Use of ultraviolet light in graduate medical education to assess confidence among residents and fellows in handwashing instruction.

Background: Coronavirus disease 2019 (COVID-19) has made it imperative to focus on strategies to improve hand hygiene to minimize threats of viral transmission in hospitals. Objective: We investigated the potential of using ultraviolet (UV) light as a visual tool in hand-hygiene education to bring awareness of individual handwashing effectiveness to healthcare workers. Methods: In 2020, 117 individuals participated in the simulation and completed surveys on proper handwashing technique. Of these, 114 were first-year residents and fellows. Surveys of confidence in hand hygiene were obtained before and after formal hand-hygiene education utilizing UV light with Glo Germ lotion. The UV light and Glo Germ lotion were used to identify deficiencies in individual handwashing technique. Results: With a total response rate of 97.4%, first-year residents and fellows demonstrated a significant decrease in handwashing confidence in pre- and posteducation surveys. Study participants who had had formal hand-hygiene training in the previous 3 years also indicated confidence in hand hygiene similar to those who had not had previous hand-hygiene training. Conclusions: Overall, resident interns and fellows may have falsely elevated their hand-hygiene confidence levels. However, conclusions regarding the confidence of residents and fellows individually could not be made due to sample size. Many healthcare personnel practice improper handwashing techniques, which may be improved with education and training that includes UV light.

Adverse childhood experiences associate with early post-trauma thalamus and thalamic nuclei volumes and PTSD development in adulthood.

Adverse childhood experiences (ACEs) potentially contribute to posttraumatic stress disorder (PTSD) after adult trauma exposure, but underlying brain changes remain unclear. The present study tested relationships between ACEs, whole thalamus and thalamic nuclei volumes, and post-trauma stress symptoms (PTSS) after adult trauma. Trauma survivors (n = 101) completed the Childhood Trauma Questionnaire (CTQ), the PTSD checklist-special stressor version 5 (PCL), and a structural magnetic resonance imaging (sMRI) scan within post-trauma 2 weeks. At post-trauma 3 months, survivors completed a second PCL survey and a PTSD diagnosis interview using the Clinician-Administered PTSD Scale (CAPS). CTQ scores significantly positively correlated with PCL scores at post-trauma 2 weeks and 3 months (respective p's < 0.01 and < 0.001). CTQ scores significantly negatively correlated with whole thalamus and 7 thalamic nuclei volumes at post-trauma 2 weeks in the PTSD (N = 50), but not the non-PTSD (N = 51) group. Whole thalamus and 22 nuclei volumes significantly negatively correlated with PCL scores at post-trauma 3 months in the PTSD, but not the non-PTSD group. These results suggest ACEs negatively influence early post-trauma thalamic volumes which, in turn, are negatively associated with PTSS in survivors who develop PTSD.

Preliminary study examining the mediational link between mild traumatic brain injury, acute stress, and post-traumatic stress symptoms following trauma.

Background: The presence of mild traumatic brain injury (mTBI) increases post-traumatic stress disorder (PTSD) symptoms in the months following injury. However, factors that link mTBI and PTSD development are still unclear. Acute stress responses after trauma have been associated with PTSD development. mTBI may impair cognitive functions and increase anxiety immediately after trauma. Objective: This research aimed to test the possibility that mTBI increases acute stress symptoms rapidly, which in turn results in PTSD development in the subsequent months. Method: Fifty-nine patients were recruited from the emergency rooms of local hospitals. Post-mTBI, acute stress, and PTSD symptom severity were measured using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), Acute Stress Disorder Scale (ASDS), and PTSD Checklist for DSM-5 (PCL-5), respectively. Results: Moderated mediation analysis indicated that ASDS, at 2 weeks post-trauma, mediated the relationship between RPQ scores at 2 weeks and PCL-5 scores at 3 months post-trauma, only for patients who met mTBI diagnostic criteria. Conclusions: These findings present preliminary evidence suggesting that acute stress disorder symptoms may be one of the mechanisms involved in the development of PTSD among trauma survivors who have experienced mTBI, which provides a theoretical basis for early intervention of PTSD prevention after mTBI.

Antecedentes: La presencia de lesiones cerebrales traumáticas leves (mTBI, por su sigla en inglés) aumenta los síntomas del trastorno de estrés postraumático (TEPT) en los meses posteriores al daño. Sin embargo, los factores que relacionan mTBI y el desarrollo del TEPT no están claros aún. Es posible que mTBI induzca una respuesta aguda al estrés inmediatamente después del trauma, que a su vez, se asocie al desarrollo posterior de TEPT.Objetivo: Este estudio buscó probar la hipótesis de si la asociación de mediación entre mTBI, estrés agudo y severidad de los síntomas de TEPT depende del estado de mTBI.Métodos: Se reclutó a cincuenta y nueve pacientes de las salas de emergencia de hospitales locales. Se midió la severidad de los síntomas post-mTBI y de estrés agudo dentro de las 2 semanas posteriores al trauma utilizando el cuestionario de síntomas post-concusión de Rivermead (RPQ, por su sigla en inglés) y la Escala para el Trastorno de Estrés Agudo (ASDS, por su sigla en inglés), respectivamente. Se midió la severidad de los síntomas de TEPT 3 meses después del trauma utilizando la Lista de Chequeo para TEPT del DSM-5 (PCL-5, por su sigla en inglés).Resultados: Los análisis de mediación moderada indicaron que los puntajes de ASDS, a las 2 semanas post-trauma, mediaban la relación entre los puntajes de RPQ a las 2 semanas y los puntajes de la PCL-5 a los 3 meses post-trauma, sólo para pacientes que cumplían los criterios diagnósticos para mTBI.Conclusiones: Estos hallazgos presentan evidencia preliminar que sugiere que los síntomas del trastorno de estrés agudo pueden ser uno de los mecanismos involucrados en el desarrollo del TEPT entre los sobrevivientes de trauma con un diagnóstico de mTBI, lo cual provee una base teórica para la intervención temprana de TEPT después de mTBI.

Emotional avoidance and social support interact to predict depression symptom severity one year after traumatic exposure.

Individuals exposed to a traumatic event commonly develop symptoms of depression, a psychiatric disorder associated with a number of negative clinical and public health consequences. Both intrapersonal and interpersonal risk factors have been associated with heightened risk for depression following traumatic event exposure; however, less is known about how these risk factors may interact to predict trauma-exposed individuals' risk of subsequently developing depression symptoms. This study examined the interactive influence of emotional avoidance (an intrapersonal risk factor) and perceived social support (an interpersonal risk factor) on the development of depression symptoms over a one-year period among N = 46 individuals recruited shortly after visiting a hospital emergency department for treatment following exposure to a traumatic event. Results revealed a significant main effect of emotional avoidance on 12-month depression symptoms. The main effect was qualified by an emotional avoidance by perceived social support interaction: the relation of emotional avoidance to 12-month depression symptoms was positive and significant only for individuals with low levels of perceived social support. Results highlight the need to consider both intrapersonal and interpersonal risk factors, as well as their interaction, when predicting which individuals may be most at risk to develop depression following traumatic event exposure.

The emergency care model: A new paradigm for skilled nursing facilities.

The population of individuals age 65 and older is increasing in the United States. One third of these individuals will utilize nursing home care before death. Nursing home residents ("NHR") average 1.8 emergency department visits annually. Improving the quality of nursing home care is of vital importance. This project describes a new paradigm for the management of acute emergent health issues affecting NHR. The model features a multidisciplinary team coordinated by emergency providers resulting in a 55% reduction in unplanned hospital admissions compared to skilled nursing facility regional data. Additionally, a reduction in ancillary lab costs was observed. Implementation of this paradigm on a national scale could result in a projected cost savings in excess of $10 billion per year for the Center for Medicare and Medicaid Services ("CMS").

Developing "Herd Immunity" in a Civilian Community Through Incorporation of "Just-In-Time" Tourniquet Application Training.

INTRODUCTION: Herd immunity, a concept normally applied in vaccinated populations, is a preventative measure to determine if a significant portion of a population can protect vulnerable individuals against a certain disease. Like vaccines, tourniquet education can be a form of herd immunity to protect vulnerable individuals in a population and prevent the loss of life from a peripheral hemorrhage. The authors have identified a deficiency in simple, quick, and effective hemorrhage control education. Therefore, to maximize herd immunity, the novel educational platform evaluates the efficacy of "Just-in-Time" (JiT) tourniquet application training. HYPOTHESIS/PROBLEM: The authors hypothesize that the utilization of JiT training will be effective in promoting both competence and confidence for individuals to utilize tourniquets in response to a disaster environment. METHODS: This Institutional Review Board-approved study recruited medical students who were trained in hemorrhage control measures at a Level 1 Trauma Center. Tourniquet training sessions were held, and naïve civilians received tourniquet education. The subjects received a five- to ten-minute lesson on indications, contraindications, and application techniques of commercial and improvisational tourniquets. Participants subsequently applied a tourniquet to an instructor's arm to demonstrate proper tourniquet application for a brachial artery hemorrhage. Pre- and post-educational surveys were completed to test participant competency and confidence. RESULTS: Of the 104 subjects who completed the course, 97 had no prior training in hemorrhage control techniques, including commercial and improvisational tourniquet application. The mean pre-test score was 2.27/5.00 and the mean post-test score was 4.38/5.00, P <.001 (n = 97). When queried "How competent would you feel applying a tourniquet (commercial or improvisational) on an individual with a bleeding wound?" 92/97 felt confident (95%), one felt less confident, and four felt no difference in confidence levels (P <.001). CONCLUSION: Just-in-Time training is an effective method in teaching naïve civilians proper tourniquet application. This platform could serve as an alternative to more extensive training programs and requires less time, costs, and resources. If a significant number of individuals in a local community can effectively apply a tourniquet in a disaster scenario, a "herd immunity" effect could be achieved to control peripheral hemorrhages.

Relationship of Hippocampal Volumes and Posttraumatic Stress Disorder Symptoms Over Early Posttrauma Periods.

BACKGROUND: Smaller hippocampal volume is associated with more severe posttraumatic stress disorder (PTSD) symptoms years after traumatic experiences. Posttraumatic stress symptoms appear early following trauma, but the relationship between hippocampal volume and PTSD symptom severity during early posttrauma periods is not well understood. It is possible that the inverse relationship between hippocampal volume and PTSD symptom severity is already present soon after trauma. To test this possibility, we prospectively examined the association between hippocampal volumes and severity of PTSD symptoms within weeks to months after trauma due to a motor vehicle collision. METHODS: Structural magnetic resonance imaging scans of 44 survivors were collected about 2 weeks and again at 3 months after a motor vehicle collision to measure hippocampal volumes. The PTSD Checklist was used to evaluate PTSD symptoms at each scan time. Full (n = 5) or partial (n = 6) PTSD was evaluated using the Clinician-Administered PTSD Scale at 3 months. RESULTS: Left hippocampal volumes at both time points negatively correlated with PTSD Checklist scores, and with subscores for re-experiencing symptoms at 3 months. Left hippocampal volumes at 3 months also negatively correlated with hyperarousal symptoms at 3 months. Finally, neither left nor right hippocampal volumes significantly changed between 2 weeks and 3 months posttrauma. CONCLUSIONS: The results suggest that small hippocampal volume at early posttrauma weeks is associated with increased risk for PTSD development. Furthermore, the inverse relationship between hippocampal volume and PTSD symptoms at 3 months did not arise from posttrauma shifts in hippocampal volume between 2 weeks and 3 months after trauma.

Early Changes in Cortical Emotion Processing Circuits after Mild Traumatic Brain Injury from Motor Vehicle Collision.

Mild traumatic brain injury (mTBI) patients frequently experience emotion dysregulation symptoms, including post-traumatic stress. Although mTBI likely affects cortical activation and structure, resulting in cognitive symptoms after mTBI, early effects of mTBI on cortical emotion processing circuits have rarely been examined. To assess early mTBI effects on cortical functional and structural components of emotion processing, we assessed cortical activation to fearful faces within the first 2 weeks after motor vehicle collision (MVC) in survivors who did and did not experience mTBI. We also examined the thicknesses of cortical regions with altered activation. MVC survivors with mTBI (n = 21) had significantly less activation in left superior parietal gyrus (SPG) (-5.9, -81.8, 33.8; p = 10-3.623), left medial orbitofrontal gyrus (mOFG) (-4.7, 36.1, -19.3; p = 10-3.231), and left and right lateral orbitofrontal gyri (lOFG) (left: -16.0, 41.4, -16.6; p = 10-2.573; right: 18.7, 22.7, -17.7; p = 10-2.764) than MVC survivors without mTBI (n = 23). SPG activation in mTBI survivors within 2 weeks after MVC was negatively correlated with subsequent post-traumatic stress symptom severity at 3 months (r = -0.68, p = 0.03). Finally, the SPG region was thinner in the mTBI survivors than in the non-mTBI survivors (F = 11.07, p = 0.002). These results suggest that early differences in activation and structure in cortical emotion processing circuits in trauma survivors who sustain mTBI may contribute to the development of emotion-related symptoms.

ED Patients with Prolonged Complaints and Repeat ED Visits Have an Increased Risk of Depression.

INTRODUCTION: The objective of this study was to explore associations between presenting chief complaints of prolonged symptomatology, patient usage of the emergency department (ED), and underlying depression so that emergency physicians may better target patients for depression screening. METHODS: A convenience sample of ED patients were administered the Beck Depression Inventory-II (BDI-II) to assess for depression. We correlated completed BDI-II surveys to patient information including demographics, pertinent history of present illness information, and past medical history. RESULTS: Out of 425 participants screened, we identified complaints of two weeks or longer in 92 patients (22%). Of these patients, mild to severe depression was recognized in over half of the population (47), yet only nine patients reported a prior depression diagnosis. These 92 patients also visited the ED three times as frequently as those patients with more acute complaints (p<0.001). Finally, our study showed that patients with mild to severe depression had three times as many ED visits compared to patients with minimal or no depression (p<0.001). CONCLUSION: Patients with complaints of symptomatology two weeks or longer are more likely to have underlying depression when presenting to the ED. Patients with three or more ED visits within the past year also have a greater incidence of underlying depression. We found a strong correlation between complaints with symptomatology of two weeks or longer and multiple ED visits, in which underlying depression may have contributed to these patients' ED visits.

Preliminary Study of Acute Changes in Emotion Processing in Trauma Survivors with PTSD Symptoms.

Accumulating evidence suggests traumatic experience can rapidly alter brain activation associated with emotion processing. However, little is known about acute changes in emotion neurocircuits that underlie PTSD symptom development. To examine acute alterations in emotion circuit activation and structure that may be linked to PTSD symptoms, thirty-eight subjects performed a task of appraisal of emotional faces as their brains were functionally and structurally studied with MRI at both two weeks and three months after motor vehicle collision (MVC). As determined by symptoms reported in the PTSD Checklist at three months, sixteen survivors developed probable PTSD, whereas the remaining 22 did not meet criteria for PTSD diagnosis (non-PTSD). The probable PTSD group had greater activation than the non-PTSD group in dorsal and ventral medial prefrontal cortex (dmPFC and vmPFC) while appraising fearful faces within two weeks after MVC and in left insular cortex (IC) three months after MVC. dmPFC activation at two weeks significantly positively correlated with PTSD symptom severity at two weeks (R = 0.462, P = 0.006) and three months (R = 0.418, p = 0.012). Changes over time in dmPFC activation and in PTSD symptom severity were also significantly positively correlated in the probable PTSD group (R = 0.641, P = 0.018). A significant time by group interaction was found for volume changes in left superior frontal gyrus (SFG, F = 6.048, p = 0.019) that partially overlapped dmPFC active region. Between two weeks and three months, left SFG volume decreased in probable PTSD survivors. These findings identify alterations in frontal cortical activity and structure during the early post-trauma period that appear to be associated with development of PTSD symptoms.

Early cortical thickness change after mild traumatic brain injury following motor vehicle collision.

In a motor vehicle collision (MVC), survivors often receive mild traumatic brain injuries (mTBI). Although there have been some reports of early white matter changes after an mTBI, much less is known about early cortical structural changes. To investigate early cortical changes within a few days after an MVC, we compared cortical thickness of mTBI survivors with non-mTBI survivors, then reexamined cortical thickness in the same survivors 3 months later. MVC survivors were categorized as mTBI or non-mTBI based on concussive symptoms documented in emergency departments (EDs). Cortical thickness was measured from MRI images using FreeSurfer within a few days and again at 3 months after MVC. Post-traumatic stress symptoms and physical conditions were also assessed. Compared with the non-mTBI group (n = 23), the mTBI group (n = 21) had thicker cortex in the left rostral middle frontal (rMFG) and right precuneus gyri, but thinner cortex in the left posterior middle temporal gyrus at 7.2 ± 3.1 days after MVC. After 3 months, cortical thickness had decreased in left rMFG in the mTBI group but not in the non-mTBI group. The cortical thickness of the right precuneus region in the initial scans was positively correlated with acute traumatic stress symptoms for all survivors and with the number of reduced activity days for mTBI survivors who completed the follow-up. The preliminary results suggest that alterations in cortical thickness may occur at an early stage of mTBI and that frontal cortex structure may change dynamically over the initial 3 months after mTBI.

Preliminary study on the relationship between visitation in the emergency department and posttraumatic mental health.

This study documented family/friend support to patients in the Emergency Department (ED), including bedside visits and transportation of patients from the ED after discharge, and measured depression, anxiety, and stress symptoms within 2 weeks, 1 month and 3 months after motor vehicle accidents. Stress and depression symptoms significantly decreased during the initial three months. Family/friend visitation in the ED was negatively associated with anxiety and depression symptoms within 2 weeks and with stress symptoms months after trauma. This pilot study suggests family/friend visitation in the ED is associated with fewer mental health issues in the months following an accident.