Clinical Care of Patients with Neurocognitive Disorders: A Qualitative Study of the Psychiatric Residency Training Experience.

OBJECTIVE: Few data describe how general psychiatry residencies prepare trainees to care for individuals with neurocognitive disorders (NCDs), despite increasing recognition of the need for psychiatrists to provide care for the growing numbers of patients with NCD. This study aims to identify training needs and approaches, as the resident experience is one important perspective that can be added to others, such as milestones developed by expert educators. METHODS: The authors conducted three focus groups of third- and fourth-year general adult psychiatry residency trainees from three different training programs in May and June of 2021. Focus groups consisted of three to eight unique participants per group. Qualitative data analysis techniques derived in grounded theory were utilized to identify themes. RESULTS: Four main themes emerged from the focus groups: unique challenges of NCD care, intrinsic rewards of working with families, perceived gaps in educational experiences, and limited comfort in future practice. CONCLUSIONS: Participants expressed that aspects of NCD care were fundamentally different than care for other mental health conditions encountered in psychiatry residency. They found the progressive nature of the disease to be particularly challenging, and they also expressed challenges with clinical interviews and establishing rapport with individuals with NCDs. However, working with families was especially rewarding. Regardless of training program, participants expressed a need for additional longitudinal and diversified training opportunities to prepare them for future practice in this area.

Should Antipsychotics' Risks Be Accepted by Clinicians on Behalf of Patients to Achieve Benefits of Mitigating Older Adults' Behavioral Symptoms in Short-Staffed Units?

This commentary on a case considers risks and benefits of pharmacological and nonpharmacological management of agitation in patients with dementia. Specifically, it considers beneficence and nonmaleficence in treatment decisions that affect both patients and staff as well as autonomy and surrogate decision making.

Psychiatry Resident Education in Neurocognitive Disorders: a National Survey of Program Directors in Psychiatry.

OBJECTIVE: As major neurocognitive disorders increase, little research has examined how psychiatry residents are prepared to provide neurocognitive care to patients. METHODS: A national survey was sent to program directors of general psychiatry in the USA and Canada, including questions about satisfaction, attitudes, and graduation expectations for training in major neurocognitive disorders. The authors examined descriptive statistics and a series of chi-squared analyses by training setting, residency type, and presence of subspecialty fellowships. The authors also collected free text responses about perceived needs for enhancing training. RESULTS: Program directors agreed that the scope of general psychiatry includes the evaluation of cognitive disorders (78.8%) and the treatment of cognitive symptoms (77.5%) and behavioral/psychological symptoms (78.8%). Required clinical rotations were the preferred method of teaching (63.7%), but didactics were most used (93.8%). The most frequently used clinical teaching setting was geriatric psychiatry (61.3%) and didactics were most frequently taught by geriatric psychiatrists (75.0%). Fifty-six percent were satisfied or very satisfied with their clinical training and 66.3% with their didactics. There were no significant differences in satisfaction or attitudes when compared by training setting, residency type, or presence of subspecialty fellowships. Additional trained faculty were most frequently listed as a need for improving clinical and didactic training. CONCLUSIONS: Psychiatry program directors view major neurocognitive disorders as part of the scope of psychiatric practice. The majority of training is provided within psychiatry rotations, especially geriatric psychiatry. Program directors reported several unmet needs for optimal training, particularly related to clinical training services.

Current Educational Practices for Major Neurocognitive Disorders in Psychiatry: a Scoping Review.

OBJECTIVE: A scoping review of the literature was performed to examine the current state of education on major neurocognitive disorders within psychiatry, to review influential factors for pursuing a career working with these patients, and to review what has been done in education to address the shortage of providers to care for patients with major neurocognitive disorders. METHODS: Using the Arksey and O'Malley framework for conducting scoping reviews, twenty-eight studies on education in geriatric psychiatry, neuropsychiatry, and major neurocognitive disorders were selected. Learner groups included medical students, residents, and psychiatrists. The results from the studies were compared, and major themes were presented. RESULTS: Several studies found that positive clinical experiences with older adult patients and effective teachers in geriatric psychiatry play a role in influencing trainees to pursue a career in geriatric psychiatry. Topics pertaining to major neurocognitive disorders are taught by the majority of medical schools during the psychiatry rotation and are rated as the most important teaching topic in neurology among psychiatry residency program directors. Several interventions have resulted in increased comfort working with geriatric patients and patients who have major neurocognitive disorders among students, but fewer studies have resulted in an increase in interest seeing these patients in practice. There is a lack of research pertaining to psychiatry residents working with patients that have major neurocognitive disorders. CONCLUSIONS: While research on geriatric psychiatry and neuropsychiatry education exists, more research is needed that focuses specifically on how medical students and psychiatry residents are being taught major neurocognitive disorders.

Metagenomic Analysis of 16S Clostridium perfringens Amplicons Corroborates C. perfringens Counts on Select Agar and C. perfringens PCR Analyses of Bacteria in Broiler Farm Litter.

The purpose of this study was twofold-first, to determine whether analysis of bacterial 16S ribosomal RNA (rRNA) in poultry litter corroborated standard Clostridium perfringens counts and PCR assay, and second, to find whether a correlation between 16S rRNA analysis and netB or Tpel toxin PCR intensity with chick mortality existed. At three time points of growout (0, 2, and 4 wk) litter samples were collected from 23 broiler houses representing eight farms during a coccidiosis vaccine control program. DNA extracted from these samples was used for microbiota determination by sequencing the hypervariable V3-V4 region of bacterial 16s rRNA. Obtained sequences were analyzed by QIIME 2 and the Greengenes database for taxonomic composition and relative abundance of C. perfringens in the litter bacterial population. Clostridium perfringens counts on select agar and semiquantitative PCR for C. perfringens were compared with 16S analysis for equivalence testing. Relative abundance of C. perfringens estimated by 16S analysis and semiquantitative PCR for netB and Tpel toxin DNA were analyzed by Pearson linear correlation and statistical equivalence analyses with cumulative chick mortality at 4 and 9 wk growout. When data from all time points were combined, abundance estimates by C. perfringens 16S were statistically equivalent (α = 0.10) to both C. perfringens PCR and C. perfringens counts. Yet, no correlations were observed between any estimate of C. perfringens abundance and cumulative percent chick mortality at 4 or 9 wk growout. However, correlation analyses revealed a significant linear relationship between netB signal at 0 wk (r = 0.55) and 4 wk (r = 0.46) and cumulative mortality at 9 wk growout (P < 0.05). Similarly, abundance of Tpel at 0 and 2 wk showed a linear relationship with cumulative percent mortality at both 4 and 9 wk growout (0.44 ≤ r ≤ 0.54, P < 0.05). No correlations were observed between any other genera or species determined by 16S and cumulative percent chick mortality.

Chia: Host Status for Meloidogyne incognita and Activity of Plant Extracts.

Chia (Salvia hispanica L.) seeds are used for food, drinks, oil, and animal feed, and all plant parts are employed in traditional medicine. The growing demand for the seed has created a need for improved disease management. Plant-parasitic nematodes have been found on other Salvia spp., but none have been reported from S. hispanica. Chia has also not been tested for production of compounds active against these nematodes. Therefore, aqueous extracts from shoots and roots of six chia lines, Brad's Organic, Cono, E2, G3, G5, and W13.1, were tested in laboratory assays. Some concentrations of all extracts were nematotoxic, killing about one-third of Meloidogyne incognita (Kofoid & White) Chitwood second-stage juveniles (J2s) in shoot extracts and up to nearly half of J2s in root extracts. Hatch was generally not affected by the extracts. In greenhouse trials, all six chia lines were hosts of M. incognita. Chia line G3 had approximately two times or more eggs per gram of root than Brad's Organic or Cono. When cucumber seedlings were transplanted into soil amended with chopped chia shoots (2.3 or 2.5% weight of fresh shoots/weight of dry soil), galling and egg production on cucumber roots were not suppressed. To our knowledge, this is the first report that chia is a host to M. incognita (or any phytoparasitic nematode) and that chia shoots and roots produce compounds active against a nematode.

Biocidal Activity of Fast Pyrolysis Biochar against Escherichia coli O157:H7 in Soil Varies Based on Production Temperature or Age of Biochar.

ABSTRACT: Soils in which fresh produce is grown can become contaminated with foodborne pathogens and are sometimes then abandoned or removed from production. The application of biochar has been proposed as a method of bioremediating such pathogen-contaminated soils. The objectives of the present study were to evaluate three fast-pyrolysis-generated biochars (FPBC; pyrolyzed in house at 450, 500, and 600°C in a newly designed pyrolysis reactor) and 10 United Kingdom Biochar Research Center (UKBRC) standard slow-pyrolysis biochars to determine their effects on the viability of four surrogate strains of Escherichia coli O157:H7 in soil. A previously validated biocidal FPBC that was aged for 2 years was also tested with E. coli to determine changes in antibacterial efficacy over time. Although neither the UKBRC slow-pyrolysis biochars or the 450 and 500°C FPBC from the new reactor were antimicrobial, the 600°C biochar was biocidal (P < 0.05); E. coli populations were significantly reduced at 3 and 3.5% biochar concentrations (reductions of 5.34 and 5.84 log CFU/g, respectively) compared with 0.0 to 2.0% biochar concentrations. The aged 500°C FPBC from the older reactor, which was previously validated as antimicrobial, lost efficacy after aging for 2 years. These results indicate that the biocidal activity of FPBC varies based on production temperature and/or age.

"He Bore it Like a Scarlet Letter": Medical Student Reflections on Substance Use Disorders.

OBJECTIVE: Substance abuse in the context of the opioid crisis presents a major public health concern. Despite some evidence that medical students' attitudes towards substance use disorders worsen during medical school, very few studies have examined how students' early clinical experiences with substance use disorders shape their views of this clinical population. This study uses student reflective essays to explore these formative educational experiences. METHODS: Using content analysis, the authors analyzed a collection of 802 medical student reflective essays written during core clerkships (excluding Psychiatry), coding for ethical and professional themes as well as descriptions of substance use disorders. In addition to the qualitative identification of themes, the authors used chi-square analysis to determine which themes had statistically significant associations with substance use disorders. RESULTS: Fifty-three essays described patients with substance use disorders. The most common substances described were opioids (n = 25), alcohol (n = 18), and cocaine (n = 11). There were five themes statistically associated with substance use disorders (p < 0.05): (1) adequate treatment, (2) pain, (3) difficult patient, (4) jumping to conclusions, and (5) malingering. CONCLUSIONS: In the sample, students found the treatment of pain to be a significant ethical challenge related to substance use disorders. In considering a comprehensive educational plan, medical educators may need to consider educational venues outside of the Psychiatry clerkship to address substance use disorders.

Survival of Salmonella during Apple Dehydration as Affected by Apple Cultivar and Antimicrobial Pretreatment.

ABSTRACT: Dehydrated fruits, including dried coconut (Cocos nucifera) and dried apple (Malus sp.) slices, have been the subject of manufacturer recalls due to contamination with Salmonella. A study was conducted to determine the survival of Salmonella on apple slices of six apple cultivars after dehydration and also following treatment with antimicrobial solutions (0.5%, w/w) and dehydration. Samples of six apple cultivars (Envy, Gala, Red Delicious, Fuji, Pink Lady, Granny Smith) were cored and sliced into 0.4-cm rings, halved, inoculated with a five-strain composite of desiccation-resistant Salmonella, and dehydrated at 60°C for 5 h. Subsequently, Gala apple slices were treated in 0.5% solutions of one of eight antimicrobial rinses for 2 min and then dehydrated at 60°C for 5 h. Antimicrobial solutions used were potassium sorbate, sodium benzoate, ascorbic acid, propionic acid, lactic acid, citric acid, fumaric acid, and sodium bisulfate. Reduction of Salmonella populations varied according to apple cultivar. Salmonella survival on Envy, Gala, Red Delicious, Fuji, Pink Lady, and Granny Smith was 5.92, 5.58, 4.83, 4.68, 4.45, and 3.84 log CFU, respectively. There was significantly greater (P < 0.05) Salmonella inactivation on Granny Smith, Pink Lady, and Fuji apples than on Gala and Envy. Survival of Salmonella on Gala apple slices following dehydration was 5.58 log CFU for the untreated control and 4.76, 3.90, 3.29, 3.13, 2.89, 2.83, 2.64, and 0.0 log CFU for those treated with potassium sorbate, sodium benzoate, ascorbic acid, propionic acid, lactic acid, citric acid, fumaric acid, and sodium bisulfate, respectively. Pretreatment of apple slices with either fumaric acid or sodium bisulfate before dehydration led to lower Salmonella survival than pretreatment with all other antimicrobial treatments. Lower apple pH was statistically correlated (P < 0.05) with decreasing survival of Salmonella following dehydration. These results may provide methodology applicable to the food industry for increasing the inactivation of Salmonella during the dehydration of apple slices.

Addicts and Admits: Metonymy in Medical Students' Reflective Writing.

Phenomenon: Metonymy refers to the substitution of the name of an attribute or adjunct for the name of the object or person being described. In medical contexts, this may involve referring to a person as a disease, body part, or other health-related noun. In this study, we explore the use of metonymy in medical students' reflective writing. Approach: Using content analysis, we identified all usages of metonymy in a sample of 802 medical student reflective essays. We analyzed them for associated themes and used the Fisher's exact test to compare frequencies of clinical ethics themes that occurred in the essays with metonymy to those without metonymy. Findings: Metonymy was used 60 times in the essays. The uses were grouped into thematic clusters of substance abuse (n = 27), illness (n = 9), body part (n = 4), clinical status (n = 6), reproductive health (n = 5), challenging clinical situations (n = 6), and other thoughts on patients as people (n = 3). Several ethical themes associated with essays using metonymy (p < .05): moral distress, substance abuse, adequate treatment, jumping to conclusions, awakening, and pain. Insights: Metonymy was relatively uncommon, and some students explicitly described the practice as dehumanizing to patients. Even so, metonymy did present in a variety of forms and was used most frequently to describe individuals with substance use disorders. Essays involving metonymy were more likely to describe a scenario that elicited moral distress in the students, which may indicate that metonymy occurs more frequently in some troubling situations.

Geriatric Psychiatry Inpatient Primer for Residents.

OBJECTIVE: The authors describe a novel curricular intervention that enhances first- and second-year psychiatry residents' geriatric psychiatry knowledge while preparing them for overnight call. METHODS: A brief, four-page document covering evaluation and management of common clinical scenarios in older adults, including agitation, falls, insomnia, chest pain, abnormal vital signs, and review of pharmacologic interventions, was presented to first- and second-year psychiatry residents. The residents completed an anonymous survey including their comfort level in answering pages and knowledge-based questions regarding evidence-based interventions both before and after the intervention. The pre-survey and post-survey were analyzed using the Wilcoxon-signed rank test, paired T test, and Mann-Whitney U test. RESULTS: The residents demonstrated statistically significant changes in first-line medication choices for common clinical scenarios such as non-aggressive agitation and insomnia. They were less likely to choose medications that should be avoided in elderly based on expert panel recommendations. CONCLUSIONS: Findings support the need for educational interventions designed to help residents taking call with geriatric patients. The results demonstrated an improvement in clinical knowledge following this brief intervention.

Moral distress in medical student reflective writing.

PURPOSE: Moral distress occurs when one identifies an ethically appropriate course of action but cannot carry it out. In this conceptualization, medical students may be particularly vulnerable to moral distress, but the literature on moral distress in medical trainees remains sparse. METHOD: Using content analysis of 802 reflective essays written by third-year medical students, the authors analyzed for the presence of moral distress and other ethical themes. The authors then used chi-squared analysis to determine which ethical themes were statistically associated with moral distress. RESULTS: Two hundred and seventy-four (34%) of the essays included student descriptions of moral distress. The most frequent theme in the moral distress essays was "role of the medical student" in the training hierarchy, and this reached a statistically significant association with moral distress (χ2=15.19, p < 0.001). Statistically significant associations (p < 0.05) were also found with moral distress and themes related to an "ethical disagreement with supervisor," "insensitive care," "disputes," "abuse," "poverty," "medical errors," and "transplant ethics." Essays discussing the "doctor-patient relationship" or observations of a "job well done" were statistically less likely to involve moral distress. CONCLUSIONS: Moral distress is a common occurrence in medical students, particularly related to medical students' role in the training hierarchy or other difficult interpersonal and clinical interactions. In our sample, moral distress was described less often in the presence of positive role models.

Medical student reflections on geriatrics: Moral distress, empathy, ethics and end of life.

Medical students' early clinical encounters may influence their perceptions of geriatrics. This study examines reflective essays written by 3rd-year medical students on required clinical rotations. Using content analysis, the authors analyzed the essays' thematic content. The authors then used chi-squared analysis to compare themes with geriatric patients (age 60+) to themes with other age groups. One hundred twenty out of 802 essays described a geriatric patient. The most common geriatric themes were (1) death and dying, (2) decision making, (3) meaningful physician-patient interactions, (4) quality of care, and (5) professional development. Geriatric essays were more likely to discuss death/dying and risk-benefit themes and less likely to discuss abuse. Geriatric essays were more likely to describe students' moral distress. Geriatric essays with moral distress were more likely to include empathy themes compared to geriatric essays without moral distress. Geriatric patients may pose unique ethical challenges for early clinical students.

Survival and Persistence of Nonpathogenic Escherichia coli and Attenuated Escherichia coli O157:H7 in Soils Amended with Animal Manure in a Greenhouse Environment.

Animal manure provides benefits to agriculture but may contain pathogens that contaminate ready-to-eat produce. U.S. Department of Agriculture National Organic Program standards include 90- or 120-day intervals between application of manure and harvest of crop to minimize risks of pathogen contamination of fresh produce. Data on factors affecting survival of Escherichia coli in soils under greenhouse conditions are needed. Three separate studies were conducted to evaluate survival of nonpathogenic E. coli (gEc) and attenuated E. coli O157:H7 (attO157) inoculated at either low (4 log CFU/ml) or high (6 log CFU/ml) populations over 56 days. Studies involved two pot sizes (small, 398 cm(3); large, 89 liters), three soil types (sandy loam, SL; clay loam, CL; silt loam, SIL), and four amendments (poultry litter, PL; dairy manure liquids, DML; horse manure, HM; unamended). Amendments were applied to the surface of the soil in either small or large containers. Study 1, conducted in regularly irrigated small containers, showed that populations of gEc and attO157 (2.84 to 2.88 log CFU/g) in PL-amended soils were significantly (P < 0.05) greater than those in DML-amended (0.29 to 0.32 log CFU/g [dry weight] [gdw]) or unamended (0.25 to 0.28 log CFU/gdw) soils; soil type did not affect E. coli survival. Results from study 2, in large pots with CL and SIL, showed that PL-amended soils supported significantly higher attO157 and gEc populations compared with HM-amended or unamended soils. Study 3 compared results from small and large containers that received high inoculum simultaneously. Overall, in both small and large containers, PLamended soils supported higher gEc and attO157 populations compared with HM-amended and unamended soils. Populations of attO157 were significantly greater in small containers (1.83 log CFU/gdw) than in large containers (0.65 log CFU/gdw) at week 8, perhaps because small containers received more regular irrigation than large pots. Regular irrigation of small pots may have affected E. coli persistence in manure-amended soils. Overall, PL-amended soils in both small and large containers supported E. coli survival at higher populations compared with DML-, HM-, or unamended soils.