Impact of COVID-19 on mental health research: is this the breaking point?

There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.

Improving Pediatric Readiness in General Emergency Departments: A Prospective Interventional Study.

OBJECTIVE: To describe the impact of a national interventional collaborative on pediatric readiness within general emergency departments (EDs). STUDY DESIGN: A prospective, multicenter, interventional study measured pediatric readiness in general EDs before and after participation in a pediatric readiness improvement intervention. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) on a 100-point scale. The study protocol extended over 6 months and involved 3 phases: (1) a baseline on-site assessment of pediatric readiness and simulated quality of care; (2) pediatric readiness interventions; and (3) a follow-up on-site assessment of WPRS. The intervention phase included a benchmarking performance report, resources toolkits, and ongoing interactions between general EDs and academic medical centers. RESULTS: Thirty-six general EDs were enrolled, and 34 (94%) completed the study. Four EDs (11%) were located in Canada, and the rest were in the US. The mean improvement in WPRS was 16.3 (P < .001) from a baseline of 62.4 (SEM = 2.2) to 78.7 (SEM = 2.1), with significant improvement in the domains of administration/coordination of care; policies, protocol, and procedures; and quality improvement. Six EDs (17%) were fully adherent to the protocol timeline. CONCLUSIONS: Implementing a collaborative intervention model including simulation and quality improvement initiatives is associated with improvement in WPRS when disseminated to a diverse group of general EDs partnering with their regional pediatric academic medical centers. This work provides evidence that innovative collaboration facilitated by academic medical centers can serve as an effective strategy to improve pediatric readiness and processes of care.

Using simulation to increase resident comfort discussing social determinants of health.

BACKGROUND: Social determinants of health (SDoH) play an important role in pediatric health outcomes. Trainees receive little to no training on how to identify, discuss and counsel families in a clinical setting. The aim of this study was to determine if a simulation-based SDoH training activity would improve pediatric resident comfort with these skills. METHODS: We performed a prospective study of a curricular intervention involving simulation cases utilizing standardized patients focused on four social determinants (food insecurity, housing insecurity, barriers to accessing care, and adverse childhood experiences [ACEs]). Residents reported confidence levels with discussing each SDoH and satisfaction with the activity in a retrospective pre-post survey with five-point Likert style questions. Select residents were surveyed again 9-12 months after participation. RESULTS: 85% (33/39) of residents expressed satisfaction with the simulation activity. More residents expressed comfort discussing each SDoH after the activity (Δ% 38-47%; all p < .05), with the greatest effect noted in post-graduate-year-1 (PGY-1) participants. Improvements in comfort were sustained longitudinally during the academic year. More PGY-1 participants reported engaging in ≥ 2 conversations in a clinical setting related to food insecurity (43% vs. 5%; p = .04) and ACEs (71% vs. 20%; p = .02). DISCUSSION: Simulation led to an increased resident comfort with discussing SDoH in a clinical setting. The greatest benefit from such a curriculum is likely realized early in training. Future efforts should investigate if exposure to the simulations and increased comfort level with each topic correlate with increased likelihood to engage in these conversations in the clinical setting.

Antidepressants for treating depression in dementia.

BACKGROUND: The use of antidepressants in dementia accompanied by depressive symptoms is widespread, but their clinical efficacy is uncertain. This review updates an earlier version, first published in 2002. OBJECTIVES: To determine the efficacy and safety of any type of antidepressant for patients who have been diagnosed as having dementia of any type and depression as defined by recognised criteria. SEARCH METHODS: We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, on 16 August 2017. ALOIS contains information on trials retrieved from databases and from a number of trial registers and grey literature sources. SELECTION CRITERIA: We included all relevant double-blind, randomised trials comparing any antidepressant drug with placebo, for patients diagnosed as having dementia and depression. DATA COLLECTION AND ANALYSIS: Two review authors selected studies for inclusion and extracted data independently. We assessed risk of bias in the included studies using the Cochrane 'Risk of bias' tool. Where clinically appropriate, we pooled data for treatment periods up to three months and from three to nine months. We used GRADE methods to assess the overall quality of the evidence. MAIN RESULTS: We included ten studies with a total of 1592 patients. Eight included studies reported sufficiently detailed results to enter into analyses related to antidepressant efficacy. We split one study which included two different antidepressants and therefore had nine groups of patients treated with antidepressants compared with nine groups receiving placebo treatment. Information needed to make 'Risk of bias' judgements was often missing.We found high-quality evidence of little or no difference in scores on depression symptom rating scales between the antidepressant and placebo treated groups after 6 to 13 weeks (standardised mean difference (SMD) -0.10, 95% confidence interval (CI) -0.26 to 0.06; 614 participants; 8 studies). There was probably also little or no difference between groups after six to nine months (mean difference (MD) 0.59 point, 95% CI -1.12 to 2.3, 357 participants; 2 studies; moderate-quality evidence). The evidence on response rates at 12 weeks was of low quality, and imprecision in the result meant we were uncertain of any effect of antidepressants (antidepressant: 49.1%, placebo: 37.7%; odds ratio (OR) 1.71, 95% CI 0.80 to 3.67; 116 participants; 3 studies). However, the remission rate was probably higher in the antidepressant group than the placebo group (antidepressant: 40%, placebo: 21.7%; OR 2.57, 95% CI 1.44 to 4.59; 240 participants; 4 studies; moderate-quality evidence). The largest of these studies continued for another 12 weeks, but because of imprecision of the result we could not be sure of any effect of antidepressants on remission rates after 24 weeks. There was evidence of no effect of antidepressants on performance of activities of daily living at weeks 6 to 13 (SMD -0.05, 95% CI -0.36 to 0.25; 173 participants; 4 studies; high-quality evidence) and probably also little or no effect on cognition (MD 0.33 point on the Mini-Mental State Examination, 95% CI -1.31 to 1.96; 194 participants; 6 studies; moderate-quality evidence).Participants on antidepressants were probably more likely to drop out of treatment than those on placebo over 6 to 13 weeks (OR 1.51, 95% CI 1.07 to 2.14; 836 participants; 9 studies). The meta-analysis of the number of participants suffering at least one adverse event showed a significant difference in favour of placebo (antidepressant: 49.2%, placebo: 38.4%; OR 1.55, 95% CI 1.21 to 1.98, 1073 participants; 3 studies), as did the analyses for participants suffering one event of dry mouth (antidepressant: 19.6%, placebo: 13.3%; OR 1.80, 95% CI 1.23 to 2.63, 1044 participants; 5 studies), and one event of dizziness (antidepressant: 19.2%, placebo: 12.5%; OR 2.00, 95% CI 1.34 to 2.98, 1044 participants; 5 studies). Heterogeneity in the way adverse events were reported in studies presented a major difficulty for meta-analysis, but there was some evidence that antidepressant treatment causes more adverse effects than placebo treatment does. AUTHORS' CONCLUSIONS: The available evidence is of variable quality and does not provide strong support for the efficacy of antidepressants for treating depression in dementia, especially beyond 12 weeks. On the only measure of efficacy for which we had high-quality evidence (depression rating scale scores), antidepressants showed little or no effect. The evidence on remission rates favoured antidepressants but was of moderate quality, so future research may find a different result. There was insufficient evidence to draw conclusions about individual antidepressant drugs or about subtypes of dementia or depression. There is some evidence that antidepressant treatment may cause adverse events.

The evolution of graduate medical education over the past decade: Building a new pediatric residency program in an era of innovation.

AIM: In 2011, Johns Hopkins Medicine integrated with All Children's Hospital in St. Petersburg Florida to create an academic campus nearly 1000 miles from Baltimore. In 2014, the newly named Johns Hopkins All Children's Hospital established a new pediatric residency program. At that time, the Association for Graduate Medical Education had not accredited a new pediatric program in the USA in over 10 years. METHODS: A unique set of circumstances provided an opportunity for program developers to build the residency under newly identified core tenets to create a number of innovative features targeted to address the many calls for change in graduate medical education. RESULTS: This paper focuses on three of those innovations and demonstrates how they address the many challenges introduced by the changing landscape of graduate medical education. CONCLUSION: Although a full evaluation of our program is only possible after many years, this article presents the core tenets which guided curricular development and discusses our experiences thus far. We provide lessons learned for programs considering similar innovations.

Safety Threats During the Care of Infants with Hypoglycemic Seizures in the Emergency Department: A Multicenter, Simulation-Based Prospective Cohort Study.

BACKGROUND: Errors in the timely diagnosis and treatment of infants with hypoglycemic seizures can lead to significant patient harm. It is challenging to precisely measure medical errors that occur during high-stakes/low-frequency events. Simulation can be used to assess risk and identify errors. OBJECTIVE: We hypothesized that general emergency departments (GEDs) would have higher rates of deviations from best practices (errors) compared to pediatric emergency departments (PEDs) when managing an infant with hypoglycemic seizures. METHODS: This multicenter simulation-based prospective cohort study was conducted in GEDs and PEDs. In situ simulation was used to measure deviations from best practices during management of an infant with hypoglycemic seizures by inter-professional teams. Seven variables were measured: five nonpharmacologic (i.e., delays in airway assessment, checking dextrose, starting infusion, verbalizing disposition) and two pharmacologic (incorrect dextrose dose and incorrect dextrose concentration). The primary aim was to describe and compare the frequency and types of errors between GEDs and PEDs. RESULTS: Fifty-eight teams from 30 hospitals (22 GEDs, 8 PEDs) were enrolled. Pharmacologic errors occurred more often in GEDs compared to PEDs (p = 0.043), while nonpharmacologic errors were uncommon in both groups. Errors more frequent in GEDs related to incorrect dextrose concentration (60% vs. 88%; p = 0.025), incorrect dose (20% vs. 56%; p = 0.033), and failure to start maintenance dextrose (33% vs. 65%; p = 0.040). CONCLUSIONS: During the simulated care of an infant with hypoglycemic seizures, errors were more frequent in GEDs compared to PEDs. Decreasing annual pediatric patient volume was the best predictor of errors on regression analysis.

Can Telemedicine Improve Adherence to Resuscitation Guidelines for Critically Ill Children at Community Hospitals? A Randomized Controlled Trial Using High-Fidelity Simulation.

OBJECTIVES: Children transferred from community hospitals lacking specialized pediatric care are more seriously ill than those presenting to pediatric centers. Pediatric consultation and adherence to management guidelines improve outcomes. The aims of the study were (1) to assess whether telemedicine consultation in critical situations is feasible and (2) to compare the impact of pediatric critical care medicine (PCCM) consultation via telemedicine versus telephone on community hospital adherence to resuscitation guidelines through a randomized controlled telemedicine trial. METHODS: In situ, high-fidelity simulation scenarios of critically ill children presenting to a community hospital and progressing to cardiopulmonary arrest were performed. Scenarios were randomized to PCCM consultation via telephone (control) or telemedicine (intervention). Primary outcome measure was proportion of teams who successfully defibrillated in 180 seconds or less from presentation of pulseless ventricular tachycardia. RESULTS: The following 30 scenarios were completed: 15 control and 15 intervention. Only 11 (37%) of 30 teams, defibrillated in 180 seconds or less from presentation of pulseless ventricular tachycardia; control: 6 (40%) of 15 versus intervention: 5 (33%) of 15, P = 0.7. Request for or use of backboard during cardiopulmonary resuscitation occurred in 24 (80%) of 30 scenarios; control: 9 (60%) of 15 versus intervention: 15 (100%) of 15, P = 0.006. Request for or use of stepstool during cardiopulmonary resuscitation occurred in 6 (20%) of 30 scenarios; control: 1 (7%) of 15 versus intervention: 5 (33%) of 15, P = 0.07. CONCLUSIONS: This study demonstrates the feasibility of using telemedicine to support acute management of children who present to community hospitals. Neither study arm adhered to current resuscitation guidelines and telemedicine consultation with PCCM experts was not associated with improvement. However, further research on optimizing telemedicine impact on the quality of pediatric care at community hospitals is warranted.

Faces of all clinically engaged staff: a quality improvement project that enhances the hospitalised patient experience.

BACKGROUND: Patients often cannot recognise the names and faces of providers involved in their hospital care. OBJECTIVE: The aim of this study was to determine whether photographs of a patient's providers (physicians and ancillary support staff) using the FACES (Faces of All Clinically Engaged Staff) instrument would increase recognition of the healthcare team, improve the perception of teamwork, and enhance patient satisfaction. METHODS: Cluster randomised controlled trial with patients admitted to four adult internal medicine services of an urban, tertiary care hospital. Patients randomly admitted to two services received the FACES instrument, while the remainder served as control. Study measurements included the proportion of patients able to recognise their care providers by photograph, name and role, as well as patient rating of communication among healthcare team members and their satisfaction with the hospital experience as assessed by a survey. RESULTS: A total of 197 of the 322 (61.2%) patients screened for participation proved eligible for the study. Key exclusion criteria included cognitive or visual impairment and non-fluency with English. Patients receiving the FACES instrument recognised more provider names, faces and roles than controls (all P<.001). The intervention group more strongly agreed with statements that healthcare providers communicated frequently and effectively with each other (68% vs 52%, P=.02), and worked well together (69% vs 53%, P=.02). When rating their satisfaction with the hospital experience, 50% of patients in the intervention group assigned the highest possible rating, compared with 36% of control (P=.06). LIMITATIONS: Nursing staff, although integral to healthcare teams, were not included in the FACES instrument due to privacy concerns. CONCLUSIONS: The FACES instrument improved patients' recognition of providers' names and roles, as well as patients' perception of inter-provider teamwork. There was a non-significant trend towards improved satisfaction.

Disparities in Adherence to Pediatric Sepsis Guidelines across a Spectrum of Emergency Departments: A Multicenter, Cross-Sectional Observational In Situ Simulation Study.

BACKGROUND: Each year in the United States, 72,000 pediatric patients develop septic shock, at a cost of $4.8 billion. Adherence to practice guidelines can significantly reduce mortality; however, few methods to compare performance across a spectrum of emergency departments (EDs) have been described. OBJECTIVES: We employed standardized, in situ simulations to measure and compare adherence to pediatric sepsis guidelines across a spectrum of EDs. We hypothesized that pediatric EDs (PEDs) would have greater adherence to the guidelines than general EDs (GEDs). We also explored factors associated with improved performance. METHODS: This multi-center observational study examined in situ teams caring for a simulated infant in septic shock. The primary outcome was overall adherence to the pediatric sepsis guideline as measured by six subcomponent metrics. Characteristics of teams were compared using multivariable logistic regression to describe factors associated with improved performance. RESULTS: We enrolled 47 interprofessional teams from 24 EDs. Overall, 21/47 teams adhered to all six sepsis metrics (45%). PEDs adhered to all six metrics more than GEDs (93% vs. 22%; difference 71%, 95% confidence interval [CI] 43-84). Adherent teams had significantly higher Emergency Medical Services for Children readiness scores, MD composition of physicians to total team members, teamwork scores, provider perceptions of pediatric preparedness, and provider perceptions of sepsis preparedness. In a multivariable regression model, only greater composite team experience had greater adjusted odds of achieving an adherent sepsis score (adjusted odds ratio 1.38, 95% CI 1.01-1.88). CONCLUSIONS: Using standardized in situ scenarios, we revealed high variability in adherence to the pediatric sepsis guideline across a spectrum of EDs. PEDs demonstrated greater adherence to the guideline than GEDs; however, in adjusted analysis, only composite team experience level of the providers was associated with improved guideline adherence.

Hedonic and disgust taste perception in borderline personality disorder and depression.

Depression and borderline personality disorder (BPD) are both thought to be accompanied by alterations in the subjective experience of environmental rewards. We evaluated responses in women to sweet, bitter and neutral tastes (juice, quinine and water): 29 with depression, 17 with BPD and 27 healthy controls. The BPD group gave lower pleasantness and higher disgust ratings for quinine and juice compared with the control group; the depression group did not differ significantly from the control group. Juice disgust ratings were related to self-disgust in BPD, suggesting close links between abnormal sensory processing and self-identity in BPD.

Can medical students identify a potentially serious acetaminophen dosing error in a simulated encounter? a case control study.

BACKGROUND: In an effort to assess medical students' abilities to identify a medication administration error in an outpatient setting, we designed and implemented a standardized patient simulation exercise which included a medication overdose. METHODS: Fourth year medical students completed a standardized patient (SP) simulation of a parent bringing a toddler to an outpatient setting. In this case-control study, the majority of students had completed a patient safety curriculum about pediatric medication errors prior to their SP encounter. If asked about medications, the SP portraying a parent was trained to disclose that she was administering acetaminophen and to produce a package with dosing instructions on the label. The administered dose represented an overdose. Upon completion, students were asked to complete an encounter note. RESULTS: Three hundred forty students completed this simulation. Two hundred ninety-one students previously completed a formal patient safety curriculum while 49 had not. A total of two hundred thirty-four students (69%) ascertained that the parent had been administering acetaminophen to their child. Thirty-seven students (11%) determined that the dosage exceeded recommended dosages. There was no significant difference in the error detection rates of students who completed the patient safety curriculum and those who had not. CONCLUSIONS: Despite a formal patient safety curriculum concerning medication errors, 89% of medical students did not identify an overdose of a commonly used over the counter medication during a standardized patient simulation. Further educational interventions are needed for students to detect medication errors. Additionally, 31% of students did not ask about the administration of over the counter medications suggesting that students may not view such medications as equally important to prescription medications. Simulation may serve as a useful tool to assess students' competency in identifying medication administration errors.

The effects of oxytocin on social reward learning in humans.

It has been hypothesised that the mechanisms modulating social affiliation are regulated by reward circuitry. Oxytocin, previously shown to support affiliative behaviour and the processing of socio-emotional stimuli, is expressed in areas of the brain involved in reward and motivation. However, limited data are available that test if oxytocin is directly involved in reward learning, or whether oxytocin can modulate the effect of emotion on reward learning. In a double-blind, randomised, placebo-controlled, within-group study design, 24 typical male volunteers were administered 24 IU of oxytocin or placebo and subsequently completed an affective reward learning task. Oxytocin selectively reduced performance of learning rewards, but not losses, from happy faces. The mechanism by which oxytocin may be exerting this effect is discussed in terms of whether oxytocin is affecting identity recognition via affecting the salience of happy faces. We conclude that oxytocin detrimentally affects learning rewards from happy faces in certain contexts.

Effects of oxytocin on attention to emotional faces in healthy volunteers and highly socially anxious males.

BACKGROUND: Evidence suggests that individuals with social anxiety demonstrate vigilance to social threat, whilst the peptide hormone oxytocin is widely accepted as supporting affiliative behaviour in humans. METHODS: This study investigated whether oxytocin can affect attentional bias in social anxiety. In a double-blind, randomized, placebo-controlled, within-group study design, 26 healthy and 16 highly socially anxious (HSA) male volunteers (within the HSA group, 10 were diagnosed with generalized social anxiety disorder) were administered 24 IU of oxytocin or placebo to investigate attentional processing in social anxiety. Attentional bias was assessed using the dot-probe paradigm with angry, fearful, happy and neutral face stimuli. RESULTS: In the baseline placebo condition, the HSA group showed greater attentional bias for emotional faces than healthy individuals. Oxytocin reduced the difference between HSA and non-socially anxious individuals in attentional bias for emotional faces. Moreover, it appeared to normalize attentional bias in HSA individuals to levels seen in the healthy population in the baseline condition. The biological mechanisms by which oxytocin may be exerting these effects are discussed. CONCLUSIONS: These results, coupled with previous research, could indicate a potential therapeutic use of this hormone in treatment for social anxiety.

What is it like to be diagnosed with bipolar illness, borderline personality disorder or another diagnosis with mood instability?

Patients with mood instability represent a significant proportion of patients with mental illness. Important lessons need to be learnt about how current assessment processes do not meet their expectations. Changes at various levels, including medical and nursing education, service provision and research priorities, appear necessary if we are to help our patients better.

Distribution of tract deficits in schizophrenia.

BACKGROUND: Gray and white matter brain changes have been found in schizophrenia but the anatomical organizing process underlying these changes remains unknown. We aimed to identify gray and white matter volumetric changes in a group of patients with schizophrenia and to quantify the distribution of white matter tract changes using a novel approach which applied three complementary analyses to diffusion imaging data. METHODS: 21 patients with schizophrenia and 21 matched control subjects underwent brain magnetic resonance imaging. Gray and white matter volume differences were investigated using Voxel-based Morphometry (VBM). White matter diffusion changes were located using Tract Based Spatial Statistics (TBSS) and quantified within a standard atlas. Tracts where significant regional differences were located were examined using fiber tractography. RESULTS: No significant differences in gray or white matter volumetry were found between the two groups. Using TBSS the schizophrenia group showed significantly lower fractional anisotropy (FA) compared to the controls in regions (false discovery rate <0.05) including the genu, body and splenium of the corpus callosum and the left anterior limb of the internal capsule (ALIC). Using fiber tractography, FA was significantly lower in schizophrenia in the corpus callosum genu (p = 0.003). CONCLUSIONS: In schizophrenia, white matter diffusion deficits are prominent in medial frontal regions. These changes are consistent with the results of previous studies which have detected white matter changes in these areas. The pathology of schizophrenia may preferentially affect the prefrontal-thalamic white matter circuits traversing these regions.

Characteristics of Pediatric Hospital Medicine Fellowship Program Directors.

BACKGROUND AND OBJECTIVES: Rapid growth in pediatric hospital medicine (PHM) fellowships has occurred, yielding many new program directors (PDs). Characteristics of PDs have potential implications on the field. To describe characteristics (demographic, educational) and scholarly interests of PHM fellowship PDs. METHODS: We developed and distributed a 15-question, cross-sectional national survey to the PHM PDs listserv. Questions were pilot tested. The survey was open for 4 weeks with weekly reminders. Responses were summarized using descriptive statistics. RESULTS: Fifty-six current fellowship leaders (40 PDs, 16 associate PDs [APDs]) responded, including at least 1 from 43 of 59 active PHM fellowship programs (73%). Most respondents identified as female (71%) and ≤50 years old (80%). Four (7%, n = 2 PD, 2 APD) leaders identified as underrepresented in medicine. About half (n = 31, 55.4%) completed a fellowship themselves (APDs > PDs; 87.5% vs 42.5%), and 53.5% (n = 30) had advanced nonmedical degrees (eg, Master of Science, Doctor of Philosophy; APDs > PDs; 62% vs 45%). Most leaders (59%, n = 33) chose multiple domains when asked to select a "primary domain of personal scholarship." Education was the most frequently selected (n = 37), followed by quality improvement (n = 29) and then clinical research (n = 19). CONCLUSIONS: This survey confirms a high percentage of women as PHM fellowship leaders and highlights the need to increase diversity. Less than half of senior PDs completed a fellowship in any specialty. Leaders report interest in multiple domains of scholarship; few focus solely on clinical research.

Pediatric caregiver attitudes toward email communication: survey in an urban primary care setting.

BACKGROUND: Overall usage of email communication between patients and physicians continues to increase, due in part to expanding the adoption of electronic health records and patient portals. Unequal access and acceptance of these technologies has the potential to exacerbate disparities in care. Little is known about the attitudes of pediatric caregivers with regard to their acceptance of email as a means to communicate with their health care providers. OBJECTIVE: We conducted a survey to assess pediatric caregiver access to and attitudes toward the use of electronic communication modalities to communicate with health care providers in an urban pediatric primary care clinic. METHODS: Participants were pediatric caregivers recruited from an urban pediatric primary care clinic in Baltimore, Maryland, who completed a 35-item questionnaire in this cross-sectional study. RESULTS: Of the 229 caregivers who completed the survey (91.2% response rate), 171 (74.6%) reported that they use email to communicate with others. Of the email users, 145 respondents (86.3%) stated that they would like to email doctors, although only 18 (10.7%) actually do so. Among email users, African-American caregivers were much less likely to support the expanded use of email communication with health care providers (adjusted OR 0.34, 95% CI 0.14-0.82) as were those with annual incomes less than US $30,000 (adjusted OR 0.26, 95% CI 0.09-0.74). CONCLUSIONS: Caregivers of children have access to email and many would be interested in communicating with health care providers. However, African-Americans and those in lower socioeconomic groups were much less likely to have positive attitudes toward email.

Pediatric caregiver attitudes and technologic readiness toward electronic follow-up communication in an urban community emergency department.

OBJECTIVE: Follow-up of pediatric patients after an emergency department (ED) visit is important for monitoring changes in patient health and informing patients of test results conducted during the visit. The telephone has been the standard method of communication, but contact rates are poor. We conducted a survey to assess pediatric caregiver attitudes toward and access to alternate electronic communication modalities after a pediatric ED encounter. SUBJECTS AND METHODS: Participants (n=102) were recruited from an urban community ED and completed a 35-item questionnaire in this cross-sectional study. RESULTS: The majority of pediatric caregivers have Internet access in their home (72%), although less than half check e-mail daily (46%). A larger percentage owns a cell phone (90%) and checks text messages daily (87%). The majority agree that more doctors should communicate by e-mail (70%), and nearly half (45%) would like to receive test results by text message. CONCLUSIONS: Caregivers of children have access to the Internet and mobile phone technologies, and many would be interested in communicating with healthcare providers following an ED visit. Cell phone and text-messaging technologies appear to be more available than e-mail and may serve as an underutilized contact method. A combination of modalities directed by caregiver preferences may improve ED follow-up contact rates.

Violence and delusional jealousy in Parkinson's disease.

Psychosis in Parkinson's disease (PD) can have a hugely detrimental effect on patient outcomes and quality of life. It can be a feature of PD itself, or can be exacerbated by the very pharmacological agents that are prescribed to treat the motor symptoms of the disease. The treatment of psychosis in PD is often complex, with clinicians having to balance the debilitating physical symptoms of PD against the risk of exacerbating the psychosis. We describe the case of an octogenarian who presented with violence motivated by delusional jealousy in the context of PD, who was treated in a specialist psychiatric inpatient environment.

Factors Associated With Improved Pediatric Resuscitative Care in General Emergency Departments.

OBJECTIVES: To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality. METHODS: Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored. RESULTS: A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores. CONCLUSIONS: A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores.