the Academy of Consultation-Liaison Psychiatry Task Force on Lessons Learned From the COVID-19 Pandemic: Executive Summary.

BACKGROUND: The COVID-19 pandemic forced consultation-liaison psychiatrists to adapt to unprecedented circumstances. The Academy of Consultation-Liaison Psychiatry (ACLP) recognized the need and opportunity to assess its response and convened a task force in mid-2020 to review the lessons learned from the initial experience of the COVID-19 pandemic. OBJECTIVE: The aim of the study was to summarize experience and make recommendations to the ACLP Board of Directors about potential ACLP directions related to current and future pandemic response. METHODS: In August-November 2020, the task force reviewed local experiences, ACLP list-serv contributions, and the published literature and generated recommendations for ACLP actions. RESULTS: Recommendations addressed telepsychiatry, hospital staff wellness, support for consultation-liaison psychiatrists, the need for additional research on psychiatric and neuropsychiatric aspects of COVID-19, and the ACLP's role in advocacy and dissemination of information. The task force report was submitted to the ACLP Board of Directors in November 2020. CONCLUSIONS: As the preeminent organization of consultation-liaison psychiatrists, the ACLP can implement actions related to pandemic awareness and preparedness for the benefit of consultation-liaison psychiatrists, other health care workers, patients, and the general population.

Prevalence, Incidence, and Factors Associated with Posttraumatic Stress at Three-Month Follow-Up among New York City Healthcare Workers after the First Wave of the COVID-19 Pandemic.

BACKGROUND: Prevalence, incidence, and factors associated with posttraumatic stress disorder (PTSD) symptoms at follow-up among healthcare workers after the first wave of the COVID-19 pandemic are unknown. METHODS: A web survey invitation was sent to healthcare worker listservs at a NYC medical center (April, 2020). The Primary Care (PC)-PTSD questionnaire was used to screen for PTSD symptoms at baseline and then every 2 weeks for 10 weeks. Incidence and prevalence of PTSD symptoms were determined at each time point. Multivariable generalized estimating equation models were performed to investigate the factors associated with a positive PC-PTSD screen at follow-up. RESULTS: Median age (interquartile range) of N = 230 participants was 36 (31-48) years; 79.6% were women; 82.6% worked in COVID-19-focused settings. The prevalence of PTSD symptoms decreased from 55.2% at baseline to 25.0% at 10 weeks (p < 0.001). Among participants who had a baseline negative screen for PTSD symptoms, the incidence of PTSD at 10 weeks was 12.2% (p-trend 0.034). In multivariable-adjusted analyses, being a nurse (odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.06-2.71), female (OR: 3.00, 95% CI: 1.59, 5.72), and working in a COVID-19-focused location (OR: 1.51, 95% CI: 1.02, 2.21) were associated with increased odds of PTSD symptoms at 10-weeks. CONCLUSIONS: PTSD symptoms improved over 3 months following the first wave of the COVID-19 pandemic. However, one out of four NYC healthcare workers still had an increased risk for PTSD at 10-weeks. Screening healthcare workers for PTSD symptoms should be considered during the COVID-19 pandemic.

The Impact of Aerobic Training on Cardiovascular Reactivity to and Recovery From Psychological and Orthostatic Challenge.

OBJECTIVE: Elevated cardiovascular reactivity to, and reduced recovery from, challenging events may increase the risk of cardiovascular disease, and exercise training may reduce this reactivity. However, in a randomized controlled trial of aerobic versus strength training in sedentary, healthy young adults, we found no training group differences in reactivity or recovery. Because strength training also may have a reactivity-reducing effect, we conducted a secondary analysis of data from another trial, this time with a wait-list control condition. METHODS: One hundred nineteen healthy, young, sedentary adults were randomized to a 12-week aerobic training program or wait-list control. Before (T1) and after (T2) training and after 4 weeks of sedentary deconditioning (T3), we measured heart rate (HR), heart rate variability, and blood pressure at rest and in response to and recovery from psychological and orthostatic challenge. Data were analyzed using a group (aerobic versus wait-list) by session (T1, T2, and deconditioning) and by period (baseline, psychological challenge, recovery, standing) three-way analysis of variance with prespecified contrasts. RESULTS: Aerobic capacity significantly increased at T2 and decreased at T3 only in the aerobic training group. The groups did not differ on HR, heart rate variability, or blood pressure reactivity to or recovery from challenge. Without baseline adjustment, there were no significant treatment differences in response to challenges. With baseline adjustment, there were significant treatment by session effects for HR (Cohen d = 0.54, p = .002), systolic blood pressure (d = 0.44, p = .014), diastolic blood pressure (d = 0.74, p = .002), and root mean squared successive difference (d = 0.48, p = .006) reactivity from T1 to T2 only for orthostatic challenge: at T2, reactivity in the aerobic group was nonsignificantly reduced, compared with T1. In the wait-list group, reactivity significantly increased after T1. CONCLUSIONS: This study raises further doubt about attenuation of cardiovascular reactivity or enhancement of recovery as a cardioprotective mechanism of aerobic exercise training.Clinical Trial Registration:ClinicalTrials.gov Unique identifier: NCT01335737.

Depression, Anxiety, and Acute Stress Disorder Among Patients Hospitalized With COVID-19: A Prospective Cohort Study.

BACKGROUND: The epidemiology of psychiatric symptoms among patients with coronavirus disease 2019 is poorly characterized. OBJECTIVE: This article sought to identify the prevalence of anxiety, depression, and acute stress disorder among hospitalized patients with coronavirus disease 2019. METHODS: Adult patients recently admitted to nonintensive care unit medical ward settings with coronavirus disease 2019 were eligible for enrollment. Enrolled patients were screened for depression, anxiety, and delirium. Subsequently, patients were followed up by phone after 2 weeks and rescreened for depression, anxiety, and acute stress disorder symptoms. Subjects' medical records were abstracted for clinical data. RESULTS: A total of 58 subjects were enrolled; of whom, 44 completed the study. Initially, 36% of subjects had elevated anxiety symptoms and 29% had elevated depression symptoms. At 2-week follow-up, 9% had elevated anxiety symptoms, 20% had elevated depression symptoms, and 25% had mild-to-moderate acute stress disorder symptoms. Discharge to home was not associated with improvement in psychiatric symptoms. CONCLUSIONS: A significant number of patients hospitalized with coronavirus disease 2019 experienced symptoms of depression and anxiety. While anxiety improved after index admission, depression remained fairly stable. Furthermore, a significant minority of patients experienced acute stress disorder symptoms, though these were largely mild to moderate.

The National Dental Practice-Based Research Network Adult Anterior Open Bite Study: Patient satisfaction with treatment.

INTRODUCTION: This article evaluates and reports on the satisfaction of adult patients across the United States who received orthodontic treatment for anterior open bite malocclusion. The factors that influence satisfaction are also described. METHODS: Practitioners were recruited from the National Dental Practice-Based Research Network. On joining the Network, practitioner demographics and information on their practices were acquired. Practitioners enrolled their adult patients in active treatment for anterior open bite. Patient demographics, patient dentofacial characteristics, and details regarding previous and current treatment were collected through questionnaires at enrollment (T1). Pretreatment lateral cephalograms and intraoral frontal photographs were submitted. Treatment performed, and details related to treatment outcome were recorded through questionnaires at the end of active treatment (T2). Posttreatment lateral cephalograms and intraoral frontal photographs were submitted. Patient satisfaction at T2 was assessed using a 5-point Likert-type scale and open-ended responses. Predictive univariate models were developed to evaluate the factors that affect patient satisfaction. Open-ended responses were reviewed for general trends. RESULTS: T2 data were received for 260 patients, and 248 of these patients completed and returned the patient satisfaction questionnaires. High levels of satisfaction were found in this sample of adult patients receiving treatment for anterior open bite malocclusion. Specifically, 96% of the sample reported being very or somewhat satisfied. Only 10 patients (4%) were not satisfied with the treatment provided or an element of the final result. Successful open bite closure, treatment modality, and certain patient characteristics may affect patient satisfaction. However, there was insufficient power to demonstrate statistical significance because of the very low number of dissatisfied patients. Open-ended responses directly associated with patient satisfaction were received from 23 patients (9%). They relayed positive, neutral, and negative feelings about the treatment received and final results. Additional responses regarding the orthodontic treatment in general, but not specifically linked to patient satisfaction, were received from 119 patients (48%). These comments depict an overwhelmingly positive experience. CONCLUSIONS: Adult patients who received orthodontic treatment for anterior open bite malocclusion were generally satisfied with the treatment provided, as well as the final esthetic and functional results.

The National Dental Practice-Based Research Network Adult Anterior Open Bite Study: Treatment success.

INTRODUCTION: Anterior open bite (AOB) continues to be a challenging malocclusion for orthodontists to treat and retain long-term. There is no consensus on which treatment modality is most successful. This study reports on the overall success rate of AOB orthodontic treatment in the adult population across the United States, as well as 4 major treatment modalities and other factors that may influence treatment success. METHODS: Practitioners and their adult patients with AOB were recruited through the National Dental Practice-Based Research Network. Patient dentofacial and demographic characteristics, practitioner demographic and practice characteristics, and factors relating to orthodontic treatment were reported. Treatment success was determined from posttreatment (T2) lateral cephalometric films and intraoral frontal photographs. Treatment was categorized into 4 main groups: aligners, fixed appliances, temporary anchorage devices (TADs), and orthognathic surgery. Extractions were also evaluated. Bivariate and multivariable models were used to investigate the association between treatment success and treatment modality, pretreatment (T1) dentofacial characteristics, patient and practitioner demographics, and practice characteristics, adjusting for clustering of patients within practice. RESULTS: A total of 254 patients, enrolled by 84 practitioners, contributed to T2 data for this study. There were 29 patients in the aligner group, 152 in fixed appliances, 20 in TADs, and 53 in surgery. A total of 49 patients underwent extractions of teeth other than third molars. Ninety-three percent finished treatment with a positive overbite on the T2 lateral cephalogram, and 84% finished with a positive vertical overlap of all incisors. The small number of aligners and TAD patients limited the ability to compare success rates in these groups. Patients treated with orthognathic surgery had a higher rate of success compared with those treated with fixed appliances only. Treatment success was also associated with academic practice setting, T1 mandibular plane angle ≤30°, no to mild T1 crowding, and treatment duration <30 months. CONCLUSIONS: The overall success of orthodontic treatment in adult patients with AOB who participated in this study was very high. Orthognathic surgery was the only treatment modality that exhibited a statistically higher odds of successful outcomes. Some T1 dentofacial characteristics and treatment factors were associated with the successful closure of AOB.

End-of-Life Care in Individuals With Serious Mental Illness.

BACKGROUND: Approximately 4.5% of the population live with serious mental illness (SMI), a term referring to mental health disorders that are chronic, impair function, and require ongoing treatment. People living with SMI are at risk of premature mortality relative to people without SMI. Chronic medical illnesses contribute significantly to mortality among individuals with SMI. The standard of care for individuals with serious medical illnesses includes palliative care. However, the provision of palliative care has not been operationalized for individuals with SMI. OBJECTIVES: To review existing data on end-of-life and palliative care for individuals with serious medical illness and comorbid serious mental illness. To operationalize the role of the consultation-liaison (C-L) psychiatrist in such care, with a particular eye towards redressing disparities. METHODS: In this narrative review, we draw upon a review of the literature on end-of-life and palliative care provision for individuals with serious medical illness and comorbid serious medical illness. We also draw upon the experiences of the authors in formulating best practices for the care of such patients. RESULTS: Individuals with SMI are at risk of suboptimal end-of-life care. Patient, clinician, and system-level factors all contribute to disparities including decreased access to palliative care, uneven continued engagement with mental health services, and low rates of advance care planning. C-L psychiatrists can use their expertise at the intersection of medicine and psychiatry to address such disparities by (1) correcting misassumptions, (2) promoting advance care planning, (3) engaging long-term caregivers, (4) recognizing social needs, (5) ensuring ongoing access to psychiatric treatment, and (6) addressing suffering. CONCLUSIONS: There are significant disparities in the end-of-life care of individuals with SMI. C-L psychiatrists have expertise to ally with medical providers and redress these disparities.

The Creation of a Psychiatry-Palliative Care Liaison Team: Using Psychiatrists to Extend Palliative Care Delivery and Access During the COVID-19 Crisis.

CONTEXT: During the course of March and April 2020, New York City experienced a surge of a 170,000 coronavirus disease 2019 (COVID-19) cases, overwhelming hospital systems and leading to an unprecedented need for palliative care services. OBJECTIVES: To present a model for rapid palliative care workforce expansion under crisis conditions, using supervised advanced psychiatry trainees to provide primary palliative services in the acute care and emergency setting. METHODS: In response to the New York City COVID-19 surge, advanced psychiatry trainees at New York-Presbyterian Columbia University Irving Medical Center were rapidly trained and redeployed to a newly formed psychiatry-palliative care liaison team. Under the supervision of consultation-liaison psychiatrists (who also served as team coordinators), these trainees provided circumscribed palliative care services to patients and/or their families, including goals-of-care discussions and psychosocial support. Palliative care attendings remained available to all team members for more advanced and specialized supervision. RESULTS: The psychiatry-palliative care liaison team effectively provided palliative care services during the early phase and peak of New York City's COVID-19 crisis, managing up to 16 new cases per day and provided longitudinal follow-up, thereby enabling palliative care specialists to focus on providing services requiring specialist-level palliative care expertise. CONCLUSION: By training and supervising psychiatrists and advanced psychiatry trainees in specific palliative care roles, palliative care teams could more effectively meet markedly increased service needs of varying complexity during the COVID-19 crisis. As new geographic regions experience possible COVID-19 surges in the coming months, this may serve as a model for rapidly increasing palliative care workforce.

Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic.

OBJECTIVE: The mental health toll of COVID-19 on healthcare workers (HCW) is not yet fully described. We characterized distress, coping, and preferences for support among NYC HCWs during the COVID-19 pandemic. METHODS: This was a cross-sectional web survey of physicians, advanced practice providers, residents/fellows, and nurses, conducted during a peak of inpatient admissions for COVID-19 in NYC (April 9th-April 24th 2020) at a large medical center in NYC (n = 657). RESULTS: Positive screens for psychological symptoms were common; 57% for acute stress, 48% for depressive, and 33% for anxiety symptoms. For each, a higher percent of nurses/advanced practice providers screened positive vs. attending physicians, though housestaff's rates for acute stress and depression did not differ from either. Sixty-one percent of participants reported increased sense of meaning/purpose since the COVID-19 outbreak. Physical activity/exercise was the most common coping behavior (59%), and access to an individual therapist with online self-guided counseling (33%) garnered the most interest. CONCLUSIONS: NYC HCWs, especially nurses and advanced practice providers, are experiencing COVID-19-related psychological distress. Participants reported using empirically-supported coping behaviors, and endorsed indicators of resilience, but they also reported interest in additional wellness resources. Programs developed to mitigate stress among HCWs during the COVID-19 pandemic should integrate HCW preferences.

Palliative Care Training for Consultation-Liaison Psychiatry Fellows: A National Survey Project.

BACKGROUND: Provision of palliative care is part of the standard of care for patients with serious, life-limiting medical illnesses. Patients in the palliative care setting have high rates of psychiatric co-morbidity. However, integration of mental health care into palliative care remains a significant gap. With appropriate training, consultation-liaison (C-L) psychiatrists are well-positioned to improve integration of mental health into palliative care. PURPOSE: To understand current palliative care training practices for C-L psychiatry fellows in the United States. METHOD: We invited all U.S. C-L psychiatry fellowship program directors to participate in a 17-item online structured survey aimed at understanding palliative care training in their fellowship programs. RESULTS: 37/61 (61%) of C-L psychiatry fellowship program directors responded to the survey. Eighty-six percent of programs provide some palliative care didactics, but the topics covered vary widely. Programs are closely split between offering a required, elective, or no clinical palliative care experiences. Only about half (45%) of programs identify formal opportunities for interaction between palliative care and C-L psychiatry fellows. Program directors identified topics such as goals-of-care discussions, systems issues in end-of-life care, and pain management as important for fellows to learn. Barriers to teaching these topics included time, lack of teaching faculty, and disciplinary siloes. CONCLUSIONS: Although C-L psychiatry fellowship program directors identify a number of key teaching topics in palliative care for C-L psychiatry fellows, there are wide discrepancies in the depth and content of existing palliative care didactic and clinical experiences in C-L psychiatry fellowships.

Mental Illness and BRCA1/2 Genetic Testing Intention Among Multiethnic Women Undergoing Screening Mammography.

OBJECTIVES: To examine associations between patient-reported mental illness diagnosis and symptoms and BRCA1/2 genetic testing intention among women undergoing screening mammography. SAMPLE & SETTING: 100 multiethnic women of lower socioeconomic status who were undergoing mammography screening and met family history criteria for BRCA1/2 genetic testing. METHODS & VARIABLES: Descriptive and bivariate nonparametric statistics and multivariate logistic regression were used to examine associations between mental illness and genetic testing intention. Variables were anxiety, depression, patient-reported mental illness diagnosis and symptoms, and testing intention. RESULTS: Prevalence rates of mental illness symptoms were 36% for clinically significant depression and 36% for anxiety. Although 76% of participants intended to undergo genetic testing, only 5% had completed testing. History of mental illness and elevated levels of anxiety and depressive symptoms were positively correlated with testing intention in the bivariate analysis. In multivariate analysis, only younger age and less education were associated with testing intention. IMPLICATIONS FOR NURSING: Future studies should address psychosocial needs and other competing barriers at the patient, provider, and healthcare system levels to increase access to BRCA1/2 genetic testing among multiethnic women.

Interventions for posttraumatic stress disorder symptoms induced by medical events: A systematic review.

OBJECTIVE: Medical events such as myocardial infarction and cancer diagnosis can induce symptoms of posttraumatic stress disorder (PTSD). The optimal treatment of PTSD symptoms in this context is unknown. METHODS: A literature search of 6 biomedical electronic databases was conducted from database inception to November 2018. Studies were eligible if they used a randomized design and evaluated the effect of treatments on medical event-induced PTSD symptoms in adults. A random effects model was used to pool data when two or more comparable studies were available. RESULTS: Six trials met full inclusion criteria. Studies ranged in size from 21 to 81 patients, and included patients with PTSD induced by cardiac events, cancer, HIV, multiple sclerosis, and stem cell transplantation. All trials assessed psychological interventions. Two trials comparing a form of exposure-based cognitive behavioral therapy (CBT) with assessment-only control found that CBT resulted in lower PTSD symptoms [Hedges's g = -0.47, (95% CI -0.82 - -0.12), p = .009]. A third trial compared imaginal exposure (another form of exposure-based CBT) with an attention control and found a trend toward reduced PTSD symptoms. Three trials compared eye movement desensitization and reprocessing (EMDR) with active psychological treatments (imaginal exposure, conventional CBT, and relaxation therapy), and found that EMDR was more effective. CONCLUSION: CBT and EMDR may be promising approaches to reducing PTSD symptoms due to medical events. However, additional trials are needed in this patient population.

The National Dental Practice-Based Research Network Adult Anterior Open Bite Study: Treatment recommendations and their association with patient and practitioner characteristics.

INTRODUCTION: This aim of this paper is to describe and identify the practitioner and patient characteristics that are associated with treatment recommendations for adult anterior open bite patients across the United States. METHODS: Practitioners and patients were recruited within the framework of the National Dental Practice-Based Research Network. Practitioners were asked about their demographic characteristics and their treatment recommendations for these patients. The practitioners also reported on their patients' dentofacial characteristics and provided initial cephalometric scans and intraoral photographs. Patients were asked about their demographic characteristics, previous orthodontic treatment, and goals for treatment. Four main treatment groups were evaluated: aligners, fixed appliances, temporary anchorage devices (TADs), and orthognathic surgery. Extractions were also investigated. Predictive multivariable models were created comparing various categories of treatment as well as extraction/nonextraction decisions. RESULTS: Ninety-one practitioners (mostly orthodontists) and 347 patients were recruited from October 2015 to December 2016. Increased aligner recommendations were associated with white and Asian patients, the presence of tongue habits, and female practitioners. TADs were recommended more often in academic settings. Recommendations for orthognathic surgery were associated with demographic factors, such as availability of insurance coverage and practitioner race/ethnicity, and dentofacial characteristics, such as anteroposterior discrepancies, more severe open bites, and steeper mandibular plane angles. Extraction recommendations were largely associated with severe crowding and incisor proclination. CONCLUSIONS: Both doctor and patient demographic factors, as well as dentofacial characteristics, were significantly associated with treatment recommendations for adult anterior open bite patients.

Standardized Semi-structured Psychosocial Evaluation before Hematopoietic Stem Cell Transplantation Predicts Patient Adherence to Post-Transplant Regimen.

In patients undergoing stem cell transplantation (SCT), nonadherence has potential for significant medical impact and potentially life-threatening complications. No study thus far has demonstrated an effective way to predict adherence in SCT recipients. A structured rating scale, the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT), has been shown to predict psychosocial outcomes and medical morbidity in solid organ transplant recipients. We assessed the SIPAT in SCT recipients. We hypothesized that the SIPAT rating would be associated with nonadherence to the post-SCT regimen. We retrospectively studied SCT recipients who had psychiatric evaluations with the SIPAT before SCT. The primary outcome was nonadherence, defined a priori as at least 1 life-threatening nonadherence event in the first 6 months post-transplant. Association of the SIPAT with outcomes was evaluated by logistic regression, and an optimal cutoff score was determined using a receiver operating characteristic curve. Of 85 patients (mean age 47 years; range, 18 to 74 years), 56 (66%) were male, and 43 (50.5%) received autologous SCT. Eighteen (21%) patients were nonadherent. The SIPAT rating, treated as a continuous variable and controlling for autologous versus allogeneic SCT, was significantly associated with nonadherence (per 1 point; odds ratio [OR], 1.162; P< .0001). Allogeneic SCT also conferred a significantly increased risk of nonadherence (OR, 14.184; P= .005). Multivariate analysis stratifying for allogeneic versus autologous transplantation and controlling for age, sex, and disease confirmed an independent association between the SIPAT score and nonadherence. A cutoff score of 18 provided optimal specificity (89.6%) and sensitivity (55.6%) for nonadherence. Nonadherence rates were 58.8% and 11.8% for subjects with SIPAT ratings of 18 and above or 17 and below, respectively (relative risk = 4.98, P < .0001). Psychosocial risk as quantified by the SIPAT correlated with SCT recipients' adherence to the post-transplant regimen, suggesting that this instrument can contribute to medical risk stratification models. Further study should evaluate long-term mortality data and the effects of intervention on psychosocial risks.

Early interventions to prevent posttraumatic stress disorder symptoms in survivors of life-threatening medical events: A systematic review.

Post-traumatic stress disorder (PTSD) induced by life-threatening medical events has been associated with adverse physical and mental health outcomes, but it is unclear whether early interventions to prevent the onset of PTSD after these events are efficacious. We conducted a systematic review to address this need. We searched six biomedical electronic databases from database inception to October 2018. Eligible studies used randomized designs, evaluated interventions initiated within 3 months of potentially traumatic medical events, included adult participants, and did not have high risk of bias. The 21 included studies (N = 4,486) assessed a heterogeneous set of interventions after critical illness (9), cancer diagnosis (8), heart disease (2), and cardiopulmonary surgery (2). Fourteen psychological, 2 pharmacological, and 5 other-type interventions were assessed. Four of the psychological interventions emphasizing cognitive behavioral therapy or meaning-making, 1 other-type palliative care intervention, and 1 pharmacological-only intervention (hydrocortisone administration) were efficacious at reducing PTSD symptoms relative to control. One early, in-hospital counseling intervention was less efficacious at lowering PTSD symptoms than an active control. Clinical and methodological heterogeneity prevented quantitative pooling of data. While several promising interventions were identified, strong evidence of efficacy for any specific early PTSD intervention after medical events is currently lacking.