Sex differences in cholesterol and triglyceride levels among hospitalized adolescents and young adults with eating disorders.

OBJECTIVE: To determine sex differences in cholesterol and triglyceride levels among adolescents and young adults hospitalized for medical complications of eating disorders. METHODS: A retrospective electronic medical record review of patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical stabilization, between 2012 and 2020, was conducted. Non-fasting total cholesterol and triglycerides were collected; however, LDL and HDL levels were not available. RESULTS: Among 83 males and 441 females, mean ± SD age was 15.5 ± 2.8 years, 64.1% had anorexia nervosa, and admission percent median body mass index was 87.3 ± 13.9. The proportion of males and females with high total cholesterol (13.3% vs. 18.1%, Cramer's V = 0.05, p = .28) and high triglyceride levels (9.6% vs. 8.1%, Cramer's V = 0.02, p = .63) did not differ. Mean total cholesterol levels were higher in females compared to males (F 169.6 ± 41.1 mg/dL vs. M 154.5 ± 45.1 mg/dL, Cohen's d = 0.36, p = .003), although a majority were within the normal range. In adjusted linear regression models, male (compared to female) sex (B = -14.40, 95% CI -24.54, -4.27) and higher percent median body mass index (B = -0.33, 95% CI -0.60, -0.06) were associated with lower total cholesterol levels in adjusted models (R2 = 0.04). DISCUSSION: Building on prior work showing equally severe complications of eating disorders in males compared to females, we did not find sex differences in those presenting with high total cholesterol or triglycerides. Future research is needed to understand the pathophysiology and role of dyslipidemia in acute malnutrition, and the impact of nutritional rehabilitation and weight restoration. PUBLIC SIGNIFICANCE: We found that the proportion of male and female adolescents and young adults hospitalized for medical complications of an eating disorder with high total cholesterol did not significantly differ. Although average total cholesterol levels were higher in female compared to male patients with eating disorders, a majority of these levels remained within the normal range. Patients with more severe malnutrition had a higher risk of elevated total cholesterol levels. Clinicians should consider monitoring cholesterol levels in young people hospitalized for restrictive eating disorders.

"God gives me hope!": Hospitalized children's perception of the influence of religion in coping with chronic illness.

PURPOSE: The mechanism of the impact of religion on health is still unclear, especially in children and adolescents with chronic illness who live in religious contexts. This study aimed to understand the influence of religion on coping with chronic diseases from the perspective of hospitalized children and adolescents diagnosed with cancer, type 1 diabetes mellitus and cystic fibrosis. DESIGN AND METHODS: Qualitative descriptive research used photo-elicitation interviews with 35 Brazilian children and adolescents with cancer, type 1 diabetes mellitus and cystic fibrosis, aged between 7 and 17 years old. A thematic analysis approach was used to analyze qualitative data. RESULTS: Participants were diagnosed with cystic fibrosis (14.3%), cancer (57.1%), and type 1 diabetes mellitus (28.6%) and 82.9% had a religious affiliation. Three themes were constructed: finding strength and support in the relationship with the divine, religion as an important source of meaning, and religious practice as a promoter of well-being. These themes demonstrate that children and adolescents themselves perceived their illness as a journey through which their faith grew. CONCLUSIONS: This research shows the influence of religion on the positive coping of chronic illness, being a source of strength and support from the relationship with the divine, as well as offering a source of meaning, purpose and well-being based on religious practices. PRACTICE IMPLICATIONS: This study supports clinical practice, based on the recognition of the patient as a religious and spiritualized person who has spiritual beliefs and needs that are capable of influencing treatment.

Sleep disturbance and suicidality in psychiatrically hospitalized adolescents: The role of specific emotion regulation domains.

BACKGROUND: Sleep disturbance is associated with broadband measurements of emotion regulation (ER). The linkage between ER, a multidimensional process, and suicidal ideation and suicide attempt is also documented in theoretical and empirical work. Recent research indicates that distinct profiles of ER are associated with psychiatric outcomes, including adolescent suicidal ideation and attempt. The present study examined whether specific domains of ER would explain the association between sleep disturbance, and ideation and attempt among psychiatrically hospitalized adolescents. METHOD: The sample included 284 adolescents who completed self-report measures on sleep disturbance, ER, suicidal ideation, suicide attempt, and psychiatric symptoms upon inpatient hospitalization. RESULTS: Findings indicated that sleep disturbance was associated with suicidal ideation. Further, a single ER domain (perceived limited access to ER strategies) fully accounted for the significant association between sleep disturbance and suicidal ideation. A reported suicide attempt in the past week was correlated with the nonacceptance of emotional responses, perceived limited access to ER strategies, and emotional clarity, but was not associated with sleep disturbance. DISCUSSION: The current findings highlight the importance of examining narrowband ER and indicate the presence of differential associations between sleep disturbance, ER, and suicide-related outcomes. Findings further elucidate the possible role of impaired cognitive responses to emotional experiences in the co-occurrence of sleep disturbance and youth psychiatric outcomes.

The rapid stabilization pathway: impact of a brief inpatient intervention on the length of stay and readmissions among psychiatrically hospitalized adolescents.

BACKGROUND: Suicide is the second leading cause of death among adolescents in the United States (Centers for Disease Control and Prevention [CDC], 2017, Death rates due to suicide and homicide among persons age 10-24: United States, 2000-2017) constituting a significant public health crisis. The demand for psychiatric emergency services and inpatient beds is increasing, while the number of beds available decreases or remains static (National Association of State Mental Health Program Directors, 2017, Trend in psychiatric inpatient capacity, United States and Each State, 1970-2014. www.nasmhpd.org/sites/default/files/TACPaper.2.Psychiatric-Inpatient-Capacity_508C.pdf) leading to delays in treatment and exacerbation of symptoms for some adolescents awaiting care. This pilot project describes the development, feasibility, and acceptability of a creative, values-based safety planning intervention for adolescents hospitalized on an acute inpatient psychiatric unit and the impact of this intervention on length of stay and readmissions to acute psychiatric care. METHODS: Thirty patients experiencing a suicidal crisis participated in the Rapid Stabilization Pathway (RSP) during their inpatient psychiatric admission. RESULTS: Results indicate that, compared to patients who underwent inpatient treatment as usual (TAU), RSP patients were discharged after a significantly shorter length of stay (4 vs. 6.1 weekdays respectively, p < .001). Further, there was no significant difference in readmission to the inpatient unit or to the psychiatric emergency room among RSP and TAU patients at 30, 60, and 90 days postdischarge. CONCLUSIONS: These findings have significant implications for acute inpatient programming. The RSP intervention treated patients in a shorter amount of time without any increase in re-admissions. Further, the shortened length of stay allowed for more patients to be treated on the inpatient unit and a significant cost savings. Future directions for programming and outcome research are discussed.

Sex differences in refeeding among hospitalized adolescents and young adults with eating disorders.

OBJECTIVE: To determine sex differences in refeeding (i.e., short-term nutritional rehabilitation) outcomes among hospitalized adolescents and young adults with eating disorders. METHODS: We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical and nutritional management between May 2012 and August 2020. Descriptive statistics, crude, and adjusted linear regression models were used to assess the association between sex and nutritional outcomes and predictors of length of stay. RESULTS: A total of 588 adolescents and young adults met eligibility criteria (16% male, mean [SD] age 15.96 [2.75], 71.6% anorexia nervosa, admission percent median body mass index [%mBMI] 87.1 ± 14.1). In unadjusted comparisons, there were no significant sex differences in prescribed kilocalories (kcal) per day at admission (2013 vs. 1980, p = .188); however, males had higher estimated energy requirements (EER, kcal) (3,694 vs. 2,925, p < .001). In linear regression models adjusting for potential confounders, male sex was associated with higher prescribed kcals at discharge (B = 835 kcal, p < .001), greater weight change (B = 0.47 kg, p = .021), and longer length of stay (B = 1.94 days, p = .001) than females. Older age, lower admission weight, lower prescribed kcal at admission, higher EER, and lower heart rate at admission were factors associated with longer length of stay in a linear regression model. DISCUSSION: These findings support the development of individualized approaches for males with eating disorders to improve quality of care and health care efficiency among an underserved population.

Substance Use Disorder among Hospitalized Adolescents in North Carolina.

OBJECTIVES: Individuals who began using alcohol or other drugs before the age of 15 are 7 times more likely to develop a substance use disorder (SUD) in adulthood. This study sought to determine the common characteristics of SUD-related hospitalizations and patterns of discharge diagnoses among adolescents in North Carolina. METHODS: Using the 2014 State Inpatient Database (SID), discharge records associated with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes for SUD were identified. Adolescents between the ages of 13 and 19 years were included. SUD and non-SUD groups were compared using the Student t test for continuous variables and the χ2 test for categorical variables. A total of 1.1 million hospital discharges were analyzed. A uniform and standardized coding system called Clinical Classifications Software was used to identify cases. The Clinical Classifications Software collapses the ICD-9-CM codes into 679 clinically meaningful categories. A cluster of 3900 ICD-9-CM procedure codes also was used to identify clinically relevant groups of procedures performed during hospitalization. RESULTS: An estimated 3276 adolescents associated with SUD were discharged from North Carolina hospitals during the study year. Discharged patients with a SUD spent a total of 21,242 inpatient days, at a cost of $62 million. Among the adolescents with a SUD, 53% were boys, 62% were White, 24% were Black, 8% were Hispanic (8%), and 6% were of other races. Compared with patients without a SUD, those with a SUD had longer mean hospital stays (6.5 days vs 4.7 days; P < 0.0001) and lower mean hospital charge per hospitalization ($18,932 vs 24,532; P < 0.0001). Adolescents with a SUD also were diagnosed primarily as having mood disorders (44.78%), followed by schizophrenia and other psychological disorders, upon discharge. Approximately 37% of the SUD-related discharges occurred in areas, denoted in this study using ZIP code designations, with mean household annual incomes <$38,999. A large proportion of the SUD-related hospitalizations (44%) were billed to Medicaid. Frequently observed diagnoses associated with adolescents with a SUD were mood disorders (45%), schizophrenia (7%), and poisoning by other medications and drugs (4%). In 16% of hospitalized adolescents with a SUD, there were at least 2 procedures performed. There was a statistically significant mean hospital charge difference of $5600 between SUD and non-SUD teens. CONCLUSIONS: The literature reflects the connection between adolescent use and the propensity for diagnosis with a SUD in adulthood; it is evident that this is a growing public health crisis. This study identified patterns of adolescent substance use that, based on the current literature, are indicative of problematic futures for these individuals. The concerning data and literature identify a significant need to address prevention, treatment, and recovery services for adolescents, not only in North Carolina but throughout the United States. The need for focused interventions, access to care, and funding of substance-specific adolescent education and services is greatly needed to change the trajectory of these adolescents' lives.

COVID-19-Specific Suicidal Thoughts and Behaviors in Psychiatrically Hospitalized Adolescents.

This study examined the presence and correlates of COVID-specific suicidal thoughts and behaviors (i.e., thoughts of or engaging in intentional COVID-19 exposure with associated suicidal intent) among psychiatrically hospitalized adolescents. Adolescents (N = 143) completed study measures as part of the standard intake process between March 13th and August 14th, 2020. Participants answered questionnaires assessing COVID-specific passive and active suicidal ideation (SI) and suicidal behavior, as well as COVID-related stressors and emotions, and public health guidance compliance. Findings highlights that COVID-specific SI is common in high-risk youth. COVID-specific SI was associated with COVID-19-related negative emotions, elevated stress, and decreased public health guidance compliance. Results suggest that COVID-specific suicidal thoughts and behaviors, and risk correlates, should be assessed within high-risk populations to facilitate prevention of risky behavior associated with intentional COVID-19 exposure.

Meaning in Life Moderates Relations between Personality and Temperament and Nonsuicidal Self-Injury in Hospitalized Adolescents.

Previous research indicates that sensation seeking, emotion dysregulation, and impulsivity are predictive of non-suicidal self-injury (NSSI). A body of research supports that meaning in life predicts improved mental health and well-being, including fewer suicidal thoughts and attempts, yet no research has examined the moderating effects of meaning in life on the relations between personality and temperament and NSSI. Given the growing incidence rates of NSSI among adolescents and the potential lifelong consequences of NSSI, it is imperative to better understand the factors that reduce the rates at which adolescents in a clinical sample engage in NSSI. The present study investigates if the protective factors of meaning in life moderate the relation between personality and temperament variables and NSSI among 126 adolescents (71% female, Mage = 16.1, SD = 1.1, range 13-18, 80% White) residing in an inpatient psychiatric hospital who endorsed NSSI in the last 12 months. Results from hurdle modeling indicate that two subtypes of meaning in life, presence of meaning in life and search for meaning of life, may serve as robust protective factors against engagement in NSSI among a clinical sample of adolescents. Additionally, results suggest that search for meaning, but not presence of meaning in life, variables moderate the relations between personality and temperament and NSSI. Results provide evidence that meaning in life is an understudied variable of importance in understanding how to prevent or treat NSSI. It also underscores the need to develop, refine, and test meaning-making interventions.

Sex differences and associations between zinc deficiency and anemia among hospitalized adolescents and young adults with eating disorders.

PURPOSE: To determine sex differences in and associations between zinc deficiency and anemia among adolescents and young adults hospitalized for medical complications of eating disorders. METHODS: We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Descriptive statistics, crude, and adjusted logistic regression models were used to assess the association between zinc deficiency (< 55 mcg/dL) and anemia (< 13.6 g/dL in males [M] and < 11.8 g/dL in females [F]). RESULTS: A total of 87 males and 450 females met eligibility criteria (age 15.98 ± 2.81, 59.4% anorexia nervosa; admission body mass index 17.49 ± 2.82). In unadjusted comparisons, plasma zinc in males and females were not statistically different (M 64.88 ± 14.89 mcg/dL vs F 63.81 ± 13.96 mcg/dL, p = 0.517); moreover, there were no differences in the percentage of males and females with zinc deficiency (M 24.14% vs F 24.89%). However, a greater percentage of males than females were anemic (M 50.00% vs F 17.61%, p < 0.001), with similar findings in the subgroup with anorexia nervosa. In logistic regression models stratified by sex and eating disorder diagnosis, zinc deficiency was significantly associated with anemia in males (AOR 3.43, 95% CI 1.16, 10.13), but not females (AOR 1.47, 95% CI 0.86, 2.54). CONCLUSIONS: For the first time, we demonstrate that zinc deficiency is equally severe in males compared to females hospitalized with medical complications from eating disorders, with nearly a quarter of inpatients experiencing zinc deficiency. Anemia is more common in males than females hospitalized with eating disorders. LEVEL OF EVIDENCE: Level V: descriptive cross-sectional study.

Suicidality and self-injurious behavior among adolescent social media users at psychiatric hospitalization.

BACKGROUND: The current study sought to examine the relationship between documented social media use and suicidality and self-injurious behaviors in adolescents at the time of psychiatric hospitalization. METHODS: We retrospectively identified adolescents (aged 12-17 years) hospitalized on an inpatient psychiatric unit during 1 year. Abstracted information included documented social media use, demographic variables, documented self-injurious behaviors, the Patient Health Questionnaire-9, and the Suicide Status Form-II. Logistic regression was implemented to examine the effect of social media use on the risk of self-injurious behaviors and suicidality. RESULTS: Fifty-six adolescents who used social media were identified and matched with 56 non-social media users. Those with reported social media use had significantly greater odds of self-injurious behaviors at admission (odds ratio, 2.55; 95% confidence intervals, 1.17-5.71; P = .02) vs youth without reported social media use. Adolescents with reported social media use also had greater odds of increased suicidal ideation and suicide risk than those with no reported use, but these relationships were not statistically significant. CONCLUSIONS: Social media use in adolescents with a psychiatric admission may be associated with the risk of self-injurious behaviors and could be a marker of impulsivity. Further work should guide the assessment of social media use as part of a routine adolescent psychiatric history.

The effectiveness of mandala drawing in reducing psychological symptoms, anxiety and depression in hospitalised adolescents with cancer: A randomised controlled trial.

OBJECTIVE: This study aimed to evaluate the effectiveness of individual mandala drawing methods on psychological symptoms, anxiety and depression in hospitalised adolescents with cancer. METHODS: A randomised controlled trial design with repeated measures was conducted. The study was carried out in a paediatric haematology and oncology clinic in Turkey. The study protocol is registered at ClinicalTrials.gov NCT04297982. The study sample consisted of 60 hospitalised adolescents aged between 12 and 17. Participants were randomly assigned to receive two 1- to 2-h mandala drawing sessions (intervention group, n = 30) or routine care only (control group, n = 30). Each adolescent was assessed using the Hospital Anxiety and Depression Scale and the Memorial Symptom Assessment Scale (Psychological subscale) questionnaires and was evaluated at baseline and after 5 days. RESULTS: The anxiety and depression scores significantly decreased in the intervention group, compared with the control group, after 5 days of intervention, F(1, 57) = 28.9, p < 0.01, η2 = 0.337. Similarly, the psychological symptoms scores significantly decreased in the intervention group, compared with the control group, F(1, 57) = 69.7, p < 0.001, η2 = 0.550). CONCLUSION: The individual mandala activity intervention was effective in reducing on psychological symptoms, anxiety and depressive symptoms in adolescents with cancer.

Difficult Bag-Mask Ventilation in Critically Ill Children Is Independently Associated With Adverse Events.

OBJECTIVES: Bag-mask ventilation is commonly used prior to tracheal intubation; however, the epidemiology, risk factors, and clinical implications of difficult bag-mask ventilation among critically ill children are not well studied. This study aims to describe prevalence and risk factors for pediatric difficult bag-mask ventilation as well as its association with adverse tracheal intubation-associated events and oxygen desaturation in PICU patients. DESIGN: A retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from January 2013 to December 2018. SETTING: Forty-six international PICUs. PATIENTS: Children receiving bag-mask ventilation as a part of tracheal intubation in a PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome is the occurrence of either specific tracheal intubation-associated events (hemodynamic tracheal intubation-associated events, emesis with/without aspiration) and/or oxygen desaturation (< 80%). Factors associated with perceived difficult bag-mask ventilation were found using univariate analyses, and multivariable logistic regression identified an independent association between bag-mask ventilation difficulty and the primary outcome. Difficult bag-mask ventilation is reported in 9.5% (n = 1,501) of 15,810 patients undergoing tracheal intubation with bag-mask ventilation during the study period. Difficult bag-mask ventilation is more commonly reported with increasing age, those with a primary respiratory diagnosis/indication for tracheal intubation, presence of difficult airway features, more experienced provider level, and tracheal intubations without use of neuromuscular blockade (p < 0.001). Specific tracheal intubation-associated events or oxygen desaturation events occurred in 40.2% of patients with reported difficult bag-mask ventilation versus 19.8% in patients without perceived difficult bag-mask ventilation (p < 0.001). The presence of difficult bag-mask ventilation is independently associated with an increased risk of the primary outcome: odds ratio, 2.28 (95% CI, 2.03-2.57; p < 0.001). CONCLUSIONS: Difficult bag-mask ventilation is reported in approximately one in 10 PICU patients undergoing tracheal intubation. Given its association with adverse procedure-related events and oxygen desaturation, future study is warranted to improve preprocedural planning and real-time management strategies.

Rates of Venous Thromboembolism and Central Line-Associated Bloodstream Infections Among Types of Central Venous Access Devices in Critically Ill Children.

OBJECTIVES: Central venous access devices, including peripherally inserted central catheters and central venous catheters, are often needed in critically ill patients, but also are associated with complications, including central-line associated bloodstream infections and venous thromboembolism. We compared different central venous access device types and these complications in the PICU. DESIGN: Multicenter, cohort study. SETTING: One hundred forty-eight participating Virtual PICU Systems, LLC, hospital PICU sites. PATIENTS: Pediatric patients with central venous access placed from January 1, 2010, to December 31, 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient and central venous access device variables postulated to be associated with central-line associated bloodstream infection and venous thromboembolism were included. Data were analyzed using Pearson chi-square test or Fisher exact test for categorical variables, Mann-Whitney U test for continuous variables, and logistic regression and classification trees for multivariable analysis that examined significant predictors of venous thromboembolism or central-line associated bloodstream infection. Analysis included 74,196 first lines including 4,493 peripherally inserted central catheters and 66,194 central venous catheters. An increased rate of venous thromboembolism (peripherally inserted central catheter: 0.93%, central venous catheter: 0.52%; p = 0.001) (peripherally inserted central catheter: 8.65/1,000 line days, central venous catheter: 6.29/1,000 line days) and central-line associated bloodstream infection (peripherally inserted central catheter: 0.73%, central venous catheter: 0.24%; p = 0.001) (peripherally inserted central catheter: 10.82/1,000 line days, central venous catheter: 4.97/1,000 line days) occurred in peripherally inserted central catheters. In multivariable analysis, central venous catheters had decreased association with central-line associated bloodstream infection (odds ratio, 0.505; 95% CI, 0.336-0.759; p = 0.001) and venous thromboembolism (odds ratio, 0.569; 95% CI, 0.330-0.982; p = 0.043) compared with peripherally inserted central catheters. CONCLUSIONS: Peripherally inserted central catheters are associated with higher rates of central-line associated bloodstream infection and venous thromboembolism than central venous catheters in children admitted to the PICU.

Borderline personality disorder and prior suicide attempts define a severity gradient among hospitalized adolescent suicide attempters.

BACKGROUND: Borderline personality disorder (BPD) and history of prior suicide attempt (SA) have been shown to be high predictors for subsequent suicide. However, no previous study has examined how both factors interact to modify clinical and suicide severity among adolescents. METHODS: This study presents a comprehensive assessment of 302 adolescents (265 girls, mean age = 14.7 years) hospitalized after a SA. To test clinical interactions between BPD and history of prior SA, the sample was divided into single attempters without BPD (non-BPD-SA, N = 80), single attempters with BPD (BPD-SA, N = 127) and multiple attempters with BPD (BPD-MA, N = 95). RESULTS: Univariate analyses revealed a severity gradient among the 3 groups with an additive effect of BPD on the clinical and suicide severity already conferred by a history of SA. This gradient encompassed categorical (anxiety and conduct disorders and non-suicidal-self-injury [NSSI]) and dimensional comorbidities (substance use and depression severity) and suicide characteristics (age at first SA). According to regression analyses, the BPD-MA group that was associated with the most severe clinical presentation also showed specific features: the first SA at a younger age and a higher prevalence of non-suicidal self-injury (NSSI) and anxiety disorders. The BPD-MA group was not associated with higher impulsivity or frequency of negative life events. CONCLUSIONS: Based on these findings and to improve youth suicide prevention, future studies should systematically consider BPD and the efficacy of reinforcing early interventions for anxiety disorders and NSSI.

Characterization of adopted suicidal behavior and its main influencing factors: A qualitative study with adolescents.

INTRODUCTION: A better understanding of the meanings that adolescents associate with suicide, contributes to the development of psychotherapeutic intervention programs to be implemented by nurse specialists in mental health and psychiatric nursing. Therefore, adolescents need to characterize their adopted suicidal behaviors and identify the personal characteristics that contribute to this same behavior. METHODOLOGY: A descriptive, exploratory, and qualitative study was conducted with 33 adolescents with suicidal behavior, hospitalized in a child psychiatry unit. Data were collected through a structured interview, and data treatment used the content analysis technique. RESULTS: Suicidal behaviors are characterized according to causality, meaning, and intent. Causality is mostly related to psychological factors (sadness, desperation, mental suffering, internal pain, emptiness, and rejection). As to the meaning, suicidal behavior is understood as an escape but also as a personal choice, sometimes regarded as rational. In what concerns intent, the intent to die is the most frequently reported. The most-reported personal characteristics which contributed to the suicidal behavior are feelings of exclusion, rejection, and humiliation, and also introversion. CONCLUSIONS: The results point to the need to reflect on the perceptions of adolescents with suicidal behavior. The current intervention strategies should be adjusted especially through the identification of the signs associated with mental distress in adolescents and the training of gatekeepers, contributing to productive and congruent suicide prevention in this vulnerable group.

Alcohol misuse among adolescents with BPD symptoms: exploring the moderating role of reasons for drinking and perceived coping skills in a clinical adolescent sample.

BACKGROUND: Adolescents who experience symptoms of borderline personality disorder (BPD) are at high risk for alcohol misuse, yet little is known about why these adolescents drink and what factors heighten or mitigate this risk. The current study explores factors that may impact risk for alcohol misuse among youth with BPD symptoms: using alcohol to self-medicate or to rebel and perceived coping skills. METHOD: A sample of 181 psychiatrically hospitalized adolescents (Mage  = 15.04 years, SD = 1.31 years; 71.8% female, 83.4% White) was recruited as part of a larger study from the northeastern United States. Assessments and diagnostic interviews were administered to adolescents. RESULTS: Use of alcohol for self-medication and perceived coping skills, but not using alcohol for rebellion, moderated the relationship between BPD symptoms and alcohol misuse. A significant positive relationship between BPD symptoms and alcohol frequency and/or problems was only found among adolescents who reported lower use of alcohol for self-medication purposes or higher perceived coping skills. CONCLUSIONS: Youth with more BPD symptoms are at high risk for alcohol misuse. Moderation effects for self-medication motives and perceived coping skills were counter to hypotheses; lower levels of self-medication motives contributed to greater alcohol problems, as did higher levels of perceived coping skills. Results suggest the importance of assessing how much youth are drinking or experiencing consequences, as well as why they are using alcohol. It is possible adolescents with more BPD symptoms may be reporting more coping skills, but actually exhibiting the phenomenon of apparent competence (i.e., present as 'in control', but actually experiencing extreme distress and lacking sufficient coping skills); collateral reports of adolescents' coping skills may provide a more objective measure of actual skill level. KEY PRACTITIONER MESSAGE: What is known? Adolescents who experience symptoms of borderline personality disorder (BPD) are at high risk for alcohol misuse, yet little is known about why these adolescents drink and what factors heighten or mitigate this risk. What is new? Adolescents who use alcohol to self-medicate or rebel are at high risk for alcohol problems, regardless of presence of BPD symptoms. Contrary to expectations, higher perceived coping skills strengthened the relation between BPD and alcohol misuse. Apparent competence (i.e., present as 'in control' but lack sufficient skills) may be at play. What is significant for clinical practice? Clinicians are encouraged to assess why adolescents are using alcohol and teach alternative coping strategies when self-medication and/or rebellion is an identified use. Clinicians are encouraged to collect collateral reports of adolescent's coping abilities rather than relying solely on self-report.

Longitudinal examination of youth readmission to mental health inpatient units.

OBJECTIVE: Significant barriers exist for youth in obtaining mental health services. These barriers are exacerbated by growing demand, attributed partially to children and adolescents who have repeat hospital admissions. The purpose of this study was to identify demographic, socioeconomic and clinical predictors of readmission to inpatient psychiatric services in New Brunswick, Canada. METHOD: Key demographic, support and clinical predictors of readmission were identified. The New Brunswick Discharge Abstract Database (DAD) was used to compile a cohort of all children and adolescents ages 3-19 years with psychiatric hospital admissions between 1 April 2003 and 31 March 2014 (N = 3825). Primary analyses consisted of Kaplan-Meier survival methods with log-rank tests to assess time-to-readmission variability, and Cox regression to identify significant predictors of readmission. RESULTS: In total, 27.8% of admitted children and adolescents experienced at least one readmission within the 10-year period, with 57.3% readmitted to hospital within 90 days following discharge. Bivariate results indicated that male, upper-middle socioeconomic status (SES) youths aged 11-15 years from nonrural communities were most likely to be readmitted. Notable predictors of increased readmission likelihood were older age, being male, higher SES, referral to care by medical practitioner, discharge to another health facility, psychosis, and previous psychiatric admission. CONCLUSION: A significant portion of the variance in readmission was accounted for by youth demographic characteristics (i.e. age, SES, geographic location) and various support structures, including referrals to inpatient care and aftercare support services. KEY PRACTITIONER MESSAGE: Readmission to inpatient psychiatric care among youth is affected by a number of multifaceted risk factors across individual, environmental and clinical domains. This study used provincial population-scale longitudinal administrative data to demonstrate the influence of various individual and demographic factors on likelihood of readmission, which is notably absent from the majority of studies that make use of smaller, short-term data samples. Ensuring that multiple factors outside of the clinical context are considered when examining readmission among youth may contribute to a more thorough understanding of youth hospitalization patterns.

Improving Tracking of Postdischarge Results of Sexually Transmitted Infection Screening Tests in Hospitalized Adolescents and Young Adults: A Quality Improvement Initiative.

Hospitalizations offer chlamydia and gonorrhea screening opportunities for youth who may not seek preventive care. Tracking of screening test results still pending after hospital discharge is an important component of clinical care. This process can be improved by protocol use and enhanced by effective, automated electronic health record tools.

Feasibility and Perceptions of PICU Diaries.

OBJECTIVES: To determine the feasibility of implementing an ICU diary in the pediatric critical care setting and to understand the perceptions held by family members who receive the diaries after PICU discharge. DESIGN: Observational pilot study. SETTING: PICU in a tertiary academic hospital in the United States. PARTICIPANTS: Critically ill pediatric patients admitted to the PICU and their families. INTERVENTIONS: The addition of a PICU diary to a patient's routine care. MEASUREMENTS AND MAIN RESULTS: Twenty families of critically ill children admitted to the PICU were enrolled in the PICU diary pilot study between May 2017 and March 2018. Patients who had an anticipated length of stay of at least 3 days and whose families were English-speaking were included. The median age of patients was 6 years, ranging from newborns to 18 years old, and the median length of stay was 11.5 days (interquartile range, 8.5-41 d). A total of 453 diary entries were written in 19 diaries over 433 PICU days, the majority of which were composed by bedsides nurses (63%). Follow-up surveys sent to parents 2 weeks after PICU discharge revealed that of the parents who had contributed to the diary, most enjoyed doing so (7/8). Nine of 12 parents had reviewed the diary at least once since discharge, and all parent respondents found the diary to be a beneficial aspect of their experience after PICU discharge. CONCLUSIONS: The use of ICU diaries in the PICU setting is feasible and perceived as beneficial by families of critically ill children. Future studies are needed to better understand if PICU diaries may objectively improve psychologic outcomes of patients and family members after PICU admission.

Anorexia nervosa requiring admission in adolescents.

Question I recently saw in my office a patient whom I had initially diagnosed with anorexia nervosa 6 months earlier and she was continuing to lose weight. Her physical examination findings in the office revealed a blood pressure of 85/55 mm Hg and a heart rate of 55 beats/min at rest. Should patients such as this one be sent to the hospital for inpatient monitoring and treatment?Answer There is a lack of clear evidence-based guidelines for hospital admission of adolescents with anorexia nervosa, resulting in a high degree of variation in practices among physicians. Clinical judgment based on expert opinion seems to be the main driver of the decision to admit for inpatient care. Acceptable indications for a patient's admission include the following: weight is less than 75% of ideal body weight, temperature is lower than 35.5°C (95.9°F), heart rate is less than 45 beats/min, systolic blood pressure level is lower than 80 mm Hg, orthostatic change in pulse is higher than 20 beats/min, or orthostatic change in blood pressure is greater than 10 mm Hg. Consultation with an adolescent medicine specialist is highly recommended for adolescents with these vital signs.