Using the Project ECHO Model to Increase Pediatric Primary Care Provider Confidence to Independently Treat Adolescent Depression.

OBJECTIVE: The model for the Extension for Community Healthcare Outcomes (Project ECHO®) was used to extend specialist support to the pediatric medical home for the treatment of adolescent depression by taking a comprehensive, disease-specific approach. METHODS: Child and adolescent psychiatrists constructed a course to train community pediatric primary care providers (PCPs) to screen patients for depression, initiate evidence-based interventions, and provide ongoing management. Participants were assessed for changes in clinical knowledge and self-efficacy. Secondary measures included self-reported practice change and emergency department (ED) mental health referrals 12 months pre- and post-course completion. RESULTS: Sixteen out of 18 participants in cohort 1 and 21 out of 23 participants in cohort 2 completed the pre- and post-assessments. Clinical knowledge and self-efficacy showed statistically significant improvement pre- and post-course completion. ED mental health referrals from participant PCPs decreased by 34% (cohort 1) and 17% (cohort 2) after course completion. CONCLUSIONS: These findings indicate that utilizing the Project ECHO format to provide subspecialist support and education on the treatment of depression can improve pediatric PCPs' clinical knowledge and confidence in their ability to independently treat depression. Secondary measures suggest that this can translate into practice change and improved treatment access with decreased ED referrals for mental health assessments by participant PCPs. Future directions include more robust outcomes measurement and developing more courses with an in-depth approach to a single or similar cluster of mental health diagnoses such as anxiety disorders.

Staphylococcus aureus infections in kidney transplantation: a matched case controlled study.

BACKGROUND: Data are lacking on the risk factors and outcomes of Staphylococcus aureus infections in kidney transplant recipients. METHODS: Kidney recipients with S. aureus infections (n = 20) were retrospectively identified and compared to age- and transplant-type-matched (1:2) non-S. aureus-infected controls (n = 40). Risk factors for S. aureus infections were identified by conditional logistic regression analysis. RESULTS: Methicillin-resistant S. aureus (MRSA) was the cause of 32.1% of infections. Localizations of the infections were as follows: skin 42.9%, intra-abdominal 35.7%, blood stream 7.1%, and pulmonary 10.7%. The infections developed at a median time of 29 days (range 0-358 days) after transplantation. By univariate analysis, variables significantly associated with infection were steroid administration 4 weeks prior to infection (odds ratio (OR) 4.2, 95% confidence interval (95% CI) 1.1-15.8; p = 0.03) and the presence of a central venous catheter 7 days prior to infection (OR 5.6, 95% CI 1.1-27.8; p = 0.03). By multivariate analysis, subjects with steroid treatment during the previous 4 weeks had a 6.13-times higher risk of developing S. aureus infection (95% CI 1.5-25.7; p = 0.01), and the risk of infection decreased by a factor of 0.65 for every 1-y increase in age (95% CI 0.44-0.97; p = 0.03); these results were adjusted for matched criteria. Post-infection outcomes (cases vs controls) included graft loss (10% vs 0%; p = 0.11) and 12-month mortality (0% vs 2.5%; p = 0.99). CONCLUSIONS: Younger age and steroid treatment were significant independent risk factors associated with S. aureus infections after kidney transplantation. Graft and patient survival were not affected, but the study was not powered for these outcomes.

Tanning themselves to death: a new teen fad.

Incidence rates of melanoma continue to rise, especially in young women, despite the enormous body of evidence that identifies ultraviolet radiation as a skin carcinogen. It is time for a change in societal norms, an increase in counseling of young adults about the risks of indoor tanning facilities, and to prevent young adults from tanning by introducing new legislation.

The State of Forensic Literature on Persons with Intellectual Disability Who Sexually Offend.

Persons with intellectual disability charged with sexual crimes (PWID/SC) pose a unique challenge for the forensic psychiatrist. They represent a heterogeneous group whose motivations and pathology range from a simple lack of adaptive functioning to more complex comorbid paraphilic disorders. Although there is a growing body of literature on the risk assessment and treatment of PWID/SC, there is a relative lack of guidance and research on the evaluation of these individuals throughout the legal processes that follow being charged with a sexual crime. To address this deficit, this article reviews the literature germane to several key aspects of this process. We first review the current understanding of intellectual disability and sexual pathology. We identify landmark legal decisions that may relate to PWID/SC. We then review the literature related to PWID/SC and competency assessments, defenses involving mental disease or impairment, sexually violent predator evaluations and court-mandated pharmacotherapy. We aim to both bring attention to this unique forensic population and highlight areas for further research and exploration.

Women accused of sex offenses: a gender-based comparison.

Sexual offenses committed by women are likely underestimated and under-reported. This exploratory study compares and contrasts women accused of sexual offenses and their male counterparts. Data were retrospectively compiled on all alleged female and age-matched male sex offenders who were referred for psychiatric evaluation to a large Midwestern city's court psychiatric clinic over a six-year period. Data were abstracted regarding their crimes, charges, demographics, social history, medical history, legal history, violence history, substance use, sexual history, psychiatric history and their victims. Like the men, women were most frequently referred for sexual predator classification evaluations. Ages ranged from 19 to 62 years, and the majority had children. Most had prior arrests. One-third had a past history of psychiatric hospitalization, and most were given a non-paraphilic psychiatric diagnosis. The majority of the women reported past histories of sexual or physical victimization. While there were many similarities between female and male sex offenders in this psychiatric sample, women more frequently had victims of both genders.

An Unusual Delayed Complication of Urogynecologic Surgical Mesh: Perirectal Abscess 10 Years After Initial Placement Treated by Endoscopic Removal.

Surgical mesh is commonly used for the management of pelvic organ prolapse and stress urinary incontinence with overall beneficial effects. However, the Food and Drug Administration has issued safety notifications about potentially serious complications assisted with the use of synthetic mesh in pelvic organ prolapse procedures. In this report, we describe a perirectal abscess in a patient which developed 10 years after initial mesh placement. Percutaneous management of the abscess was not possible because of the deep pelvic location. The abscess was successfully managed endoscopically, including the removal of a large piece of mesh. Endoscopic management of pelvic abscesses, including an endoscopic ultrasound-guided approach, should be considered early.

Misconceptions About Working in Correctional Psychiatry.

Incarcerated individuals have high rates of mental disorders and substance use disorders compared with the general population, yet correctional facilities in the United States have difficulty recruiting mental health professionals. This has led to shortages in the availability of clinicians who can provide psychiatric care in these settings. During training and in practice, mental health professionals may develop misconceptions about correctional psychiatry that deter them from the field. This article examines common misconceptions about working in correctional psychiatry, including that correctional psychiatry provides unnecessary care to criminals, supports mass incarceration, is dangerous work, represents a less respectable subspecialty, and excludes clinicians from teaching and research opportunities. This article seeks to provide a resource for mental health professionals considering working with incarcerated patients.

Transrectal Endoscopic Ultrasound-Guided Drainage of a Tubo-Ovarian Abscess Via a Lumen-Apposing Metal Stent.

Tubo-ovarian abscess (TOA) is a potentially lethal condition, often requiring a combination of medical and surgical interventions. Endoscopic ultrasound (EUS)-guided drainage is a known modality for safe and effective management of pelvic fluid collections, but its role for the treatment of TOA is not well documented. We report the first known case of successful treatment of a large TOA with EUS-guided transrectal drainage using a lumen-apposing metal stent.