What healthcare leadership can do in a climate crisis.

Healthcare governing boards, executives, medical staff, health professionals, and allied staff members should all play a role in devising, promoting, and implementing solutions for climate change mitigation, which must extend beyond the boundaries of their own workplaces and healthcare institutions. Such actions can potentially influence not only healthcare professionals and their patients but also healthcare supply chains and entire communities. Thus, leaders of healthcare organizations can play a vital role in leading by example. The authors herein propose some initiatives for promoting and implementing a culture of sustainability and climate action in medicine.

Identifying Opportunities for Greenhouse Gas Reductions and Cost Savings in Hospitals: A Knowledge Translation Tree.

Research has shown that the healthcare sector is among the least green sectors and constitutes one of the largest contributors to greenhouse gas (GHG) emissions, posing risks to human health. This review discusses the development of a knowledge translation tool that aims to compare a range of interventions that can be applied in hospital settings to reduce the local GHG emissions and associated financial costs. It discusses several interventions that potentially have the most impact on GHG reduction and compares these to interventions that are commonly used in different hospital departments. The authors propose opportunities to advance the implementation of these interventions within hospital operations across many other geographic locations.

Reproductive rights on the path of liberation: from deconstructing the concept of control in our society to emphasizing pro-attachment attitudes.

The debate about abortion is recurrently pervading not only politics and public health but also society at large, even within the utilization of mass media. The authors reinforce that access to reproductive health is a human rights issue and discuss facts and misconceptions associated with the procedure. They reframe the discussion and scripts sometimes found in pop culture, illuminating how attitudes towards reproductive rights may affect people. To address the polarization impasse, they propose using the lens of attachment relationships and offer corresponding solutions on three core levels: educational, social and narrative.

Bridging the gap: Responding to resident burnout and restoring well-being.

There is an increasing awareness of high burnout found among physicians. Resident physicians particularly face heightened stress due to inherent pressures of training in addition to systemic challenges common to healthcare. It is crucial that medical training programs and organizations create a culture which promotes physician well-being. We conducted an evaluation of a quality assurance pilot program aimed at creating a safe space for increasing burnout awareness and well-being among resident physicians. The program was voluntary, offered to psychiatry residents enrolled at McMaster University, and comprised an online resilience curriculum, peer groups, and wellness newsletters. Data analysis took place between December 15, 2018 and July 15, 2019. The educational goals were evaluated by outcome measures obtained over time in aggregated response data through residents' anonymous survey feedback. All aspects of the triad received positive feedback, with peer groups being perceived as most helpful. Of all residents, 31% (n = 22) engaged in all three aspects of the program; the majority were female (83%) and senior residents (63%). While 48% reported burnout upon enrollment, there was an average 50% stress reduction perceived post-attendance. This project has shown that peer groups can make a difference in the daily experience of psychiatry residents at our institution.

Cerebrovascular Steal Phenomenon and Electroconvulsive Therapy: A Case Report and Review of the Literature.

Electroconvulsive therapy (ECT) is a safe and effective treatment for major depressive disorder, but cerebrovascular and cardiovascular complications, although rare, remain the most concerning. This is particularly notable in those with preexisting cerebrovascular disease, which impacts dynamic cerebral autoregulation. In these patients, the increased blood flow to the seizing portions of the brain induced by ECT potentially can reduce cerebral blood flow to ischemic areas, possibly causing adverse neurological events. The authors describe a patient with chronic cerebral ischemic disease, chronic anemia, and major depressive disorder undergoing ECT to achieve remission. The patient developed recurrent focal neurological deficits after each ECT procedure, with neurological recovery within 48 hours post-ECT. Clinical guidelines may need to be updated for the management of ECT patients with cerebrovascular disease who may be at an increased risk of intraictal and possibly postictal regional ischemia, especially in areas already compromised by a prior stroke and/or by reduced cerebral oxygenation caused by symptomatic anemia at risk of ischemia. Research is needed to assess changes in regional cerebral blood flow during and after ECT in patients with cerebrovascular disease, including small-vessel cerebral ischemia, and to evaluate these changes in relation to the location, intensity, and duration of induced seizure.

Geriatric gambling disorder: challenges in clinical assessment.

To the Editor: The gaming industry is growing rapidly, as is the proportion of older adults aged 65 years or older who participate in gambling (Tse et al., 2012). With casinos tailoring their venues and providing incentives to attract older adults, and with the increasing popularity of "pleasure trips" to casinos organized by retirement homes, plus active promotion of government-operated lotteries in many countries, this trend is likely to continue. Gambling disorder (GD) or "pathological" or "problem" gambling presents a public health concern in the geriatric population. However, ascertainment of its prevalence and diagnostic accuracy have proven challenging. This is largely due to the absence of diagnostic criteria specific to the geriatric age and rating scales validated for use in this population.

Academics anonymous: A medical student's 12-step guide to scholarly productivity.

An important aspect of academic medicine is publication in peer-reviewed journals and other media. Early scholarly productivity in medical school may jump-start a successful academic career. Topic choice, search methodology, writing strategies, mentorship, and collaboration are all fundamental to successful academic productivity. The authors reviewed the importance of instituting the germinal stages of scholarly productivity during medical training and created 12 steps for facilitating productive academic writing by students.

Aging with autism spectrum disorder: an emerging public health problem.

From 1943, when Leo Kanner originally described autism, and to the first objective criteria for "infantile autism" in DSM-III and the inclusion of Asperger's disorder in DSM-IV, the subsequent classification scheme for autistic disorders has led to a substantial change with the 2013 issuance of the DSM-5 by including subcategories into one umbrella diagnosis of autism spectrum disorder (ASD) (Baker, 2013). ASD is a lifelong neurodevelopmental disorder, characterized by social and communication impairments and restricted, stereotypical patterns of behavior (Baker, 2013). It is currently expected that most, or all of the actual cases of ASD, are identified in a timely way (i.e. in early childhood). However, there are many undiagnosed older adults who may have met the current diagnostic criteria for ASD as children, but never received such a diagnosis due to the fact it had yet to be established. In addition, some patients with relatively less impairing phenotypes may escape formal diagnosis in childhood, only to later be diagnosed in adulthood. Nevertheless, the first generation of diagnosed patients with ASD is now in old age. Many such ASD patients have needed family and institutional support for their lives subsequent to childhood diagnosis. Due to aging and death of their parents and other supportive figures leading to a loss of social structures, there is no better time than now for the medical community to act.

Donepezil-associated manic episode with psychotic features: a case report and review of the literature.

OBJECTIVE: Reports of manic episodes associated with the use of cholinesterase inhibitors (including donepezil) are limited. Despite the previous notion of procholinergic drugs potentially inducing depression, the contemporary evidence for cholinesterase inhibitors appears to also indicate a trend for elevated mood (in patients with or without a history of depressive disorder). METHOD: Case report. RESULTS: The authors report a case of a manic episode with psychotic features associated with the up-titration of donepezil in a patient with Alzheimer's disease and a distant history of major depression but without a preexisting bipolar disorder. CONCLUSION: Pathophysiology of donepezil-induced mania appears to contradict the traditional cholinergic-adrenergic hypothesis. Donepezil-associated mania should be suspected after donepezil initiation/dose up-titration when correlated to new onset of mania. Donepezil should be used more cautiously in patients with current or previous mood episodes or in those who are otherwise at high risk for manic episodes (e.g., cerebrovascular disease). Although this requires further investigation in different patient populations, there may be subtypes of older patients with neurocognitive disorders who are particularly vulnerable to activation effects of cholinesterase inhibitors.

Geriatric Homelessness: Association with Emergency Department Utilization.

BACKGROUND: Homeless adults frequently use emergency departments (EDs), yet previous studies investigating ED utilization by the older segment received little attention. This study sought to characterize older homeless adults who utilized local urban EDs. METHODS: ED encounters at three hospitals in Hamilton (Ont.) were analyzed, and demographic and clinical characteristics of the older homeless (age > 50) vs. younger counterparts (age ≤ 50) were compared during a 24-month period. RESULTS: Of all adults, 1,330 were homeless, of whom 66% were above age 50. Older homeless adults sought less acute care within 30 days from an index visit compared with their younger counterparts. Non-acute illnesses constituted only 18% of triaged cases. Older homeless women with access to a primary care physician (PCP) were 3.3 times more likely to return to ED within 30 days, whereas older homeless men (irrespective of PCP access) were less likely to return to ED. CONCLUSIONS: Despite high homeless patient acuity, a lesser number of ED visits with increasing age remains concerning because of previously reported high morbidity and mortality rates. Access to primary care may not be enough to reduce ED utilization. Further research is needed to evaluate acute care interventions and their effectiveness in ED, and to identify homeless patients requiring more targeted services.

Competency-based medical education and scholarship: Creating an active academic culture during residency.

The competency-based medical education movement has been adopted in several medical education systems across the world. This has the potential to result in a more active involvement of residents in the educational process, inasmuch as scholarship is regarded as a major area of competency. Substantial scholarly activities are well within the reach of motivated residents, especially when faculty members provide sufficient mentoring. These academically empowered residents have the advantage of early experience in the areas of scholarly discovery, integration, application, and teaching. Herein, the authors review the importance of instituting the germinal stages of scholarly productivity in the creation of an active scholarly culture during residency. Clear and consistent institutional and departmental strategies to promote scholarly development during residency are highly encouraged.