Addressing the needs of adolescents with treatment resistant depressive disorders: a systematic review of rTMS.

BACKGROUND: Depressive disorders are among the most commonly experienced mental health concerns and a leading cause of mortality in adolescence. Current treatment guidelines recommend the use of antidepressant medication, cognitive behavioral therapy or both treatments. Unfortunately 40­60% of adolescents fail to respond to these treatments, therefore a new effective alternative treatment modality would be of particular benefit. rTMS is effective in addressing treatment resistant depression in adults and investigation into its effectiveness with adolescent populations has begun. OBJECTIVE: To examine the existing literature regarding the efficacy and safety of rTMS treatment with adolescents experiencing depressive symptoms, especially research conducted since the last published review. METHODS: A systematic review was conducted in accordance with PRISMA guidelines. The databases of OVID PsycINFO, PubMed, Ovid Medline and Web of Science were searched for research utilizing rTMS treatment with adolescents experiencing depressive symptomology. RESULTS: The review identified seven studies that examined rTMS as a treatment for depressive symptomology in adolescence. Findings indicate rTMS is likely to be an effective treatment for young people with preliminary longitudinal results suggesting maintenance of effects 3 years post-treatment. Reported side effects have included headaches, scalp discomfort and single incidences of hypomania and seizure. All side effects were transitory and did not recur. CONCLUSION: Preliminary results suggest rTMS is an effective and well tolerated antidepressant treatment for adolescents with treatment resistant depressive symptomology. Further research allowing for comparison across studies is necessary to establish the efficacy of rTMS in adolescent depression.

Follow-up study of complicated grief among parents eighteen months after a child's death in the pediatric intensive care unit.

OBJECTIVE: We previously demonstrated that parents whose children die in a pediatric intensive care unit (PICU) have a high level of complicated grief symptoms 6 months after the death. In this study, we investigate the change in the extent of complicated grief symptoms among these parents between 6 and 18 months postdeath and identify factors predicting improvement. METHODS: One hundred thirty-eight parents of 106 children completed surveys at 6 and 18 months. Surveys included the Inventory of Complicated Grief (ICG), measures of grief avoidance, attachment, caregiving and social support, and demographics. Multivariable analysis was performed using generalized estimating equations to identify characteristics independently associated with improvement in ICG score. RESULTS: ICG scores were 33.4 ± 13.6 at 6 months and 28.0 ± 13.5 at 18 months, representing an improvement in ICG score of 5.4 + 8.0 (95% confidence interval [CI] 4.1-6.8, p < 0.001). Variables independently associated with greater improvement in ICG score included traumatic death and greater grief avoidance. Variables independently associated with less improvement included being the biological parent and having more responsive caregiving. Parents with one or two surviving children had more improvement in ICG score than those with no surviving children whereas parents with three or more surviving children had less improvement. CONCLUSION: Complicated grief symptoms decrease among parents between 6 and 18 months after their child's death in the PICU; however, high symptom levels persists for some. Better understanding of the trajectory of complicated grief will allow parents at risk for persistent distress to receive professional support.

Multicenter cohort study of out-of-hospital pediatric cardiac arrest.

OBJECTIVES: To describe a large cohort of children with out-of-hospital cardiac arrest with return of circulation and to identify factors in the early postarrest period associated with survival. These objectives were for planning an interventional trial of therapeutic hypothermia after pediatric cardiac arrest. METHODS: A retrospective cohort study was conducted at 15 Pediatric Emergency Care Applied Research Network clinical sites over an 18-month study period. All children from 1 day (24 hrs) to 18 yrs of age with out-of-hospital cardiac arrest and a history of at least 1 min of chest compressions with return of circulation for at least 20 mins were eligible. MEASUREMENTS AND MAIN RESULTS: One hundred thirty-eight cases met study entry criteria; the overall mortality was 62% (85 of 138 cases). The event characteristics associated with increased survival were as follows: weekend arrests, cardiopulmonary resuscitation not ongoing at hospital arrival, arrest rhythm not asystole, no atropine or NaHCO3, fewer epinephrine doses, shorter duration of cardiopulmonary resuscitation, and drowning or asphyxial arrest event. For the 0- to 12-hr postarrest return-of-circulation period, absence of any vasopressor or inotropic agent (dopamine, epinephrine) use, higher lowest temperature recorded, greater lowest pH, lower lactate, lower maximum glucose, and normal pupillary responses were all associated with survival. A multivariate logistic model of variables available at the time of arrest, which controlled for gender, age, race, and asystole or ventricular fibrillation/ventricular tachycardia anytime during the arrest, found the administration of atropine and epinephrine to be associated with mortality. A second model using additional information available up to 12 hrs after return of circulation found 1) preexisting lung or airway disease; 2) an etiology of arrest drowning or asphyxia; 3) higher pH, and 4) bilateral reactive pupils to be associated with lower mortality. Receiving more than three doses of epinephrine was associated with poor outcome in 96% (44 of 46) of cases. CONCLUSIONS: Multiple factors were identified as associated with survival after out-of-hospital pediatric cardiac arrest with the return of circulation. Additional information available within a few hours after the return of circulation may diminish outcome associations of factors available at earlier times in regression models. These factors should be considered in the design of future interventional trials aimed to improve outcome after pediatric cardiac arrest.

Would access to device therapies improve transplant outcomes for adults with congenital heart disease? Analysis of the United Network for Organ Sharing (UNOS).

BACKGROUND: Patients with congenital heart disease (CHD) now survive into adulthood and often present with end-stage heart failure (HF). HF management and approach to orthotopic heart transplant (OHT) may differ from adults without CHD. We sought to compare OHT waitlist characteristics and outcomes for these 2 groups. METHODS: The Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) database was used to identify adults (≥18 years) listed for OHT from 2005 to 2009. The cohort was divided into those with or without CHD. RESULTS: Of 9,722 adults included, 314 (3%) had CHD. Adults with CHD were younger (35 ± 13 vs 52 ± 12 years, p < 0.01) and more often had undergone prior cardiac surgery (85% vs. 34%, p < 0.01). Patients with CHD were less likely to have a defibrillator (44% vs 75%, p < 0.01) or ventricular assist device (5% vs 14%, p < 0.01) and were more likely to be listed at the lowest urgency status than patients without CHD (64% vs 44%, p < 0.01). Fewer CHD patients achieved OHT (53% vs 65%, p < 0.001). Although overall waitlist mortality did not differ between groups (10% vs 8%, p = 0.15), patients with CHD were more likely to experience cardiovascular death (60% vs 40%, p = 0.03), including sudden in 44% and due to HF in 16%. CONCLUSIONS: Despite lower urgency status, patients with CHD have greater cardiovascular mortality awaiting OHT than those without. Increased defibrillator use could improve survival to OHT, because sudden death is common. VAD support may benefit select patients, but experience in CHD is limited. Referral to specialized adult congenital heart centers can enhance utilization of device therapies and potentially improve waitlist outcomes.

Complicated grief and associated risk factors among parents following a child's death in the pediatric intensive care unit.

OBJECTIVE: To investigate the extent of complicated grief symptoms and associated risk factors among parents whose child died in a pediatric intensive care unit. DESIGN: Cross-sectional survey conducted by mail and telephone. SETTING: Seven children's hospitals affiliated with the Collaborative Pediatric Critical Care Research Network from January 1, 2006, to June 30, 2008. PARTICIPANTS: Two hundred sixty-one parents from 872 families whose child died in a pediatric intensive care unit 6 months earlier. MAIN EXPOSURE: Assessment of potential risk factors, including demographic and clinical variables, and parent psychosocial characteristics, such as attachment style, caregiving style, grief avoidance, and social support. MAIN OUTCOME MEASURE: Parent report of complicated grief symptoms using the Inventory of Complicated Grief. Total scale range is from 0 to 76; scores of 30 or higher suggest complicated grief. RESULTS: Mean (SD) Inventory of Complicated Grief scores among parents were 33.7 (14.1). Fifty-nine percent of parents (95% confidence interval, 53%-65%) had scores of 30 or higher. Variables independently associated with higher symptom scores in multivariable analysis included being the biological mother or female guardian, trauma as the cause of death, greater attachment-related anxiety and attachment-related avoidance, and greater grief avoidance. CONCLUSIONS: Parents who responded to our survey experienced a high level of complicated grief symptoms 6 months after their child's death in the pediatric intensive care unit. However, our estimate of the extent of complicated grief symptoms may be biased because of a high number of nonresponders. Better understanding of complicated grief and its risk factors among parents will allow those most vulnerable to receive professional bereavement support.

Different perspectives: a comparison of newspaper articles to medical examiner data in the reporting of violent deaths.

This study compared violent death information reported in state-wide newspaper articles to the medical examiner reports collected for a state public health surveillance system-the National Violent Death Reporting System (NVDRS). While suicides accounted for 83% of deaths in the NVDRS database, more than three-quarters (79%) of violent deaths reported in newspaper articles were homicides. The majority of the suicide incidents were reported in 1-2 newspaper articles whereas the majority of homicide incidents were reported in 11-34 articles. For suicide incidents, the NVDRS reported more circumstances related to mental health problems while newspaper articles reported recent crisis more often. Results show that there is a mismatch in both frequency and type of information reported between a public health surveillance system (NVDRS) and newspaper reporting of violent deaths. As a result of these findings, scientists and other public health professionals may want to engage in media advocacy to provide newspaper reporters with timely and important health information related to the prevention and intervention of violent deaths in their community.

Effect of ABO-incompatible listing on infant heart transplant waitlist outcomes: analysis of the United Network for Organ Sharing (UNOS) database.

BACKGROUND: Midterm heart transplant outcomes of ABO-incompatible (ABO-I) organ use in infants are favorable. ABO-I transplantation has resulted in reduced waitlist mortality in some countries. This study assessed the effect of an ABO-I listing strategy on pre-transplant outcomes in the United States. METHODS: The Organ Procurement and Transplantation Network (OPTN)/United Network of Organ Sharing (UNOS) database was used to identify infants aged younger than 1 year listed as status 1 for heart transplantation between January 1, 2001, and May 20, 2008. The cohort was divided into 2 groups: eligible for ABO-compatible (ABO-C) transplant and eligible for ABO-I transplant. Baseline characteristics, waitlist times, and outcomes were compared in univariate analysis. Competing risks analysis evaluated differences in time to transplant in the presence of other outcomes. RESULTS: Of 1,029 infants listed for transplant, 277 (27%) were listed for an ABO-I transplant. Overall, 92% of transplant recipients received an ABO-C organ regardless of listing type. Among recipients eligible for ABO-I, only 27% received an ABO-I organ. The percentage that underwent transplant in each group did not differ. Although infants listed for an ABO-I organ had a shorter wait time for transplant, waitlist mortality was similar. CONCLUSIONS: Despite the intended merits of ABO-I heart transplantation, ABO-I listing and organ acceptance have not yielded lower waitlist mortality in the United States under the current UNOS allocation algorithm. Consideration should be given to altering the allocation system to one that gives less preference toward blood group compatibility in hopes of improving organ use and reducing waitlist mortality.

In-hospital versus out-of-hospital pediatric cardiac arrest: a multicenter cohort study.

OBJECTIVES: : To describe a large multicenter cohort of pediatric cardiac arrest (CA) with return of circulation (ROC) from either the in-hospital (IH) or the out-of-hospital (OH) setting and to determine whether significant differences related to pre-event, arrest event, early postarrest event characteristics, and outcomes exist that would be critical in planning a clinical trial of therapeutic hypothermia (TH). DESIGN: : Retrospective cohort study. SETTING: : Fifteen Pediatric Emergency Care Applied Research Network sites. PATIENTS: : Patients aged 24 hours to 18 years with either IH or OH CA who had a history of at least 1 minute of chest compressions and ROC for at least 20 minutes were eligible. INTERVENTIONS: : None. MEASUREMENTS AND MAIN RESULTS: : A total of 491 patients met study entry criteria with 353 IH cases and 138 OH cases. Major differences between the IH and OH cohorts were observed for patient prearrest characteristics, arrest event initial rhythm described, and arrest medication use. Several postarrest interventions were used differently, however, the use of TH was similar (<5%) in both cohorts. During the 0-12-hour interval following ROC, OH cases had lower minimum temperature and pH, and higher maximum serum glucose recorded. Mortality was greater in the OH cohort (62% vs. 51%, p = 0.04) with the cause attributed to a neurologic indication much more frequent in the OH than in the IH cohort (69% vs. 20%; p < 0.01). CONCLUSIONS: : For pediatric CA with ROC, several major differences exist between IH and OH cohorts. The finding that the etiology of death was attributed to neurologic indications much more frequently in OH arrests has important implications for future research. Investigators planning to evaluate the efficacy of new interventions, such as TH, should be aware that the IH and OH populations differ greatly and require independent clinical trials.

The effect of family presence on the efficiency of pediatric trauma resuscitations.

STUDY OBJECTIVE: Family presence has broad professional organizational support and is gaining acceptance. We seek to determine whether family presence prolonged pediatric trauma team resuscitations as measured by time from emergency department arrival to computed tomographic (CT) scan, and to resuscitation completion. METHODS: A prospective trial offered families of pediatric trauma patients family presence on even days and no family presence on odd days. Primary outcome measures were time from arrival to CT scan and to resuscitation completion (laboratory tests, emergency procedures, portable radiographs, and secondary survey). We evaluated the effect of family presence in an adjusted Cox proportional hazards model. Staff and family experiencing a resuscitation with family presence were asked their opinions of that experience. RESULTS: Of 1,229 pediatric trauma activations, 705 patients were included in the study protocol, 283 with family presence on even days, 422 without family presence on odd days. Median times to CT scan (21 minutes; IQR 16 to 29 minutes) and median resuscitation times (15 minutes; IQR 10 to 20 minutes) were similar with and without family presence. There was no clinically relevant difference in CT time (hazard ratio 1.04; 95% confidence interval [CI] 0.83 to 1.30) or resuscitation time (hazard ratio 0.98; 95% CI 0.83 to 1.15). Families believed that family presence was helpful both to their child and themselves. CONCLUSION: This prospective trial shows that family presence does not prolong time to CT imaging or to resuscitation completion for pediatric trauma patients. Family presence does not negatively affect the time efficiency of the pediatric trauma resuscitation.

Preventable harm occurring to critically ill children.

OBJECTIVE: To develop a trigger tool for identifying adverse events occurring in critically ill pediatric patients; to identify and characterize adverse events and preventable adverse events experienced by critically ill pediatric patients; and to characterize the patients who experience preventable adverse events. DESIGN: Retrospective chart review using a trigger tool. SETTING: Pediatric intensive care unit of a tertiary, university-affiliated pediatric hospital. PATIENTS: A systematic sample of 259 pediatric intensive care unit patients from a 1-yr period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured frequency of occurrence (0.19 preventable adverse events per patient-day), severity of harm (78% minor, 19% moderate, 3% serious, no deaths), and type of event (sedation, 22%; skin, 16%; medical device complication, 14%; pulmonary, 13%; and cardiovascular, 11%). Patients who experienced preventable adverse events were younger, had longer lengths of stay, and had higher illness burdens. Preventable adverse events occurred more frequently among surgical patients than medical patients. CONCLUSIONS: Preventable adverse events occurred fairly frequently in the pediatric intensive care unit, but serious harm was rare. Conditions that increased the likelihood of a preventable adverse event were a) need for sedation or pain control; b) relative immobility; and c) need for vascular devices, feeding tubes, or ventilators. Adverse event prevention strategies that focus on improving patient monitoring under increased-risk conditions and improving early detection and treatment of potential harm will likely be more effective than strategies aimed at general error prevention.

The safety culture in a children's hospital.

Efforts to improve patient safety require an understanding of organizational culture. In a survey of inpatient healthcare providers in a children's hospital, physician perceptions of teamwork were higher than those of all other staff (P < .001). Recognition of the impact of stress and fatigue was low, and job satisfaction was high for all groups. A majority of respondents did not feel rewarded for incident reporting. Information on hospital-level safety culture can lead to targeted system improvement.

Crossing county lines: the impact of crash location and driver's residence on motor vehicle crash fatality.

INTRODUCTION: Studies have demonstrated that the fatality risk for motor vehicle crashes (MVCs) is higher in rural than urban areas. The purpose of this study was to quantify the risk of a fatal outcome associated with a crash by the urban/rural classification of the driver's county of residence and the county of crash before and after adjusting for potentially confounding factors. METHODS: County of crash and driver's county of residence were classified as urban or rural for 514,648 Utah crash participants. Multivariate regression analysis was used to assess the impact of rural versus urban crash location on fatality outcomes for both urban and rural drivers. RESULTS: Before adjusting for confounding factors the relative risk of fatality in a rural versus urban crash was 9.7 (95% CI: 8.0-11.7) for urban drivers and their passengers compared to 1.8 (95% CI: 1.3-2.6) for rural residents. Adjustment for behavioral, road, and crash characteristics reduced risk estimates to 2.8 (95% CI: 2.2-3.5) and 1.2 (95% CI: 0.8-1.7), respectively. CONCLUSION: Urban and rural drivers may have distinct risk factors for MVC fatality in rural areas. Interventions to reduce the risk of fatality in rural areas should evaluate the needs of both urban and rural drivers.

Understanding and reducing stress and psychological distress in older women with heart disease.

Stress and psychological distress were assessed in 457 older women who were subsequently randomized to a six-week heart disease management program ("Women take PRIDE") or to a "usual care" control group. Baseline distress was significantly associated with age, symptoms, physical functioning, social support, optimism, and self-esteem (p < .05). Only 20% of women reported their physician had recommended reducing stress. At four months follow-up, intervention women compared to controls were significantly more likely to report reductions in stress levels (p = 0.02) and also showed improvement in emotional behavior (p = 0.09).