Understanding Therapists' Work With Suicidal Patients: An Examination of Qualitative Data.

The collaborative assessment and management of suicidality (CAMS) serves as a framework for maintaining a collaborative relationship between the therapist and patient. This study used an original coding manual to examine responses to open-ended questions to better understand the ways in which therapists use CAMS collaboratively as well as their reasons for adhering (or not adhering) to certain aspects of the framework. Results suggest differences in treatment application based on therapist characteristics including amount of experience, intensity of training received, and experience of a patient suicide attempt. Implications of this research include informing therapists interested in using the CAMS framework about the specific ways in which implementation can be made collaborative. Further, this research helps to shed light on how experiencing a client's death by suicide can impact therapists' future work with suicidal clients.

Resistant hypertension: a frequent and ominous finding among hypertensive patients with atherothrombosis.

AIMS: The effect of resistant hypertension on outcomes in patients with atherothrombotic disease is currently unknown. Accordingly, we sought to determine the prevalence and outcomes of resistant hypertension in stable hypertensive outpatients with subclinical or established atherothombotic disease enrolled in the international Reduction of Atherothrombosis for Continued Health (REACH) registry. METHODS AND RESULTS: Resistant hypertension was defined as a blood pressure ≥140/90 mmHg at baseline (≥130/80 mmHg if diabetes/renal insufficiency) with the use of ≥3 antihypertensive medications, including a diuretic. The primary outcome was a composite of cardiovascular death, myocardial infarction, or stroke at 4 years. A total of 53 530 hypertensive patients were included. The prevalence of resistant hypertension was 12.7%; 6.2% on 3 antihypertensive agents, 4.6% on 4 agents, and 1.9% on ≥5 agents (mean: 4.7 ± 0.8). In addition to a diuretic, these patients were being treated mostly with ACE-inhibitors/angiotensin receptor blockers (90.1%), beta-blockers (67.0%), and calcium channel blockers (50.8%). Patients with resistant hypertension had a higher risk of the primary endpoint on multivariable analysis [hazard ratio (HR) 1.11, 95% confidence interval (CI) 1.02-1.20; P = 0.017], including an increased non-fatal stroke risk (HR: 1.26; 95% CI: 1.10-1.45; P = 0.0008). Hospitalizations due to congestive heart failure were higher (P < 0.0001). Patients on ≥5 agents had a higher adjusted risk for the primary endpoint when compared with those on ≤3 agents (P = 0.03). CONCLUSION: The presence of resistant hypertension identifies a subgroup of patients with hypertension and atherothrombosis who are at heightened risk for adverse long-term outcomes.

Chemical Profiles of the Oxides on Tantalum in State of the Art Superconducting Circuits.

Over the past decades, superconducting qubits have emerged as one of the leading hardware platforms for realizing a quantum processor. Consequently, researchers have made significant effort to understand the loss channels that limit the coherence times of superconducting qubits. A major source of loss has been attributed to two level systems that are present at the material interfaces. It is recently shown that replacing the metal in the capacitor of a transmon with tantalum yields record relaxation and coherence times for superconducting qubits, motivating a detailed study of the tantalum surface. In this work, the chemical profile of the surface of tantalum films grown on c-plane sapphire using variable energy X-ray photoelectron spectroscopy (VEXPS) is studied. The different oxidation states of tantalum that are present in the native oxide resulting from exposure to air are identified, and their distribution through the depth of the film is measured. Furthermore, it is shown how the volume and depth distribution of these tantalum oxidation states can be altered by various chemical treatments. Correlating these measurements with detailed measurements of quantum devices may elucidate the underlying microscopic sources of loss.

Adverse effects of steroid therapy in children with pharyngitis with unsuspected malignancy.

Pharyngitis is a common clinical complaint for children and accounts for 3.1% of all visits to selected ambulatory care settings. Most children with pharyngitis have benign, self-limited disease with infrequent complications such as peritonsillar abscess, mastoiditis, or lymphadenitis. Recent studies have touted the benefits of steroids in the treatment of children with pharyngitis for pain control. These studies do not address the potential life-threatening complication of steroids in patients with pharyngitis or lymphadenopathy in the setting of undiagnosed acute lymphocytic leukemia (ALL) or lymphoma. We report 4 cases of children treated with steroids for pharyngitis or adenitis that subsequently were diagnosed with ALL or lymphoma. If steroids are to be used in children with pharyngitis or adenitis, the following recommendations should be strongly considered: Careful history and physical examination should be obtained. Presence of hepatosplenomegaly or lymphadenopathy outside the cervical region should raise suspicions regarding an underlying malignancy. Normal results of complete blood cell count in the setting of clear cut pharyngitis with exudates and a lack of significant adenopathy essentially rules out the diagnosis of ALL. Because traditional analgesics are available, which do not affect the curability of ALL or lymphoma, the routine use of steroids in pharyngitis in children should be considered only in rare circumstances.

ß-Blocker use and clinical outcomes in stable outpatients with and without coronary artery disease.

CONTEXT: ß-Blockers remain the standard of care after a myocardial infarction (MI). However, the benefit of ß-blocker use in patients with coronary artery disease (CAD) but no history of MI, those with a remote history of MI, and those with only risk factors for CAD is unclear. OBJECTIVE: To assess the association of ß-blocker use with cardiovascular events in stable patients with a prior history of MI, in those with CAD but no history of MI, and in those with only risk factors for CAD. DESIGN, SETTING, AND PATIENTS: Longitudinal, observational study of patients in the Reduction of Atherothrombosis for Continued Health (REACH) registry who were divided into 3 cohorts: known prior MI (n = 14,043), known CAD without MI (n = 12,012), or those with CAD risk factors only (n = 18,653). Propensity score matching was used for the primary analyses. The last follow-up data collection was April 2009. MAIN OUTCOME MEASURES: The primary outcome was a composite of cardiovascular death, nonfatal MI, or nonfatal stroke. The secondary outcome was the primary outcome plus hospitalization for atherothrombotic events or a revascularization procedure. RESULTS: Among the 44,708 patients, 21,860 were included in the propensity score-matched analysis. With a median follow-up of 44 months (interquartile range, 35-45 months), event rates were not significantly different in patients with ß-blocker use compared with those without ß-blocker use for any of the outcomes tested, even in the prior MI cohort (489 [16.93%] vs 532 [18.60%], respectively; hazard ratio [HR], 0.90 [95% CI, 0.79-1.03]; P = .14). In the CAD without MI cohort, the associated event rates were not significantly different in those with ß-blocker use for the primary outcome (391 [12.94%]) vs without ß-blocker use (405 [13.55%]) (HR, 0.92 [95% CI, 0.79-1.08]; P = .31), with higher rates for the secondary outcome (1101 [30.59%] vs 1002 [27.84%]; odds ratio [OR], 1.14 [95% CI, 1.03-1.27]; P = .01) and for the tertiary outcome of hospitalization (870 [24.17%] vs 773 [21.48%]; OR, 1.17 [95% CI, 1.04-1.30]; P = .01). In the cohort with CAD risk factors only, the event rates were higher for the primary outcome with ß-blocker use (467 [14.22%]) vs without ß-blocker use (403 [12.11%]) (HR, 1.18 [95% CI, 1.02-1.36]; P = .02), for the secondary outcome (870 [22.01%] vs 797 [20.17%]; OR, 1.12 [95% CI, 1.00-1.24]; P = .04) but not for the tertiary outcomes of MI (89 [2.82%] vs 68 [2.00%]; HR, 1.36 [95% CI, 0.97-1.90]; P = .08) and stroke (210 [6.55%] vs 168 [5.12%]; HR, 1.22 [95% CI, 0.99-1.52]; P = .06). However, in those with recent MI (≤1 year), ß-blocker use was associated with a lower incidence of the secondary outcome (OR, 0.77 [95% CI, 0.64-0.92]). CONCLUSION: In this observational study of patients with either CAD risk factors only, known prior MI, or known CAD without MI, the use of ß-blockers was not associated with a lower risk of composite cardiovascular events.

The Simons Observatory: A large-diameter truss for a refracting telescope cooled to 1 K.

We present the design and measured performance of a new carbon fiber strut design that is used in a cryogenically cooled truss for the Simons Observatory small aperture telescope. The truss consists of two aluminum 6061 rings separated by 24 struts. Each strut consists of a central carbon fiber tube fitted with two aluminum end caps. We tested the performance of the strut and truss by (i) cryogenically cycling and destructively pull-testing strut samples, (ii) non-destructively pull-testing the final truss, and (iii) measuring the thermal conductivity of the carbon fiber tubes. We found that the strut strength is limited by the mounting fasteners and the strut end caps, not the epoxy adhesive or the carbon fiber tube. This result is consistent with our numerical predictions. Our thermal measurements suggest that the conductive heat load through the struts (from 4 to 1 K) will be less than 1 mW. This strut design may be a promising candidate for use in other cryogenic support structures.

The impact of opioid prescribing reduction interventions on prescribing patterns across orthopedic subspecialties.

OBJECTIVE: To date, the majority of studies have focused on the adverse effect of opioid overutilization on outcomes, risk factors for overutilization and dependence, and the development of procedure-specific guidelines. We present the results of a multiphased approach to reducing opioid prescribing. DESIGN: A retrospective pre-post study of opioid prescriptions across 386,393 patient encounters was conducted. The preintervention cohort included patient encounters from November 2016 to March 2017, and the post-intervention cohort included encounters from April 2017 to October 2019. SETTING: Single-institution orthopedic practice. PATIENTS, PARTICIPANTS: 386,393 patient encounters. INTERVENTION: Multiple prescribing reduction interventions were implemented from April 2017 to July 2018. MAIN OUTCOME MEASURE: Average morphine milligram equivalent (MME) per patient encounter. RESULTS: Implementation of the interventions resulted in an average reduction of 15.2 MME per encounter (54.5 percent) compared to the preimplementation cohort (pre: avg. MME = 27.9, SD 113.6; post: avg. MME = 12.7, SD 66.1; p < 0.001). The number of pills per opioid prescription was reduced by 13.4 (29.5 percent) (pre: avg. pill count = 45.5, S.D. 25.1; post: avg. pill count = 32.1, SD 21.1; p < 0.001), and the percent of patients receiving opioids was reduced from 8.3 percent to 5.8 percent (p < 0.001). Prescribing compliance was evaluated for 7,664 surgical encounters, with 98.2 percent of prescriptions meeting stated guidelines; 5.5 percent of these encounters required second prescriptions. CONCLUSIONS: The use of a multiphase approach effectively reduced the opioid prescribing patterns of a large orthopedic practice and was successful across subspecialties. This approach provides a template that other institutions may use to reduce opioid overprescribing in orthopedic practices.

A critical examination of bifrontal electroconvulsive therapy: clinical efficacy, cognitive side effects, and directions for future research.

Bifrontal (BF) electroconvulsive therapy (ECT), although researched less extensively than bitemporal (BT) or right unilateral (RUL) ECT, has been suggested to be comparable to the other 2 electrode placements with respect to clinical efficacy while resulting in less cognitive impairment than BT ECT. Imaging studies have indicated that seizures induced by BF ECT affect the brain differently than BT or RUL ECT, in that BF ECT increases cerebral blood flow in the frontal lobes more intensely than either of the other 2 placements. Therefore, it is possible that the cognitive impairment manifested after a course of BF ECT could also be different than the impairment seen with BT and RUL ECT. Research conducted on cognitive impairment from BF ECT to date has been inadequate due to the use of nonspecific cognitive measures (such as the Mini-Mental Status Examination) or an inordinate focus on memory functioning (which is believed to be mostly subsumed in the temporal lobes). Because BF ECT increases cerebral blood flow in the frontal lobes more intensely than either of the other placements, research must instead focus on investigating the possible effects of BF ECT on executive functioning, which is believed to be subsumed in the frontal lobes. This is especially important because of the established relationship between executive dysfunction and depression and also because of the increasing popularity of BF ECT.

Risk Factors, Warning Signs, and Drivers of Suicide: What Are They, How Do They Differ, and Why Does It Matter?

Research investigating suicide attempts and deaths by suicide has yielded many specific risk factors and warning signs for future suicidal behaviors. Yet, even though these variables are each valuable for suicide prevention efforts, they may be limited in their applicability to clinical practice. The differences among risk factors, warning signs, and "drivers," which are person-specific variables that lead individuals to desire death by suicide, are highlighted. The scarce evidence on drivers is described and specific recommendations for conducting future drivers-focused research and targeting them in clinical practice are suggested.

Differential bilingual laterality: mythical monster found in Wales.

Paradis (1992) likens studies of bilingual laterality to reported sightings of the Loch Ness Monster, in that although some studies claim differential laterality much conflicting research evidence does not-and like the mythical Scottish monster, what reason have we to suspect that any such phenomenon might exist? This study reexamines differential bilingual laterality using four groups of English-Welsh bilinguals which differ in their age of acquisition and in their environment of acquisition. Using a split visual field paradigm we present evidence which, supports the notion of greater right hemisphere processing in a later learned language. Our findings also suggest the pattern of lateralization in bilinguals is strongly affected by the specific language environment during development such that the shift toward greater right hemisphere involvement for the later learned language will be more pronounced in individuals which are brought up in areas where that language is not regularly heard.