Clinical Issues in the Assessment of Competency.

The evaluation of a patient's competency to consent to treatment, regardless of the test of competency used, can be substantially affected by a number of clinical factors. The authors point out that, in assessing competency, the clinician must consider 1) psychodynamic elements of the patient's personality, 2) the accuracy of the historical information conveyed by the patient, 3) the accuracy and completeness of the information disclosed to the patient, 4) the stability of the patient's mental status over time, and 5) the effect of the setting in which consent is obtained. Inattention to these factors can lead to errors in assessment of competency that can have important implications for patient care. Reprinted from Am J Psychiatry 1981; 138:1462-1467, with permission from American Psychiatric Association Publishing. Copyright © 1981.

Prioritized Research for the Prevention, Treatment, and Reversal of Chronic Disease: Recommendations From the Lifestyle Medicine Research Summit.

Declining life expectancy and increasing all-cause mortality in the United States have been associated with unhealthy behaviors, socioecological factors, and preventable disease. A growing body of basic science, clinical research, and population health evidence points to the benefits of healthy behaviors, environments and policies to maintain health and prevent, treat, and reverse the root causes of common chronic diseases. Similarly, innovations in research methodologies, standards of evidence, emergence of unique study cohorts, and breakthroughs in data analytics and modeling create new possibilities for producing biomedical knowledge and clinical translation. To understand these advances and inform future directions research, The Lifestyle Medicine Research Summit was convened at the University of Pittsburgh on December 4-5, 2019. The Summit's goal was to review current status and define research priorities in the six core areas of lifestyle medicine: plant-predominant nutrition, physical activity, sleep, stress, addictive behaviors, and positive psychology/social connection. Forty invited subject matter experts (1) reviewed existing knowledge and gaps relating lifestyle behaviors to common chronic diseases, such as cardiovascular disease, diabetes, many cancers, inflammatory- and immune-related disorders and other conditions; and (2) discussed the potential for applying cutting-edge molecular, cellular, epigenetic and emerging science knowledge and computational methodologies, research designs, and study cohorts to accelerate clinical applications across all six domains of lifestyle medicine. Notably, federal health agencies, such as the Department of Defense and Veterans Administration have begun to adopt "whole-person health and performance" models that address these lifestyle and environmental root causes of chronic disease and associated morbidity, mortality, and cost. Recommendations strongly support leveraging emerging research methodologies, systems biology, and computational modeling in order to accelerate effective clinical and population solutions to improve health and reduce societal costs. New and alternative hierarchies of evidence are also be needed in order to assess the quality of evidence and develop evidence-based guidelines on lifestyle medicine. Children and underserved populations were identified as prioritized groups to study. The COVID-19 pandemic, which disproportionately impacts people with chronic diseases that are amenable to effective lifestyle medicine interventions, makes the Summit's findings and recommendations for future research particularly timely and relevant.

The Classification of Violence Risk.

(Reprinted with permission from Behav. Sci. Law 24: 721-730, 2006).

Building diversity in a complex academic health center.

For 30 years, the many diversity-related health sciences programs targeting the University of Pittsburgh undergraduate campus, school of medicine, schools of the health sciences, clinical practice plan, and medical center were run independently and remained separate within the academic health center (AHC). This lack of coordination hampered their overall effectiveness in promoting diversity and inclusion. In 2007, a group of faculty and administrators from the university and the medical center recognized the need to improve institutional diversity and to better address local health disparities. In this article, the authors describe the process of linking the efforts of these institutions in a way that would be successful locally and applicable to other academic environments. First, they engaged an independent consultant to conduct a study of the AHC's diversity climate, interviewing current and former faculty and trainees to define the problem and identify areas for improvement. Next, they created the Physician Inclusion Council to address the findings of this study and to coordinate future efforts with institutional leaders. Finally, they formed four working committees to address (1) communications and outreach, (2) cultural competency, (3) recruitment, and (4) mentoring and retention. These committees oversaw the strategic development and implementation of all diversity and inclusion efforts. Together these steps led to structural changes within the AHC and the improved allocation of resources that have positioned the University of Pittsburgh to achieve not only diversity but also inclusion and to continue to address the health disparities in the Pittsburgh community.

Reduction in the incidence of influenza A but not influenza B associated with use of hand sanitizer and cough hygiene in schools: a randomized controlled trial.

BACKGROUND: Laboratory-based evidence is lacking regarding the efficacy of nonpharmaceutical interventions (NPIs) such as alcohol-based hand sanitizer and respiratory hygiene to reduce the spread of influenza. METHODS: The Pittsburgh Influenza Prevention Project was a cluster-randomized trial conducted in 10 elementary schools in Pittsburgh, PA, during the 2007 to 2008 influenza season. Children in 5 intervention schools received training in hand and respiratory hygiene, and were provided and encouraged to use hand sanitizer regularly. Children in 5 schools acted as controls. Children with influenza-like illness were tested for influenza A and B by reverse-transcriptase polymerase chain reaction. RESULTS: A total of 3360 children participated in this study. Using reverse-transcriptase polymerase chain reaction, 54 cases of influenza A and 50 cases of influenza B were detected. We found no significant effect of the intervention on the primary study outcome of all laboratory-confirmed influenza cases (incidence rate ratio [IRR]: 0.81; 95% confidence interval [CI]: 0.54, 1.23). However, we did find statistically significant differences in protocol-specified ancillary outcomes. Children in intervention schools had significantly fewer laboratory-confirmed influenza A infections than children in control schools, with an adjusted IRR of 0.48 (95% CI: 0.26, 0.87). Total absent episodes were also significantly lower among the intervention group than among the control group; adjusted IRR 0.74 (95% CI: 0.56, 0.97). CONCLUSIONS: NPIs (respiratory hygiene education and the regular use of hand sanitizer) did not reduce total laboratory-confirmed influenza. However, the interventions did reduce school total absence episodes by 26% and laboratory-confirmed influenza A infections by 52%. Our results suggest that NPIs can be an important adjunct to influenza vaccination programs to reduce the number of influenza A infections among children.

PrepLink: a novel web-based tool for healthcare emergency planning and response.

Effective planning and response to bioterrorism or other disasters, natural or manmade, requires timely and effective communication as well as situational awareness. During a catastrophic event, decision makers--including first responders, hospital workers, and command center emergency workers--will have a short time to make crucial decisions. Preparing to receive and treat patients, especially when there are mass casualties, requires immediate access to large amounts of integrated health data from disparate sources. This article describes PrepLink, a novel comprehensive web-based healthcare-related all-hazards electronic disaster management system. Over the past 3 years, PrepLink has been developed and tested at the University of Pittsburgh Medical Center in partnership with the Pennsylvania National Guard. It can be deployed in multiple sites across a region or state or more broadly. The system includes pages for public awareness about planning for and responding to disasters, as well as secure, password-protected private pages that can be used by many types of emergency and healthcare personnel who are involved in such events. Timely information related to public health, safety, planning, preparation, and response can be accessed from both sets of pages. The system permits rapid communication and sharing of team plans across disparate locations; it stores multiple key documents and contains asset inventories, a GIS, patient tracking, and a command-and-control module. Each function is directly related to providing healthcare treatment for victims. PrepLink's comprehensive and user friendly approach to health-related disaster management holds promise for future progress in this challenging arena.

The relationship between the University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center--a profile in synergy.

In the synergistic evolution of their research, educational, and clinical programs, the University of Pittsburgh (Pitt) School of Medicine (SOM) and the University of Pittsburgh Medical Center (UPMC) have followed one core principle: What is good for one is good for both. The collaboration is underpinned by UPMC's commitment to its community mission, including support for the academic and research objectives of the SOM. UPMC's conceptual origin was fostered by its experience with Western Psychiatric Institute and Clinic in the 1970s. Over time, UPMC acquired other hospitals through merger and negotiation and, by 2008, had grown into a $7 billion global health enterprise. From the outset, the senior leaders of both UPMC and Pitt committed to collaborative decision making on all key issues. Under this coordinated decision-making model, UPMC oversees all clinical activity, including that from a consolidated physicians' practice plan. Pitt remains the guardian of all academic priorities, particularly faculty-based research. UPMC's steady financial success underpins the model. A series of interrelated agreements formally defines the relationship between Pitt and UPMC, including shared board seats and UPMC's committed ongoing financial support of the SOM. In addition, the two institutions have jointly made research growth a priority. The payoff from this dynamic has been a steadily growing Pitt research portfolio; enhanced growth, visibility, and stature for UPMC, the SOM, and Pitt as a whole; and the sustained success of UPMC's clinical enterprise, which now has an international scope. Given the current stagnation in the National Institutes of Health budget, the Pitt-UPMC experience may be instructive to other academic health centers.

The classification of violence risk.

The Classification of Violence Risk (COVR) is an interactive software program designed to estimate the risk that a person hospitalized for mental disorder will be violent to others. The software leads the evaluator through a chart review and a brief interview with the patient. At the end of this interview, the software generates a report that contains a statistically valid estimate of the patient's violence risk-ranging from a 1% to a 76% likelihood of violence-including the confidence interval for that estimate, and a list of the risk factors that the program took into account to produce the estimate. In this article, the development of the COVR software is described and several issues that arise in its administration are discussed.

An actuarial model of violence risk assessment for persons with mental disorders.

OBJECTIVES: An actuarial model was developed in the MacArthur Violence Risk Assessment Study to predict violence in the community among patients who have recently been discharged from psychiatric facilities. This model, called the multiple iterative classification tree (ICT) model, showed considerable accuracy in predicting violence in the construction sample. The purpose of the study reported here was to determine the validity of the multiple ICT model in distinguishing between patients with high and low risk of violence in the community when applied to a new sample of individuals. METHODS: Software incorporating the multiple ICT model was administered with independent samples of acutely hospitalized civil patients. Patients who were classified as having a high or a low risk of violence were followed in the community for 20 weeks after discharge. Violence included any battery with physical injury, use of a weapon, threats made with a weapon in hand, and sexual assault. RESULTS: Expected rates of violence in the low- and high-risk groups were 1 percent and 64 percent, respectively. Observed rates of violence in the low- and high-risk groups were 9 percent and 35 percent, respectively, when a strict definition of violence was used, and 9 percent and 49 percent, respectively, when a slightly more inclusive definition of violence was used. These findings may reflect the "shrinkage" expected in moving from construction to validation samples. CONCLUSIONS: The multiple ICT model may be helpful to clinicians who are faced with making decisions about discharge planning for acutely hospitalized civil patients.