Phenylacetylene-Terminated Poly(Ethylene Glycol) as Ligands for Colloidal Noble Metal Nanoparticles: a New Tool for "Grafting to" Approach.

We report a new design of polymer phenylacetylene (PA) ligands and the ligand exchange methodology for colloidal noble metal nanoparticles (NPs). PA-terminated poly(ethylene glycol) (PEG) can bind to metal NPs through acetylide (M-C≡C-R) that affords a high grafting density. The ligand-metal interaction can be switched between σ bonding and extended π backbonding by changing grafting conditions. The σ bonding of PEG-PA with NPs is strong and it can compete with other capping ligands including thiols, while the π backbonding is much weaker. The σ bonding is also demonstrated to improve the catalytic performance of Pd for ethanol oxidation and prevent surface absorption of the reaction intermediates. Those unique binding characteristics will enrich the toolbox in the control of colloidal surface chemistry and their applications using polymer ligands.

Inpatient Care Utilization Following Mobile Crisis Response Encounters Among Racial/Ethnic Minoritized Youth.

OBJECTIVE: There has been an increase in youth psychiatric emergencies and psychiatric inpatient hospitalizations in recent years. Mobile crisis response (MCR) services offer an opportunity to meet acute youth mental health needs in the community and to provide linkage to care. However, an understanding of MCR encounters as a care pathway is needed, including how patterns of subsequent care may vary by youth race/ethnicity. The current study examines racial/ethnic differences in the rates of inpatient care use following MCR among youth. METHOD: Data included Los Angeles County Department of Mental Health (LACDMH) administrative claims for MCR in 2017 and psychiatric inpatient hospitalizations and outpatient services from 2017-2020 for youth aged 0 to 18 years. RESULTS: In this sample of 6,908 youth (70.4% racial/ethnic minoritized youth) who received an MCR, 3.2% received inpatient care within 30 days of their MCR, 18.6% received inpatient care beyond 30 days of their MCR, and 14.7% received repeated inpatient care episodes during the study period. Multivariate models revealed that Asian American/Pacific Islander (AAPI) youth were less likely to receive inpatient care, whereas American Indian/Alaska Native (AI/AN) youth were more likely to receive inpatient care following MCR. Youth age, primary language, primary diagnosis, and insurance status also predicted future inpatient episodes. CONCLUSION: Findings highlight differential rates of inpatient use following MCR among AAPI and AI/AN youth relative to youth from other groups. Alternative interpretations for the findings are offered related to differential levels of need and disparate penetration of community-based outpatient and prevention-focused services.

After the Crisis: Racial/Ethnic Disparities and Predictors of Care Use Following Youth Psychiatric Emergencies.

OBJECTIVE: Youth psychiatric emergencies have increased at alarming rates, and disproportionately so for youth of color. Outpatient follow-up care is critical for positive youth outcomes, but rates of follow-up remain low, especially for racial/ethnic minoritized youth. Mobile crisis response can initiate care connection. The current study (1) describes the population who received mobile crisis response (MCR) within the nation's largest county public mental health system, (2) assesses rates of follow-up outpatient services after MCR, and (3) examines racial/ethnic disparities in outpatient services and correlates of receipt of therapy dose (≥8 sessions). METHOD: Administrative claims for MCR and outpatient services for youth ages 0 to 18 were abstracted from the Los Angeles County Department of Mental Health. RESULTS: From October 2016-2019, 20,782 youth received a MCR, 52.5% of youth were female, and youth mean age was 13.41 years. The majority of youth (91.8%) received some outpatient services after their first MCR. However, only 56.7% of youth received ≥1 therapy session. In a logistic regression, youth age, gender, race/ethnicity, primary language, primary diagnosis, insurance status, MCR call location, and MCR disposition significantly predicted receipt of ≥8 therapy sessions. CONCLUSIONS: Findings highlight disparities in therapy receipt for Asian American Pacific Islander, Black, and White youth (relative to Latinx youth), older youth, youth whose MCR was initiated from a police station call, and youth whose MCR did not result in hospitalization. We discuss priorities for quality improvement for MCR processes and strategies to promote linkage to care to achieve mental health equity.

Reduction in school individualized education program (IEP) services during the COVID-19 pandemic.

Purpose: The COVID-19 pandemic created novel challenges for school systems and students, particularly students with disabilities. In the shift to remote/distance learning, this report explores the degree to which children with disabilities did not receive the special education and related services defined in their individualized education program (IEP). Methods: Patients attending an outpatient tertiary care center for neurodevelopmental disabilities in Maryland were surveyed on the impact of the pandemic on educational services provision. Results: Nearly half (46%) of respondents qualified for special education and related services through an IEP before the start of the COVID-19 pandemic. Among those with IEPs, 48% attested to reduced frequency and/or duration of special education and/or related services during the pandemic. The reduction was greatest in occupational therapy services (47%), followed physical therapy services (46%), and special education services (34%). Conclusion: This survey of children with disabilities observes a substantial reduction in IEP services reported in their completed surveys. To address the observed reduction in IEP services, we sought additional education for clinicians on the rights of students with disabilities in anticipation of students' re-entry to the classroom. A special education law attorney provided an instructional session on compensatory education and recovery services to prepare clinicians to properly inform parents about their rights and advocate for patients with unmet IEP services during the pandemic.

Pandemic intake questionnaire to improve quality, effectiveness, and efficiency of outpatient neurologic and developmental care at the Kennedy Krieger institute during the COVID-19 pandemic.

Background: The COVID-19 pandemic uniquely affects patients with neurologic and developmental disabilities at the Kennedy Krieger Institute. These patients are at increased risk of co-morbidities, increasing their risk of contracting COVID-19. Disruptions in their home and school routines, and restrictions accessing crucial healthcare services has had a significant impact. Methods: A Pandemic Intake questionnaire regarding COVID-19 related medical concerns of guardians of patients was distributed using Qualtrics. Data from May-December 2020 were merged with demographic information of patients from 10 clinics (Center for Autism and Related Disorders (CARD), Neurology, Epigenetics, Neurogenetics, Center for Development and Learning (CDL) Sickle Cell, Spinal Cord, Sturge-Weber syndrome (SWS), Tourette's, and Metabolism). A provider feedback survey was distributed to program directors to assess the effectiveness of this intervention. Results: Analysis included responses from 1643 guardians of pediatric patients (mean age 9.5 years, range 0-21.6 years). Guardians of patients in more medically complicated clinics reported perceived increased risk of COVID-19 (p < 0.001) and inability to obtain therapies (p < 0.001) and surgeries (p < 0.001). Guardian responses from CARD had increased reports of worsening behavior (p = 0.01). Providers increased availability of in-person and virtual therapies and visits and made referrals for additional care to address this. In a survey of medical providers, five out of six program directors who received the responses to this survey found this questionnaire helpful in caring for their patients. Conclusion: This quality improvement project successfully implemented a pre-visit questionnaire to quickly assess areas of impact of COVID-19 on patients with neurodevelopmental disorders. During the pandemic, results identified several major areas of impact, including patient populations at increased risk for behavioral changes, sleep and/or disruptions of medical care. Most program directors reported improved patient care as a result.

Addressing Pediatric Developmental and Mental Health in Primary Care Using Tele-Education.

This study evaluates the effectiveness of an early childhood tele-education program in preparing community pediatric clinicians to manage developmental and mental health disorders in young children. Community pediatric clinicians from rural, underserved, or school-based health center practices in the mid-Atlantic region participated in a weekly tele-education videoconference. There was a significant knowledge gain evidenced by the percentage of questions answered correctly from pre- to post- didactic exposure (P < .001). Participants reported an increase in knowledge from pre- (P < .001) and in confidence from pre- to post- participation (P < .001). Practice management changes demonstrated an encouraging trend toward managing patients in the Medical Home, as compared with immediately deferring to specialists following participation. This early childhood tele-education videoconferencing program is a promising response to the urgent need to confidently increase the role of pediatricians in the provision of care for childhood developmental and mental health disorders.

An Ethics Early Action Protocol to Promote Teamwork and Ethics Efficacy.

BACKGROUND: Moral dilemmas and ethical conflicts occur in critical care. Negative consequences include misunderstandings, mistrust, patient and family suffering, clinician moral distress, and patient safety concerns. Providing an opportunity for team-based ethics assessments and planning could improve communication and reduce moral distress. OBJECTIVES: The aims of this study were to explore whether an early action ethics intervention affects intensive care unit (ICU) clinicians' moral distress, ethics self-efficacy, and perceptions of hospital climate and to compare nurses' and physicians' scores on moral distress, ethics self-efficacy, and ethical climate at 3 time points. METHODS: Intensive care unit nurses and physicians were asked to complete surveys on moral distress, ethics self-efficacy, and ethical climate before implementing the ethics protocol in 6 ICUs. We measured responses to the same 3 surveys at 3 and 6 months after the protocol was used. RESULTS: At baseline, nurses scored significantly higher than physicians in moral distress and significantly lower in ethics self-efficacy. Plot graphs revealed that nurses' and physicians' outcome scores trended toward one another. At 3 and 6 months post intervention, nurse and physician scores changed differently in moral distress and ethics self-efficacy. When examining nurse and physician scores separately over time, we found nurses' scores in moral distress and moral distress frequency decreased significantly over time and ethics self-efficacy and ethics climate increased significantly over time. Physicians' scores did not change significantly. DISCUSSION: This study indicates that routine, team-based ethics assessment and planning opens a space for sharing information, which could decrease nurses' moral distress and increase their ethics self-efficacy. This, in turn, can potentially promote teamwork and reduce burnout.

How much therapy is enough? The dose-response effect and its moderators in a psychology training clinic.

OBJECTIVE: The current study aims to sharpen the understanding of the psychotherapy dose-response effect and its moderators in a psychology training clinic. METHOD: Data were extracted from 58 client records. Weekly Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7, as well as Outcomes Questionnaire-45.2, administered every fifth session, assessed whether clients achieved reliable change (RC) and clinically significant and reliable change (CSR) during treatment. Survival analyses were conducted to determine the sessions required for 50% of the sample to achieve these outcomes. Multilevel Cox frailty regressions were used to investigate client-and-therapy-based moderators. RESULTS: The median time for 50% of the sample to achieve RC was 8-10 sessions and 11 sessions to achieve initial CSR. Past treatment history was a significant moderator of time to achieve RC. CONCLUSIONS: From a population perspective, psychotherapy is most beneficial to patients early in treatment. Sharper understanding of the number of sessions required to achieve meaningful change can inform practice in training settings.

Diagnostic Sensitivity of the Dynamic Appraisal of Situational Aggression to Predict Violence and Aggression by Behavioral Health Patients in the Emergency Department.

INTRODUCTION: The Dynamic Appraisal of Situational Aggression (DASA) is an assessment tool that has been validated to predict violent or aggressive behavior in psychiatric inpatient settings. Its validity has not been established for use in the emergency department. METHODS: The DASA was implemented within the electronic health record of an academic medical center with inpatient psychiatric services. A retrospective analysis was conducted using Spearman rank-correlation coefficients to compare a final risk score with the subsequent occurrence of violence or aggression, defined as the use of hard leather physical restraints or the administration of intramuscular sedative medication. A receiver operating characteristic curve was used to summarize the predictive accuracy of the tool to assess aggression in behavioral health patients in the emergency department. RESULTS: A total of 3,433 scores were analyzed, representing 1,548 patients. The DASA had predictive validity with increasing scores comparing all tested cutoff scores against incidence of violence and aggression. The area under the curve comparing scores of 0 versus more than 0 was 0.79. The median time to subsequent aggression was 110 minutes. DISCUSSION: The DASA has predictive validity for use in evaluating behavioral health patients in the ED setting in an urban academic medical center. The tool is capable of predicting violence or aggression within a time frame conducive to the implementation of noninvasive measures. The DASA should be tested in other ED settings to further establish its predictive validity.

A Team-Based Early Action Protocol to Address Ethical Concerns in the Intensive Care Unit.

BACKGROUND: Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical conflicts escalate, patient and family distress and dissatisfaction with care increase and trust in clinicians erodes, reducing care quality and patient safety. OBJECTIVE: To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families. METHODS: In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via multivariate logistic regression controlled for patient variables. RESULTS: The odds of receiving a family conference and a chaplain visit were significantly higher after the intervention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change. CONCLUSIONS: When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced.

A National Survey on Moral Obligations in Critical Care.

BACKGROUND: Critical care clinicians routinely encounter ethically complex situations. Ethical conflicts sometimes arise from different perspectives regarding goals of care and moral obligations. These conflicts contribute to providers' moral distress and burnout and can erode trust between patients, families, and clinicians. OBJECTIVES: To explore the most disturbing and most frequent types of ethically complex situations; compare clinicians' perceptions of their own, each other's, and shared moral obligations for providing quality care in these situations; and examine perceptions of communication and teamwork. METHODS: A national, web-based survey was made available to members of the American Association of Critical-Care Nurses and the Society for Critical Care Medicine. The survey included rank order, rating, and open-ended questions. RESULTS: Nurses and physicians ranked similarly the most frequent and disturbing ethical situations encountered during critical care practice. Nurses and physicians rated similarly physicians' moral obligations, but their ratings of nurses' moral obligations differed, with physicians giving lower ratings. Physicians also were more likely than nurses to report higher levels of trust (90.6% vs 66.8%) and more satisfaction with team communication (81.3% vs 66.9%). Narrative comments revealed embedded, entwined, and sometimes divergent expectations about moral obligations, which interfered with effective teamwork during ethically complex situations. CONCLUSIONS: Teamwork in critical care would benefit from acknowledgment of and clear communication about role-specific, interdependent, and shared moral obligations. Opportunities for routine, team-based dialogue about ethical aspects of care and moral obligations could reduce role ambiguity and ethical conflicts.

From Modules to MOOCs: Application of the Six-Step Approach to Online Curriculum Development for Medical Education.

Online curricula can make high-quality health professions education accessible in virtually any setting. They can enhance teaching and learning by both standardizing curricular resources and individualizing curricular experiences. Despite growing demand for and institutional interest in online curricula for medical education, many medical educators lack a framework for online curriculum development. Without rigorous and thoughtful development, online curricula can waste opportunity and resources by leading to education that is inferior to traditional methods. In this article, the authors describe a systematic approach to online curriculum development based on the Six-Step Approach for Curriculum Development for Medical Education, a widely used method that has led to successful implementation of a variety of traditional and online curricula. In each step, special considerations for curricula with larger and more diverse learner audiences-characteristic of many online curricula-are highlighted. Four common online curricular formats are also discussed: blended curricula, instructor-led fully online curricula, self-paced modules, and massive open online courses (MOOCs). The authors emphasize factors that differentiate one online format from another, including the budgetary, technical, and human resource requirements for each. The article concludes by urging medical educators to pursue opportunities to study and disseminate online curricular work.

Electrocardiographic Correlates of Acute Allograft Rejection Among Heart Transplant Recipients.

BACKGROUND: Acute allograft rejection appears to be associated with increases in QT/QTc intervals. OBJECTIVES: To determine the relationship between acute allograft rejection and electrocardiogram changes in patients undergoing an orthotopic heart transplant. METHODS: The study population comprised 220 adult patients undergoing heart transplant and enrolled in the NEW HEART study. Electrocardiograms obtained within 72 hours of endomyocardial biopsy were analyzed; electrocardiograms obtained fewer than 10 days after transplant surgery were excluded. Repeated-measures analysis was performed with statistical models including effects for rejection severity (mild and moderate/severe) and time trends independent of rejection status. RESULTS: The 151 male and 69 female transplant recipients (mean age [SD], 54 [13] years) had 969 biopsy/electrocardiogram pairs: 677 with no rejection, 280 with mild rejection, and 12 with moderate/severe rejection. Moderate to severe organ rejection was associated with significant increases in QRS duration (P < .001), QT (P = .009), QTc (P = .003), and PR interval (P = .03), as well as increased odds of right bundle block branch (P = .002) and fascicular block (P = .009) occurring. CONCLUSIONS: Moderate to severe acute allograft rejection was associated with electrocardiographic changes after transplant surgery. Studies are needed to assess the value of computerized electrocardiogram measurement algorithms for detecting acute allograft rejection.

Perceived control and health-related quality of life in heart transplant recipients.

BACKGROUND: Perceived control has been associated with improved mental health and health-related quality of life (HRQOL) in cardiac populations. However, this concept has not been well-studied in heart transplant groups. AIMS: We examine the relationship of perceived control to symptoms of anxiety and depression and HRQOL after transplant. We also examine the extent to which anxiety and depressive symptoms mediate the relationship between perceived control and HRQOL. METHODS: Our cross-sectional analysis included 113 adult heart transplant patients from the NEW HEART study. High versus low perceived control groups were determined by median split for chi-square and t-test analyses. Hierarchical multiple linear regression models were used to examine the influence of perceived control on symptoms of depression and anxiety and HRQOL. Mediation analyses included Baron and Kenny's four-step regression approach and Preacher and Hayes' bootstrapping technique to test the indirect effect of perceived control on HRQOL. RESULTS: Heart transplant patients who reported lower perceived control were more likely to be female ( p=0.003), and had significantly more depressive symptoms ( p<0.001) and anxiety ( p<0.001), and lower HRQOL ( p<0.001) than those with higher perceived control. Perceived control was a significant predictor in regression models of depressive and anxiety symptoms and HRQOL. In mediation analyses, depressive and anxiety symptoms mediated the effect of perceived control on HRQOL. CONCLUSION: Perceived control is associated with improved depressive and anxiety symptoms and HRQOL after transplant. The relationship between perceived control and HRQOL is mediated by depressive and anxiety symptoms. Future interventions should target perceived control to improve overall HRQOL.

Teaching to varied disciplines and educational levels simultaneously: An innovative approach in a neonatal follow-up clinic.

PURPOSE: Across various health conditions and geographic regions, there remains a dearth of clinicians with the expertise and confidence to identify and manage children with disabilities. At the front line of this crisis are clinician-educators, who are tasked with caring for these unique patients and with training the future workforce. Balancing patient care and clinical instruction responsibilities is particularly challenging when trainees of varied educational levels and specialties report simultaneously. The lack of a standard curriculum further compounds the clinician-educator's teaching demands and threatens the consistency of trainees' learning. Recognizing these challenges in their work in a neonatal follow-up clinic, the authors sought a solution through an established curriculum development process. MATERIALS AND METHODS: A needs assessment survey was conducted to gauge medical trainees' knowledge, skills, and experiences. Applying needs assessment findings, the authors developed a curriculum, which was administered online to several trainee cohorts just prior to rotations in the neonatal follow-up clinic. RESULTS: After completing the curriculum, trainees scored significantly higher on neonatal follow-up knowledge tests. CONCLUSIONS: Providing advance exposure helped to ensure that trainees arrived with comparable basal knowledge, which served as a foundation for more advanced instruction. This curricular approach may be useful across teaching venues, especially those with multi-level or multi-discipline learners.

Evaluation of the SIPAT instrument to assess psychosocial risk in heart transplant candidates: A retrospective single center study.

OBJECTIVES: We evaluated the reliability of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) in heart transplant (HT) recipients and explored its usefulness in predicting post-transplant outcomes. BACKGROUND: Pre-transplant psychosocial and behavioral risk is associated with post-transplant clinical outcomes. SIPAT is a risk assessment tool created for pre-transplant psychosocial evaluation. METHODS: Via retrospective chart review, three examiners applied the SIPAT to 51 adult HT recipients. Examiners blinded to SIPAT scores extracted data and interviewed clinicians for one-year post-transplant outcomes. Analysis included Intra-class correlation coefficient (ICC), Pearson's correlation coefficient and Chi-square. RESULTS: SIPAT demonstrated strong inter-rater reliability (ICC = 0.89, 95% CI = 0.76-0.96). Compared to those with SIPAT ratings of "Excellent/Good", the "Minimally Acceptable Candidate/High Risk" group was more likely to miss clinic visits (p = 0.004). CONCLUSIONS: The SIPAT tool had strong IRR. Less favorable SIPAT ratings were associated with nonadherence to clinic visits. Further study is warranted to determine association of SIPAT ratings to clinical outcomes.

Clinical and gender differences in heart transplant recipients in the NEW HEART study.

BACKGROUND: Little attention has focused on gender differences in cardiac comorbidities and outcomes in patients undergoing orthotropic heart transplant. OBJECTIVE: The objective of this study was to investigate gender differences at baseline and during follow-up among heart transplant patients. METHODS: An observational cohort within the NEW HEART study was evaluated to determine gender differences in relation to age, coexisting cardiac comorbidities, and outcomes. Differences were assessed by t-test, Fisher's exact test, and logistic regression analysis. RESULTS: Male transplant recipients ( n = 238) were significantly older than female recipients ( n = 92), with a greater percentage over 60 years of age (45% vs. 24%, p = 0.0006). Males were more likely to have hypertension (63% vs. 49%, p = 0.034), dyslipidemia (62% vs. 45%, p = 0.006), a history of smoking (52% vs. 35%, p = 0.009), and diabetes (42% vs. 21%, p = 0.0002). Analysis of endomyocardial biopsies obtained during the 1-year follow-up period demonstrated that women averaged more episodes of acute rejection than men (3.9 vs. 3.0, p = 0.009). While most episodes of rejection were mild, women were more likely than men to have episodes of moderate or severe rejection (14% vs. 5%, p = 0.012) and to be hospitalized for acute rejection (15% vs. 6%, p = 0.013). There were no significant differences in mortality. CONCLUSIONS: Men were more likely than women to be older and to have diabetes, dyslipidemia, hypertension, and a history of smoking. Women were more likely to experience moderate or severe allograft rejection and to be hospitalized for acute rejection. Future investigation of the reasons for these gender differences is warranted and may improve clinical care of women undergoing cardiac transplantation.

Cognitive behavioral therapy for depression improves pain and perceived control in cardiac surgery patients.

BACKGROUND: Depression after cardiac surgery (CS) is associated with increased pain and decreased sleep quality. While cognitive behavioral therapy (CBT) aimed at depression is effective in relieving depressive symptoms after cardiac surgery, little is known about its ability to ameliorate other common postoperative problems that affect recovery and quality of life. AIMS: The purpose of this study was to evaluate the effects of CBT for depression on pain severity, pain interference, sleep, and perceived control in patients recovering from CS. METHODS: Depressed patients recovering from CS were randomized to receive either eight weeks of CBT or usual care. At baseline and post-intervention, patients completed questionnaires for depressive symptoms, pain, sleep, and perceived control. Group comparisons were conducted using t-tests or chi square analysis. Repeated measures analysis was used to assess the effect of the intervention in changes over time. RESULTS: The sample (n=53) included 16.9% women and had a mean age of 67.8±9.2 years. CBT for depression increased perceived control (p<0.001) and decreased pain interference (p=0.02) and pain severity (p=0.03). Group effects remained significant (p<0.05) for perceived control and pain interference and a trend was observed for pain severity (p<0.10) after controlling for variables that differed at baseline. There were no group differences in sleep disturbance over time. CONCLUSIONS: A depression-focused CBT intervention yields benefits in other common postoperative problems, specifically improved perceived control and decreased pain in depressed cardiac surgery patients.