Factors Associated With Mortality in Low-Risk Pediatric Critical Care Patients in The Netherlands.

OBJECTIVE: To determine differences between survivors and nonsurvivors and factors associated with mortality in pediatric intensive care patients with low risk of mortality. DESIGN: Retrospective cohort study. SETTING: Patients were selected from a national database including all admissions to the PICUs in The Netherlands between 2006 and 2012. PATIENTS: Patients less than 18 years old admitted to the PICU with a predicted mortality risk lower than 1% according to either the recalibrated Pediatric Risk of Mortality or the Pediatric Index of Mortality 2 were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 16,874 low-risk admissions were included of which 86 patients (0.5%) died. Nonsurvivors had more unplanned admissions (74.4% vs 38.5%; p < 0.001), had more complex chronic conditions (76.7% vs 58.8%; p = 0.001), were more often mechanically ventilated (88.1% vs 34.9%; p < 0.001), and had a longer length of stay (median, 11 [interquartile range, 5-32] d vs median, 3 [interquartile range, 2-5] d; p < 0.001) when compared with survivors. Factors significantly associated with mortality were complex chronic conditions (odds ratio, 3.29; 95% CI, 1.97-5.50), unplanned admissions (odds ratio, 5.78; 95% CI, 3.40-9.81), and admissions in spring/summer (odds ratio, 1.67; 95% CI, 1.08-2.58). CONCLUSIONS: Nonsurvivors in the PICU with a low predicted mortality risk have recognizable risk factors including complex chronic condition and unplanned admissions.

Overlooking Feigning Behavior May Result in Potential Harmful Treatment Interventions: Two Case Reports of Undetected Malingering.

Clinicians tend to overestimate their ability to recognize feigning behavior in psychiatric patients, especially if it concerns patients who have been admitted for observation. Feigning can be either externally motivated (e.g., for financial compensation, known as malingering) or internally motivated (e.g., to assume the "sick role," known as factitious disorder). Persistent presentation of severe symptoms is usually associated with the factitious disorder. We present two patients with strong external incentives who consistently and convincingly feigned severe psychiatric symptoms during a protracted period of inpatient observation in a specialized center; both were engaged in a procedure for medical asylum. The first case presented with the clinical picture of a psychotic depression with severe motor symptoms, and the second case showed symptoms of a chronic post-traumatic stress disorder with secondary psychotic symptoms. Both cases were thoroughly investigated but feigning was overlooked, and unnecessary and harmful treatment interventions were given. To prevent iatrogenic damage, we recommend a critical attitude that takes malingering as an option into account in settings where patients are often involved in high stake legal procedures. A clinical sign that might indicate feigning is therapy-resistant symptoms. To rule out feigning a comprehensive, multimethod approach is required, but an active stance toward collateral information is essential. Specialized psychological tests may be useful for preliminary screening, but for their use in culturally diverse populations as in refugee mental health more research is needed.

Plausibility Judgments of Atypical Symptoms Across Cultures: an Explorative Study Among Western and Non-Western Experts.

Symptom validity tests (SVTs) are predicated on the assumption that overendorsement of atypical symptoms flags symptom exaggeration (i.e., questionable symptom validity). However, few studies have explored how practitioners from different cultural backgrounds evaluate such symptoms. We asked professionals working in Western (n = 56) and non-Western countries (n = 37) to rate the plausibility of uncommon symptoms taken from the Structured Inventory of Malingered Symptomatology (SIMS), dissociative symptoms from the Dissociative Experience Scale (DES-T), and standard symptoms (e.g., anxiety, depression) from the Brief Symptom Inventory-18 (BSI-18). Western and non-Western experts gave similar plausibility ratings to atypical, dissociative, and standard symptoms: both groups judged BSI-18 symptoms as significantly more plausible than either dissociative or atypical symptoms, while the latter two categories did not differ. Our results suggest that the strategy to detect symptom exaggeration by exploring overendorsement of atypical items might work in a non-western context as well.

Validity of symptom reports of asylum seekers in a psychiatric hospital: A descriptive study.

Our study involved three samples (N=85; N=38, and N=27) of asylum seekers in a Dutch psychiatric hospital. We looked at how often they reported severe dissociative episodes (i.e., not recognizing oneself in a mirror; seeing traumatic images in a mirror) and whether these symptoms were related to deviant performance on Symptom Validity Tests (SVTs), notably items from the Structured Inventory of Malingered Symptomatology (SIMS; Widows & Smith, 2005) and a forced-choice task modeled after the Morel Emotional Numbing Test (MENT; Morel, 1998). We also examined whether poor language proficiency and the presence of incentives to exaggerate symptoms might affect scores on SVTs. Dissociative target symptoms were reported by considerable percentages of patients (27-63%). Patients who reported these symptoms had significantly more often deviant scores on SVT items compared with those who did not report such symptoms. With a few exceptions, deviant scores on SVT items were associated with incentives rather than poor language skills. We conclude that the validity of self-reported symptoms in this target group should not be taken for granted and that SVTs may yield important information.

Off-hours admission and mortality in two pediatric intensive care units without 24-h in-house senior staff attendance.

PURPOSE: To compare risk-adjusted mortality of children non-electively admitted during off-hours with risk-adjusted mortality of children admitted during office hours to two pediatric intensive care units (PICUs) without 24-h in-house attendance of senior staff. DESIGN: Prospective observational study, performed between January 2003 and December 2007, in two PICUs without 24-h in-house attendance of senior staff, located in tertiary referral children's hospitals in the Netherlands. METHODS: Standardized mortality rates (SMRs) of patients admitted during off-hours were compared to SMRs of patients admitted during office hours using Pediatric Index of Mortality (PIM1) and Pediatric Risk of Mortality (PRISM2) scores. Office hours were defined as week days between 8:00 a.m. and 6:00 p.m., with in-house attendance of senior staff, and off-hours as week days between 6:00 p.m. and 8:00 a.m., Saturdays, Sundays and public holidays, with one resident covering the PICU and senior staff directly available on-call. RESULTS: Of 3,212 non-elective patients admitted to the PICUs, 2,122 (66%) were admitted during off-hours. SMRs calculated according to PIM1 and PRISM2 did not show a significant difference with those of patients admitted during office hours. There was no significant effect of admission time on mortality in multivariate logistic regression with odds ratios of death in off-hours of 0.95 (PIM1, 95% CI 0.71-1.27, p = 0.73) and 1.03 (PRISM2, 95% CI 0.76-1.39, p = 0.82). CONCLUSION: Off-hours admission to our PICUs without 24-h in-house attendance of senior staff was not associated with higher SMRs than admission during office hours when senior staff were available in-house.