Peer-to-Peer Trauma-Informed Training for Surgical Residents Facilitated by Psychiatry Residents.

OBJECTIVE: This article describes the implementation of trauma-informed care (TIC) didactic training, using a novel, interdisciplinary peer-to-peer teaching model to improve confidence surrounding trauma-informed practices in a surgical residency program. METHODS: Eight psychiatry residents and two medical students with a background in psychological trauma and TIC and an interest in medical education were recruited to participate in three 2-hour "train the trainer" sessions led by a national expert in TIC. Eight psychiatry residents and two medical students subsequently developed and delivered the initial TIC training to 29 surgical interns. Training included the neurobiology of psychological trauma, principles of trauma-informed care, and developing trauma-informed curricula. RESULTS: Surgical interns reported significantly improved understanding of the physiology of trauma, knowledge of TIC approaches, and confidence and comfort with TIC and practices. Among surgical interns, understanding of the physiology of the fear response increased from 3.36 to 3.85 (p = 0.03). Knowledge of the neurobiology of trauma improved between pre- and post-training surveys (2.71 to 3.64, p = 0.006). Surgery interns also expressed an improved understanding of the connection between fear, trauma, and aggression (3.08 to 4.23, p = 0.002) from pre- to post-training surveys. Post-training knowledge of trauma-informed approaches increased from 2.57 to 4.71 (p < 0.001) and confidence in delivering TIC on the wards increased from 2.79 to 4.64 (p < 0.001). CONCLUSION: This TIC curriculum delivered via a peer-to-peer training model presents an effective way to improve comfort and confidence surrounding TIC practices and approaches in a surgical residency training program.

Characteristics, barriers, and career intentions of a national cohort of LGBTQ+ MD/PhD and DO/PhD trainees.

BACKGROUND: Lesbian, gay, bisexual, transgender, queer, non-binary, intersex, and/or asexual (LGBTQ+) individuals continue to suffer worse health outcomes compared to the general population. Data on LGBTQ+ individuals in medicine, particularly in medical training, remain sparse. National studies of LGBTQ+ students in MD/PhD and DO/PhD training programs have not been reported. METHODS: Trainees pursuing MD, DO, MD/PhD, and DO/PhD degrees at 32 nationally representative institutions completed a 70-item survey about their future career and anticipated challenges using an online survey tool from September 2012 to December 2014. There were 4,433 respondents to the survey. Of those, 2,837 completed the gender identity questions and 2,849 completed the sexual orientation questions. Completion of these questions was required for inclusion. Survey results were analyzed to examine differences between LGBTQ+ and non-LGBTQ+ medical and dual degree trainees. RESULTS: LGBTQ+ students were underrepresented among MD/PhD and DO/PhD trainees (8.70%) compared to the US population, though their representation was higher than among MD and DO trainees (5.20%). LGBTQ+ dual degree trainees endorsed the greatest interest in pursuing careers involving academic medicine, with varying career focuses including research, clinical duties, education, and advocacy. LGBTQ+ dual degree trainees prioritized opportunities in patient care, work-life balance, and research as the most important factors for their career selection. Importantly, a higher percentage of LGBTQ+ dual degree trainees (15.50%) identified sexual harassment as a past barrier to career advancement compared to their non-LGBTQ+ peers (8.27%). LGBTQ+ dual degree trainees were more likely to report having a mentor who advocated for them. CONCLUSIONS: LGBTQ+ physician scientist trainees remain under-represented and under-studied. It is vital that medical institutions devote more time and resources towards identifying and addressing the unique needs of this group in training. Training programs should be aware of the current and prior challenges faced by their LGBTQ+ dual degree trainees, work to overcome the unique barriers they face, highlight the strengths and unique perspectives they bring, and foster their professional growth and goals during and beyond their training.

Trauma Exposure and Suicidality in a Pediatric Emergency Psychiatric Population.

OBJECTIVES: The increasing rates of depression and suicidality in children and adolescents are reflected in the increasing number of mental health-related visits to emergency departments. Despite the high rates of traumatic exposure experienced by high-acuity children and adolescents and a known link to suicidal ideation, the systematic review of trauma history is not a consistent part of emergency department assessments for suicide ideation or attempt. In the present study, we examined the prevalence of suicidality as well as traumatic exposures in children and adolescents presenting to a dedicated pediatric psychiatric emergency department. METHODS: Suicide ideation, suicide attempts, and trauma exposure history were identified through a retrospective chart review of youth (n = 861) who presented to a dedicated child psychiatric emergency department during a 1-year period. Bivariate analyses comparing demographic and trauma history for children with and without suicidality and a multivariable logistic regression were performed. RESULTS: Childhood adversity was common, with 52% of youth reporting at least one type of trauma exposure. Emotional abuse, physical abuse, and sexual abuse/assault were associated with suicidality. Any trauma exposure and the total number of different trauma exposures were associated with reported suicide attempt. After adjusting for sociodemographic characteristics, children who reported a history of emotional abuse had 3.2-fold increased odds of attempted suicide. Children who reported a history of being a victim of bullying had 1.9-fold increased odds of current suicidal ideation. CONCLUSIONS: Traumatic experiences were common in youth presenting with suicidality. Traumatic experiences are frequently underrecognized in treatment settings because they are not part of routine evaluations and are often overlooked when trauma-related symptoms are not the presenting problem. Addressing traumatic experiences underlying depression and suicidal ideation is a necessary step in effective treatment. Emergency departments need to implement routine screening for traumatic exposures in children presenting with suicidal ideation or attempt.

Friendly Faces: Characteristics of Children and Adolescents With Repeat Visits to a Specialized Child Psychiatric Emergency Program.

OBJECTIVES: Pediatric mental health emergency department (ED) visits continue to rise with 19% to 62% of youth presenting to the ED ultimately returning for a mental health-related complaint. To better understand the needs of children returning to the ED, this study examines the clinical, demographic, and environmental factors associated with revisits to a dedicated child psychiatric ED. METHODS: Clinical factors, home environment, and mental health service utilization of 885 children presenting to a dedicated child psychiatric ED over a 1-year period were abstracted by retrospective chart review. Bivariate analyses comparing demographic and clinical characteristics for children with and without revisits and a multivariable logistic regression were performed. RESULTS: Of the children presenting to the ED, 186 (21.0%) had at least 1 revisit in the subsequent 180 days. Thirty-one percent of initial visits presented as urgent, 55% presented as emergent. Children presenting with more severe symptoms at their initial visit were more likely to return within 6 months. Female gender, suicidal and disruptive behavioral symptomatology, and a diagnosis of oppositional defiant disorder were associated with repeat visits. Children with mental health system involvement were more likely to have revisits than those who were "treatment naive." CONCLUSIONS: Revisits to the ED are driven by both clinical factors, including severity and psychosocial complexity, and barriers to accessing services. Addressing the problem of return ED visits will require the development of a robust mental health service system that is accessible to children and families of all socioeconomic levels.

Correction: Documenting Social Media Engagement as Scholarship: A New Model for Assessing Academic Accomplishment for the Health Professions.

[This corrects the article DOI: 10.2196/25070.].

Documenting Social Media Engagement as Scholarship: A New Model for Assessing Academic Accomplishment for the Health Professions.

BACKGROUND: The traditional model of promotion and tenure in the health professions relies heavily on formal scholarship through teaching, research, and service. Institutions consider how much weight to give activities in each of these areas and determine a threshold for advancement. With the emergence of social media, scholars can engage wider audiences in creative ways and have a broader impact. Conventional metrics like the h-index do not account for social media impact. Social media engagement is poorly represented in most curricula vitae (CV) and therefore is undervalued in promotion and tenure reviews. OBJECTIVE: The objective was to develop crowdsourced guidelines for documenting social media scholarship. These guidelines aimed to provide a structure for documenting a scholar's general impact on social media, as well as methods of documenting individual social media contributions exemplifying innovation, education, mentorship, advocacy, and dissemination. METHODS: To create unifying guidelines, we created a crowdsourced process that capitalized on the strengths of social media and generated a case example of successful use of the medium for academic collaboration. The primary author created a draft of the guidelines and then sought input from users on Twitter via a publicly accessible Google Document. There was no limitation on who could provide input and the work was done in a democratic, collaborative fashion. Contributors edited the draft over a period of 1 week (September 12-18, 2020). The primary and secondary authors then revised the draft to make it more concise. The guidelines and manuscript were then distributed to the contributors for edits and adopted by the group. All contributors were given the opportunity to serve as coauthors on the publication and were told upfront that authorship would depend on whether they were able to document the ways in which they met the 4 International Committee of Medical Journal Editors authorship criteria. RESULTS: We developed 2 sets of guidelines: Guidelines for Listing All Social Media Scholarship Under Public Scholarship (in Research/Scholarship Section of CV) and Guidelines for Listing Social Media Scholarship Under Research, Teaching, and Service Sections of CV. Institutions can choose which set fits their existing CV format. CONCLUSIONS: With more uniformity, scholars can better represent the full scope and impact of their work. These guidelines are not intended to dictate how individual institutions should weigh social media contributions within promotion and tenure cases. Instead, by providing an initial set of guidelines, we hope to provide scholars and their institutions with a common format and language to document social media scholarship.

Group trauma-informed treatment for adolescent psychiatric inpatients: a preliminary uncontrolled trial.

Despite high rates of trauma exposure (46%-96%) and significant posttraumatic stress disorder (PTSD; 21%-29%) symptoms in adolescent psychiatric inpatients, there is a dearth of research on effective interventions delivered in inpatient settings. The current report describes the development of Brief STAIR-A, a repeatable 3-module version of skills training in affective and interpersonal regulation (STAIR) developed for adolescents in inpatient care. An uncontrolled design was used to conduct a preliminary examination of the group intervention's effectiveness. Adolescent psychiatric inpatients (N = 38; ages 12 years-17 years) admitted to a public hospital participated in Brief STAIR-A and attended a median of 6 sessions (range 3-36). They completed measures of PTSD and depressive symptom severity, coping skill use, and coping efficacy upon admission and again prior to discharge. Participants reported significant reductions in symptom severity (d = 0.65-0.67), no change in the absolute level of coping skills used (d = 0.16), but greater coping efficacy when discharged from care (d = 0.75). Results from this pilot study suggest that this brief group treatment shows promise for treating adolescents' trauma-related difficulties in inpatient psychiatry settings, but additional research examining its effectiveness is essential.

Student-Led Webinar to Support LGBTQ+ Students Applying to Medical School During the COVID-19 Pandemic.

Lesbian, gay, bisexual, transgender, queer, intersex, asexual, non-binary, two-spirit, and other (LGBTQ+) students are a diverse group with unique and frequently overlooked needs in medical training. The present study was designed to understand the concerns of LGBTQ+ applicants to medical school and examine the effectiveness of a webinar in alleviating concerns. Sixty participants joined webinars discussing the medical school application process with particular attention to concerns pertinent to the LGBTQ+ population. Pre and post surveys were administered to examine webinar effectiveness and participant concerns. Results were analyzed using quantitative and qualitative methods. Pre-medical students reported that the webinar format was helpful for their application process. Specifically, pre- and post-test analyses revealed that the webinar increased both students' preparedness as well as their confidence in disclosing their LGBTQ+ identity or being "out" when applying to medical school. Student-led, online webinars increase LGBTQ+ students' confidence and help address SGM students' concerns about applying to medical school.

Traumatic Stress and Resilience Among Transgender and Gender Diverse Youth.

Traumatic stress increases the risk for mental health conditions and adversely impacts health, academic performance, and coping. Transgender and gender diverse (TGD) youth experience higher rates of abuse and maltreatment and interpersonal and community-embedded discrimination than their cisgender peers. Neurobiologic stress responses and social stress theory provide useful frameworks for understanding the effects of discrimination, stigma, and rejection. Despite facing higher rates of interpersonal trauma, TGD youth are quite resilient when able to access supports and affirming trauma-informed services. Clinicians play an important role in identifying and addressing traumatic stress impacting TGD youth and bolstering resilience.

Graduate Medical Education Curriculum Regarding the Health and Healthcare of Older Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Adults.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) adults experience a wide variety of unique challenges accessing healthcare. These barriers may be exacerbated among older LGBTQ+ people due to intersecting, marginalized identities. To prepare physicians to address the healthcare needs of older LGBTQ+ adults, graduate medical education (GME) must include training about the specific needs of this population. Prior studies demonstrate a lack of LGBTQ+ training in GME curricula. Here, we investigated the presence of LGBTQ+ curricula in internal medicine residencies and geriatrics fellowships through a national survey. Over 62.0% of internal medicine (n = 49) and 65.6% (n = 21) of geriatric medicine fellowship program directors, responding to the survey, reported content relevant to the health of older LGBTQ+ adults. Education about LGBTQ+ health in internal medicine residencies and geriatrics fellowships is vital for the provision of culturally-competent healthcare and to create an inclusive environment for older LGBTQ+ patients.

Maternal Perinatal Stress Trajectories and Negative Affect and Amygdala Development in Offspring.

OBJECTIVE: Maternal psychological stress during pregnancy is a common risk factor for psychiatric disorders in offspring, but little is known about how heterogeneity of stress trajectories during pregnancy affect brain systems and behavioral phenotypes in infancy. This study was designed to address this gap in knowledge. METHODS: Maternal anxiety, stress, and depression were assessed at multiple time points during pregnancy in two independent low-risk mother-infant cohorts (N=115 and N=2,156). Trajectories in maternal stress levels in relation to infant negative affect were examined in both cohorts. Neonatal amygdala resting-state functional connectivity MRI was examined in a subset of one cohort (N=60) to explore the potential relationship between maternal stress trajectories and brain systems in infants relevant to negative affect. RESULTS: Four distinct trajectory clusters, characterized by changing patterns of stress over time, and two magnitude clusters, characterized by severity of stress, were identified in the original mother-infant cohort (N=115). The magnitude clusters were not associated with infant outcomes. The trajectory characterized by increasing stress in late pregnancy was associated with blunted development of infant negative affect. This relationship was replicated in the second, larger cohort (N=2,156). In addition, the trajectories that included increasing or peak maternal stress in late pregnancy were related to stronger neonatal amygdala functional connectivity to the anterior insula and the ventromedial prefrontal cortex in the exploratory analysis. CONCLUSIONS: The trajectory of maternal stress appears to be important for offspring brain and behavioral development. Understanding heterogeneity in trajectories of maternal stress and their influence on infant brain and behavioral development is critical to developing targeted interventions.

Editorial: From Bipolar Disorder to Disruptive Mood Dysregulation Disorder: Challenges to Diagnostic and Treatment Specificity in Traumatized Youths.

This valuable contribution by Findling et al. reports on trends in diagnostic patterns since the inclusion of disruptive mood dysregulation disorder (DMDD) in the DSM-5. As the authors note, the introduction of the DMDD diagnosis was designed to address the problematic over-diagnosis of bipolar disorder and the associated rise in antipsychotic and polypharmacy use in youths.1 Using a large, national, electronic health record database (n = 14,157), this study showed a clear increase in the treated prevalence of DMDD from 2016 to 2018 (0.08-0.35%, p < .0001) coupled with a decrease in the treated prevalence of bipolar disorder from 2015 to 2018 (0.42%-0.36%, p < .0001).1 This suggests that the introduction of DMDD did seem to achieve the aim of reducing the rates of bipolar diagnoses. In what is discouraging but not surprising news, the study demonstrates a troubling increase in the use of antipsychotics (58.9% DMDD vs 51.0% bipolar disorder) and polypharmacy in the DMDD cohort compared to the bipolar disorder cohort (45.0% DMDD vs 37.4% bipolar disorder).1.

Effects of Maternal Psychological Stress During Pregnancy on Offspring Brain Development: Considering the Role of Inflammation and Potential for Preventive Intervention.

Heightened psychological stress during pregnancy has repeatedly been associated with increased risk for development of behavior problems and psychiatric disorders in offspring. This review covers a rapidly growing body of research with the potential to advance a mechanistic understanding of these associations grounded in knowledge about maternal-placental-fetal stress biology and fetal brain development. Specifically, we highlight research employing magnetic resonance imaging to examine the infant brain soon after birth in relation to maternal psychological stress during pregnancy. This approach increases capacity to identify specific alterations in brain structure and function and to differentiate between effects of pre- versus postnatal exposures. We then focus on the extensive preclinical literature and emerging research in humans that have found that heightened maternal inflammation during pregnancy as a mechanism through which maternal stress influences the developing fetal brain. We place these findings in the context of recent work identifying psychotherapeutic interventions that have been found to be effective for reducing psychological stress among pregnant individuals and that also show promise for reducing inflammation. We argue that a focus on inflammation, among other mechanistic pathways, may lead to a productive and necessary integration of research focused on the effects of maternal psychological stress on offspring brain development and on prevention and intervention studies aimed at reducing maternal psychological stress during pregnancy. In addition to increasing capacity for common measurements and understanding potential mechanisms of action relevant to maternal mental health and fetal neurodevelopment, this focus may inform and broaden thinking about prevention and intervention strategies.

Alcohol use by pedestrians who are struck by motor vehicles: how drinking influences behaviors, medical management, and outcomes.

BACKGROUND: Injuries to pedestrians struck by motor vehicles represent a significant public health hazard in large cities. The purpose of this study is to investigate the demographics of alcohol users who are struck by motor vehicles and to assess the effects of alcohol on pedestrian crossing patterns, medical management, and outcomes. METHODS: Data were prospectively collected between December 2008 to September 2010 on all pedestrians who presented to a Level I trauma center after being struck by a motor vehicle. Variables were obtained by interviewing patients, scene witnesses, first responders, and medical records. RESULTS: Pedestrians who used alcohol were less likely to cross the street in the crosswalk with the signal (22.6% vs. 64.7%) and more likely to cross either in the crosswalk against the signal (22.6% vs. 12.4%) or midblock (54.8% vs. 22.8%). Alcohol use was associated with more initial computed tomography imaging studies compared with no alcohol involvement. Alcohol use was associated with a higher Injury Severity Score (8.82 vs. 4.85; p < 0.001) and hospital length of stay (3.89 days vs. 1.82 days; p < 0.001) compared with those with no alcohol involvement. Patients who used alcohol had a lower average Glasgow Coma Scale score (13.80 vs. 14.76; p < 0.001) and a higher rate of head and neck, face, chest, abdomen, and extremity/pelvic girdle injuries (based on Abbreviated Injury Scale) than those with no alcohol involvement. CONCLUSION: Alcohol use is a significant risk factor for pedestrians who are struck by motor vehicles. These patients are more likely to cross the street in an unsafe manner and sustain more serious injuries. Traffic safety and injury prevention programs must address irresponsible alcohol use by pedestrians.

Understanding Vulnerability and Adaptation in Early Brain Development using Network Neuroscience.

Early adversity influences brain development and emerging behavioral phenotypes relevant for psychiatric disorders. Understanding the effects of adversity before and after conception on brain development has implications for contextualizing current public health crises and pervasive health inequities. The use of functional magnetic resonance imaging (fMRI) to study the brain at rest has shifted understanding of brain functioning and organization in the earliest periods of life. Here we review applications of this technique to examine effects of early life stress (ELS) on neurodevelopment in infancy, and highlight targets for future research. Building on the foundation of existing work in this area will require tackling significant challenges, including greater inclusion of often marginalized segments of society, and conducting larger, properly powered studies.

Priorities for pediatric prehospital research.

UNLABELLED: Up to 3 million US children are cared for by emergency medical services (EMSs) annually. Limited research exists on pediatric prehospital care. The Pediatric Emergency Care Applied Research Network (PECARN) mission is to perform high-quality research for children, including prehospital research. Our objective was to develop a pediatric-specific prehospital research agenda. METHODS: Representatives from all 4 PECARN nodes and from EMS agency partners participated in a 3-step process. First, participants ranked potential research priorities and suggested others. Second, participants reranked the list in order of importance and scored each priority using a modified Hanlon method (prevalence, seriousness, and practicality of each research area were assessed). Finally, the revised priority list was presented at a PECARN EMS summit, and consensus was sought. RESULTS: Forty-two representatives participated, including PECARN representatives, EMS agency leaders, and nationally recognized prehospital researchers. Consensus was reached on the priority ranking. The prioritization processes resulted in 2 ranked lists: 15 clinical topics and 5 EMS system topics. The top 10 clinical priorities included (1) airway management, (2) respiratory distress, (3) trauma, (4) asthma, (5) head trauma, (6) shock, (7) pain, (8) seizures, (9) respiratory arrest, and (10) C-spine immobilization. The 5 EMS system topics identify methods to improve prehospital care on the system level. CONCLUSIONS: PECARN has identified high-priority EMS research topics for children using a consensus-derived method. These research priorities include novel EMS system topics. The PECARN EMS pediatric research priority list will help focus future pediatric prehospital research both within and outside the network.

Women Physicians and the Suffrage Movement.

Women physicians have a long history of advocacy, dating to the 19th century women's suffrage movement. As history recounts the work of the suffragists, many women physicians bear mention. Some were leaders on the national scene, and others led suffrage efforts in their own state. In this article, we provide a snapshot of 7 prominent suffragists who were also physicians: Mary Edwards Walker, Mary Putnam Jacobi, Esther Pohl Lovejoy, Marie Equi, Mattie E. Coleman, Cora Smith Eaton, and Caroline E. Spencer. In sharing their stories, we hope to better understand some of the challenges and struggles of the suffrage movement and how their advocacy paved the way not only for women's voting rights but also the role of women physicians as advocates for change.

Polygenic Risk Score-Derived Subcortical Connectivity Mediates Attention-Deficit/Hyperactivity Disorder Diagnosis.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) has substantial heritability, and a recent large-scale investigation has identified common genome-wide significant loci associated with increased risk for ADHD. Along the same lines, many studies using noninvasive neuroimaging have identified differences in brain functional connectivity in children with ADHD. We attempted to bridge these studies to identify differences in functional connectivity associated with common genetic risk for ADHD using polygenic risk score (PRS). METHODS: We computed ADHD PRSs for all participants in our sample (N = 315, children 7-13 years of age, 196 with ADHD and 119 unaffected comparison children) using ADHD data from the Psychiatric Genomics Consortium as a discovery set. Magnetic resonance imaging was used to evaluate resting-state functional connectivity of targeted subcortical structures. RESULTS: The functional connectivity between 2 region pairs demonstrated a significant correlation to PRS: right caudate-parietal cortex and nucleus accumbens-occipital cortex. Connectivity between these areas, in addition to being correlated with PRS, was correlated with ADHD status. The connection between the caudate and the parietal region acted as a statistical suppressor, such that when it was included in a path model, the association between PRS and ADHD status was enhanced. CONCLUSIONS: Our results suggest that functional connectivity to certain subcortical brain regions is directly altered by genetic variants, and certain cortico-subcortical connections may modulate ADHD-related genetic effects.