A randomized double-blinded trial to assess recurrence of systemic allergic reactions following COVID-19 mRNA vaccination.

BACKGROUND: Systemic allergic reactions (sARs) following coronavirus disease 2019 (COVID-19) mRNA vaccines were initially reported at a higher rate than after traditional vaccines. OBJECTIVE: We aimed to evaluate the safety of revaccination in these individuals and to interrogate mechanisms underlying these reactions. METHODS: In this randomized, double-blinded, phase 2 trial, participants aged 16 to 69 years who previously reported a convincing sAR to their first dose of COVID-19 mRNA vaccine were randomly assigned to receive a second dose of BNT162b2 (Comirnaty) vaccine and placebo on consecutive days in a blinded, 1:1 crossover fashion at the National Institutes of Health. An open-label BNT162b2 booster was offered 5 months later if the second dose did not result in severe sAR. None of the participants received the mRNA-1273 (Spikevax) vaccine during the study. The primary end point was recurrence of sAR following second dose and booster vaccination; exploratory end points included biomarker measurements. RESULTS: Of 111 screened participants, 18 were randomly assigned to receive study interventions. Eight received BNT162b2 second dose followed by placebo; 8 received placebo followed by BNT162b2 second dose; 2 withdrew before receiving any study intervention. All 16 participants received the booster dose. Following second dose and booster vaccination, sARs recurred in 2 participants (12.5%; 95% CI, 1.6 to 38.3). No sAR occurred after placebo. An anaphylaxis mimic, immunization stress-related response (ISRR), occurred more commonly than sARs following both vaccine and placebo and was associated with higher predose anxiety scores, paresthesias, and distinct vital sign and biomarker changes. CONCLUSIONS: Our findings support revaccination of individuals who report sARs to COVID-19 mRNA vaccines. Distinct clinical and laboratory features may distinguish sARs from ISRRs.

Beyond presence of symptoms: Self-reported psychosocial distress interference among outpatient youth with cancer and other life-limiting conditions.

BACKGROUND: Youth with life-limiting conditions face significant psychosocial challenges (e.g., symptoms of anxiety, depression, and pain) throughout illness and treatment. Without appropriate intervention, this can negatively affect long-term outcomes (e.g., disease management, health-related quality of life). Prompt identification and appropriate attention to distress can mitigate these effects. We aimed to determine the prevalence and severity of distress interference among outpatient youth with cancer and other life-limiting conditions, using the Checking IN screener. PROCEDURE: Within a larger study across four hospital centers, English-speaking pediatric outpatients aged 8-21, and a caregiver-proxy-reporter, completed a brief distress screener. Descriptive analyses were used to characterize the sample and evaluate reported distress symptoms. RESULTS: Checking IN was completed by 100 participants, aged 8-21 (M = 14.27, SD = 3.81); caregivers completed an equivalent proxy screener. Youth most frequently endorsed fatigue (moderate: n = 50, 50.0%; high: n = 21, 21.0%), paying attention (moderate: n = 45, 45.0%; high: n = 16, 16.0%), and sleep difficulty (moderate: n = 46, 46.0%; high: n = 13; 13.0%) as problematic. Caregivers proxy reported fatigue (moderate: n = 46, 46.0%; high: n = 32, 32.0%), worry (moderate: n = 56, 56.0%; high: n = 10, 10.0%), and sleep difficulty (moderate: n = 47, 47.0%; high: n = 14; 14.0%) as most problematic. Group differences between youth and caregiver responses were not significant. CONCLUSIONS: Youth self-report via Checking IN can detect psychosocial distress interference. By directing resources based on real-time assessment of symptom interference, there is potential to simplify outpatient psychosocial screening and improve referral timeliness and specificity, thus allowing for more effective attention to evolving symptoms of distress.

Reflections on experiential training in meaning-centered psychotherapy: How MCP ended up facilitating professional wellbeing.

OBJECTIVE: Meaning-centered psychotherapy (MCP) principles may provide a framework for engaging healthcare professionals in meaning-centered exploration as a novel approach to prevent burnout and enhance wellbeing in healthcare professionals through heightening personal meaning. This case study aimed to teach MCP to masters-trained social workers for use with medical patients. While the primary aim was to teach MCP to masters-trained social workers, this proof-of-concept project and this paper focus on a secondary aim of enhancing meaning and connection in the virtual workplace. METHODS: A group of social workers participated in a 7-session MCP pilot from October 13th to November 24th, 2020. After each session, participants were asked to complete an anonymous continuing education evaluation with questions regarding clarity, organization, and relevance of the presentation related to use with their patient populations. Additional open-ended items queried participants for general comments about their experience using MCP to enhance professional fulfillment during COVID-19. RESULTS: Nine social workers participated in the MCP pilot. Several qualitative themes emerged, including enhanced meaning, communication, connection, and agency in the virtual workplace. SIGNIFICANCE OF THE RESULTS: This pilot demonstrated the feasibility and acceptability of using an adapted MCP instruction with hospital-based social workers during the COVID-19 pandemic to facilitate wellbeing. While MCP was originally created to intervene with patients with life-threatening illnesses, the brief, manualized experiential nature of the intervention lends itself to modification with staff for the purpose of enhancing meaning and community in their own lives.

Self-reported Symptoms of Anxiety Predict Positive Suicide Risk Screening in Adolescents Presenting to the Emergency Department.

OBJECTIVE: The objective of this study was to assess whether patient-reported anxiety symptoms are associated with suicide risk in pediatric emergency department (ED) patients. An additional objective was to examine differences between patients presenting for medical/surgical or psychiatric complaints. METHODS: Pediatric patients aged 10 to 21 years were recruited from 3 pediatric EDs. Participants completed self-report questionnaires assessing for suicidal ideation and behavior, in addition to questions of interest about recent feelings of unbearable anxiety and depression. Adjusted odds ratios were calculated to assess the relationship between endorsement of recent anxiety and screening positive for suicide risk. RESULTS: Data were analyzed from 522 participants, including 344 presenting with medical/surgical chief complaints and 178 presenting with psychiatric complaints. Overall, 28.9% of participants screened positive for suicide risk, 29.9% endorsed recent feelings of anxiety, and 24.3% endorsed recent feelings of depression. Patients who self-reported recent anxiety symptoms were 5 times more likely to screen positive for suicide risk (adjusted odds ratios = 5.18, 95% confidence interval = 3.06-8.76). Analysis of the 344 medical/surgical patients revealed that this subsample was also 5 times more likely to screen positive for suicide risk if they endorsed recent anxiety (adjusted odds ratios = 4.87, 95% confidence interval = 2.09-11.36). CONCLUSIONS: Self-reported suicidal ideation and feelings of unbearable anxiety are prevalent among patients presenting to pediatric EDs. Patients who self-report recent feelings of unbearable anxiety are significantly more likely to screen positive for suicide risk, regardless of whether their presenting complaint is medical/surgical or psychiatric in nature.

Voicing their choices: Advance care planning with adolescents and young adults with cancer and other serious conditions.

OBJECTIVES: To determine whether engaging in advance care planning (ACP) using a formal tool, Voicing My CHOiCES (VMC), would alleviate adolescent and young adults (AYAs) anxiety surrounding ACP and increase social support and communication about end-of-life care preferences with family members and health care providers (HCPs). METHODS: A total of 149 AYAs aged 18-39 years receiving cancer-directed therapy or treatment for another chronic medical illness were enrolled at seven US sites. Baseline data included prior ACP communication with family members and HCPs and measures of generalized anxiety, ACP anxiety, and social support. Participants critically reviewed each page of VMC and then completed three pages of the document. ACP anxiety was measured again immediately after the completion of VMC pages. One month later, participants repeated anxiety and social support measures and were asked if they shared what they had completed in VMC with a family member or HCP. RESULTS: At baseline, 50.3% of participants reported that they previously had a conversation about EoL preferences with a family member; 19.5% with an HCP. One month later, 65.1% had subsequently shared what they wrote in VMC with a family member; 8.9% shared with an HCP. Most (88.6%) reported they would not have had this conversation if not participating in the study. No significant changes occurred in social support. There was an immediate drop in anxiety about EoL planning after reviewing VMC which persisted at 1 month. Generalized anxiety was also significantly lower 1 month after reviewing VMC. SIGNIFICANCE OF RESULTS: Having a document specifically created for AYAs to guide ACP planning can decrease anxiety and increase communication with family members but not necessarily with HCPs. Future research should examine ways ACP can be introduced more consistently to this young population to allow their preferences for care to be heard, respected, and honored, particularly by their healthcare providers.

Training Needs Assessment Survey in Pediatric Consultation-Liaison Psychiatry.

OBJECTIVE: Despite growing recognition of how curriculum modules can benefit child and adolescent psychiatry (CAP) training, there are few standardized teaching resources for pediatric consultation-liaison psychiatry (PCLP). A Special Interest Group (SIG) of the American Academy of Child and Adolescent Psychiatry Physically Ill Child Committee (PICC) conducted a needs assessment to establish interest in, and availability of, a library of online, self-paced learning modules specific to PCLP. METHOD: An email needs assessment survey was distributed to the PICC listserv in the fall of 2019 with four core areas of inquiry: (1) clinical service description, (2) teaching barriers, (3) interest in curriculum resources, and (4) interest in evaluation resources. RESULTS: Respondents were representative of typical academic PCLP programs. The response rate was 28% (n = 39). Programs endorsed barriers to teaching including high service obligations and limited protected teaching time. All respondents indicated that they would utilize high-quality, online learning modules. Psychiatric complications of medical illness, catatonia, and delirium were identified as priority topics in the care of pediatric patients with comorbid medical conditions. CONCLUSIONS: There are currently no published educational studies regarding the training needs for PCLP programs, even among tertiary care academic facilities. This training needs assessment is the first step in establishing a national PCLP training curriculum. New paradigms to develop standardized curriculum resources for PCLP are needed.

The acceptability of screening for suicide risk among youth in outpatient medical settings: Child and parent perspectives.

OBJECTIVE: Psychosocial providers in medical settings are increasingly being asked to identify suicide risk in youth with medical illnesses. This pilot study aimed to determine the acceptability of suicide risk screening among youth with cancer and other serious illnesses and their parents. METHODS: Youth ages 8-21 years presenting to an outpatient medical setting were screened for suicide risk using a modified version of the Ask Suicide-Screening Questions (ASQ) screening tool. Patient and parent perceptions of acceptability were collected. FINDINGS: The sample included 32 patient/parent dyads. The overall positive screen rate was 9.4% (n = 3/32). Most patients (75%; n = 24/32) and parents (84.4%; n = 27/32) reported that medical settings should screen young patients for suicide risk. CONCLUSIONS: Suicide risk screening was acceptable to most patients and parents in a pediatric clinic. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: Medically ill patients are at risk for suicide. Universal suicide risk screening using a validated measure can provide meaningful clinical information to patients' families and providers and has the potential to save young lives.

Validation of the Ask Suicide-Screening Questions for Adult Medical Inpatients: A Brief Tool for All Ages.

BACKGROUND: Few brief suicide risk screening instruments are validated for use in both adult and pediatric medical populations. Using the pediatric Ask Suicide-Screening Questions (ASQ) development study as a model, this study aimed to determine whether the ASQ is a valid suicide risk-screening instrument for use among adults medical patients, as well as to evaluate a set of other potential screening questions for use in adults. METHODS: Adult patients hospitalized on inpatient medical/surgical units from 4 hospitals were recruited to participate in a cross-sectional instrument-validation study. The 4-item ASQ and other candidate items were compared against the 25-item, previously validated Adult Suicidal Ideation Questionnaire as the criterion standard. RESULTS: A total of 727 adult medical inpatients completed the screening process. Compared with the Adult Suicidal Ideation Questionnaire, the ASQ performed best among the full set of candidate items, demonstrating strong psychometric properties, with a sensitivity of 100% (95% confidence interval = 90%-100%), a specificity of 89% (95% confidence interval = 86%-91%), and a negative predictive value of 100% (95% confidence interval = 99%-100%). A total of 4.8% (35/727) of the participants screened positive for suicide risk based on the standard criterion Adult Suicidal Ideation Questionnaire. CONCLUSIONS: The ASQ is a valid and brief suicide risk-screening tool for use among adults. Screening medical/surgical inpatients for suicide risk can be performed effectively for both adult and pediatric patients using this brief, primary screener.

Comparing Parent and Child Self-report Measures of the State-Trait Anxiety Inventory in Children and Adolescents with a Chronic Health Condition.

Anxiety symptoms in children and adolescents with a chronic health condition have been estimated as high as 40% lifetime prevalence. Clinicians often rely on parent/caregiver information to supplement or substitute child self-report related to pediatric physical and mental health. We developed a caregiver proxy version (STAI-P) for the State-Trait Anxiety Inventory (STAI) State Anxiety Scale that was compared with a child self-report version in 201 parent-child dyads to evaluate its utility in measuring state anxiety in chronically ill youth. For patients aged 7-12, self-reports of state anxiety were moderately associated with parent distress and health provider-reported functional status, but negatively associated with parent STAI-P scores. For patients aged 13-17, self-reports of state anxiety were significantly associated with STAI-P scores, parent distress, and health provider-reported functional status. The STAI-P parent version may be a useful tool in identifying and addressing anxiety symptoms in youth living with a chronic health condition.