Suicide Risk in Adolescents During the COVID-19 Pandemic

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic created high levels of psychological distress and may have increased suicide risk. METHODS: We used the 4-item Ask Suicide-Screening Questions (ASQ) to assess suicide risk among all patients 12 to 24 years of age at a children’s hospital. We compared demographics, encounter type (telehealth or face-to-face [F2F]), and screening results from April to June 2020 (T2) to those from April to June 2019 (T1). RESULTS: Fewer patients were seen at T2 than T1 (17 986 vs 24 863). A greater proportion of visits at T2 were by telehealth (0% vs 43%). The rate of positive suicide screens was higher in T2 than in T1 (12.2% vs 11.1%, adjusted odds ration [aOR], 1.24; 95% confidence interval [CI], 1.15–1.35). The odds of a positive screen were greater for older patients (aOR of 1.12 for age in years; 95% CI, 1.10–1.14), female patients (aOR, 2.23; 95% CI, 2.00–2.48), patients with public versus private insurance (aOR, 1.88; 95% CI, 1.72–2.07), and lower for Black versus White patients (aOR, 0.85; 95% CI, 0.77–0.95). Rates of positive screens were highest among inpatients (20.0%), intermediate for emergency department patients (14.4%), and lowest in outpatient clinics (9.9%) (P < .05). CONCLUSIONS: Rates of positive suicide risk screens among adolescents rose in the pandemic’s early months with differences related to sociodemographics and visit type. Changes in health care delivery highlight the complexities of assessing and responding to mental health needs of adolescents. Additional research might determine the effects of screening methods and patient populations on screening results.

Child Abuse Screening in the Emergency Department Before and After Implementation of a Formal Screening Tool

Background: Child abuse and neglect is a leading cause of mortality and morbidity in children. Victims of abuse often present to emergency departments due to these injuries. Early identification of suspected child abuse by emergency department staff allows the opportunity for intervention prior to a devastating injury. Signs of child abuse can be subtle and may not always be identified. Recent efforts have worked to improve suspected child abuse identification by implementation of validated screening protocols. Specifically, the IU Health Riley Emergency Department has recently implemented a new child abuse screening tool (effective on 15Apr2021). The Covid-19 pandemic has further exacerbated this issue, creating social isolation and additional socioeconomic stressors that contribute to child abuse. Method: A retrospective chart review was conducted to analyze patients identified for child abuse evaluation in the Riley emergency department. Patients prior to the implementation of the screening tool were identified by those undergoing a social work evaluation for child abuse. For patients presenting after implementation of the screening tool, all patients with a positive screen were reviewed. Charts were then reviewed for baseline demographics, diagnostic testing performed, and injuries identified. All data was recorded in an electronic Redcap database. Results: Implementation of a formal screening tool increased the number of patients identified for a child abuse evaluation (1.34% vs 3.17%) and those evaluated who had an injury also increased (1.15% vs 1.81%). More patients received a head CT scan after implementation of the screening tool (0.89% vs 1.07%), while the percentage of patients with an abnormal head CT decreased (62% vs 45%). Conclusions: Implementation of a formal screening tool for child abuse in the emergency department successfully improved identification of patients that should be further evaluated for child abuse. These results may be used to support implementation of the tool in additional emergency departments.

Quality Improvement Approach to Increase Inpatient Pediatric Secondhand Smoke Exposure Screening

BACKGROUND: Secondhand smoke exposure (SHSe) is highly prevalent among children and has numerous adverse health effects. Consistent screening for SHSe is an essential first step to helping families break the toxic cycle of smoking. METHODS: With this quality improvement project, we evaluated a SHSe screening and cessation resource distribution protocol in a general pediatrics inpatient unit of a safety-net hospital. Our primary outcome measure was the percent of admissions screened for SHSe, with a goal of increasing our documented rate of SHSe screening from 0% to 70% within 6 months of implementation. Our secondary outcome measure was the percent of those who screened positive for SHSe who were offered smoking cessation resources. Process measures included tracking nurse confidence in screening and compliance with new workflow training. Balancing measures were nurse satisfaction and brevity of screening. RESULTS: From May 1, 2019, to April 30, 2020, nurses screened 97.2% of the 394 patients admitted to the pediatric unit for SHSe. Of the patients screened, 15.7% were exposed to cigarettes or other tobacco products, 5.6% to e-cigarettes, and 6.5% to marijuana. Nurses documented offering “Quit Kits” with cessation materials to 45 caregivers (72.6% of positive screen results) and offering 33 referrals to the California Smokers' Helpline (53.2% of positive screen results). CONCLUSION: In this project, we successfully implemented a screening protocol for SHSe to tobacco, e-cigarettes, and marijuana and a workflow for cessation resource distribution in an inpatient pediatric setting that far exceeded goals. Requiring minimal maintenance and using just a simple paper-based format, the workflow could be adopted at other institutions.

A Web-Based Self-Management Intervention for Veterans With Chronic Conditions and Their Caregivers: A Pilot Study

Web-based Self-management Using Collaborative Coping Enhancement in Diseases (Web-SUCCEED) is a dyadic intervention for patients and their caregivers designed to improve self-management through improving dyadic stress coping, dyadic relationships, and positive emotions. Veterans Affairs (VA) patients with one or more chronic conditions and positive screen for self-management distress were recruited with their informal caregiver from VA Palo Alto. Of the 17 patients and 16 caregivers recruited (62.3% of eligible), 8 patients and 8 caregivers (48.5%) completed the intervention and assessments. Twelve participants withdrew mostly citing the stress of the pandemic as their reason; 5 did not respond to multiple outreach efforts. Veterans were 66□18 y and caregivers were 58□16 y. Veterans and caregivers who completed the program rated it high on usability and acceptability. Pre-post t-tests across a psychosocial battery did not reveal significant differences; results were limited by incomplete post-intervention data. Further testing with modified retention strategies is recommended.

Greater Adolescent Cognitive Ability Is Linked to Lower Risk of Cognitive Impairment in Later Life

There have been few investigations of the role that adolescent cognitive ability plays in predicting later-life cognitive impairment, and the mechanisms, such greater life course educational exposure, that might underlie these connections. This knowledge gap is due, in part, to a lack of cohorts with early-life cognitive assessment who are followed to later adulthood. We capitalized on data from the 1960 Project Talent (PT) high school cohort (n>360,000) and two recent follow-ups, the Project Talent Twin & Sibling (PTTS; n=2,491 in 2014) Study and the Project Talent Aging Study (PTAS; n=6,421 in 2018), to examine these potential links. In 1960, ability was assessed in multiple cognitive domains (e.g., general aptitude, quantitative, reasoning). Participants/proxies reporting 2 or more symptoms of cognitive impairment in 2018 on the AD8 Dementia Screener were classified as having a positive screen. Binary logistic generalized estimating equations with race, sex, and adolescent family SES covariates, indicated that in multiple cognitive domains, higher ability in adolescence predicted lower odds of a positive AD8 screen in later life (ORs of 0.80 - 0.85). The effects were only slightly attenuated with inclusion of life course educational attainment. Sibling models found a similar pattern of associations and effect sizes, indicating that the association is not attributable to shared family and genetic background. These findings indicate that higher cognitive ability as indicated by better performance in multiple cognitive domains in adolescence may be protective against cognitive impairment five decades later and life course educational attainment only partially mediates this association.

The Association Between Immediate Postpartum Depot Medroxyprogesterone Acetate Use and Postpartum Depressive Symptoms

Objective While postpartum depot medroxyprogesterone acetate (DMPA) is a highly effective form of contraception, some data suggest an association with depressive symptoms. Our objective was to evaluate the relationship between receipt of DMPA in the immediate postpartum period and postpartum depressive symptoms. Methods This retrospective cohort study included all women who received prenatal and postpartum care at academic obstetric clinics affiliated with a tertiary care institution between January 1, 2008 and December 31, 2014. All women were counseled on contraception prior to hospital discharge. DMPA was available in the hospital pharmacy, and its utilization was documented in the electronic health record. The Patient Health Questionnaire 9 (PHQ-9) was used to screen for postpartum depression for all women at all postpartum visits. A score of 10 or greater was categorized as positive. Bivariable and multivariable analyses were used to identify the association between immediate postpartum DMPA use and a positive postpartum depression screen. Results Of the 5,073 women who met inclusion criteria, 410 (8.1%) received DMPA prior to hospital discharge. Compared with women who did not receive DMPA, women who received DMPA prior to hospital discharge were younger, more likely to identify as Black race or Latinx ethnicity, and more likely to be publicly insured. Clinical characteristics also differed. Women who received DMPA were more likely to be obese and to have experienced prenatal depressive symptoms, been diagnosed with a hypertensive disorder of pregnancy, delivered preterm, and delivered vaginally. Receipt of immediate postpartum DMPA was not associated with having a positive screen for postpartum depression in bivariable (5.4 vs. 6.0%, p = 0.29) or multivariable (adjusted odds ratio 0.94, confidence interval 0.53–1.68) analyses. Conclusion Receipt of postpartum DMPA is not associated with a positive postpartum PHQ-9 screen. Concerns about precipitating postpartum depression should not preclude the utilization of DMPA as a contraceptive agent. Key Points

A Dispatch Screening Tool to Identify Patients at High Risk for COVID-19 in the Prehospital Setting

Introduction: Emergency medical services (EMS) dispatchers have made efforts to determine whether patients are high risk for coronavirus disease 2019 (COVID-19) so that appropriate personal protective equipment (PPE) can be donned. A screening tool is valuable as the healthcare community balances protection of medical personnel and conservation of PPE. There is little existing literature on the efficacy of prehospital COVID-19 screening tools. The objective of this study was to determine the positive and negative predictive value of an emergency infectious disease surveillance tool for detecting COVID-19 patients and the impact of positive screening on PPE usage. Methods: This study was a retrospective chart review of prehospital care reports and hospital electronic health records. We abstracted records for all 911 calls to an urban EMS from March 1–July 31, 2020 that had a documented positive screen for COVID-19 and/or had a positive COVID-19 test. The dispatch screen solicited information regarding travel, sick contacts, and high-risk symptoms. We reviewed charts to determine dispatch-screening results, the outcome of patients’ COVID-19 testing, and documentation of crew fidelity to PPE guidelines. Results: The sample size was 263. The rate of positive COVID-19 tests for all-comers in the state of Massachusetts was 2.0%. The dispatch screen had a sensitivity of 74.9% (confidence interval [CI], 69.21-80.03) and a specificity of 67.7% (CI, 66.91-68.50). The positive predictive value was 4.5% (CI, 4.17-4.80), and the negative predictive value was 99.3% (CI, 99.09-99.40). The most common symptom that triggered a positive screen was shortness of breath (51.5% of calls). The most common high-risk population identified was skilled nursing facility patients (19.5%), but most positive tests did not belong to a high-risk population (58.1%). The EMS personnel were documented as wearing full PPE for the patient in 55.7% of encounters, not wearing PPE in 8.0% of encounters, and not documented in 27.9% of encounters. Conclusion: This dispatch-screening questionnaire has a high negative predictive value but moderate sensitivity and therefore should be used with some caution to guide EMS crews in their PPE usage. Clinical judgment is still essential and may supersede screening status.

A Positive Depression Screen Is Associated with Emergency Medicine Resident Burnout and Is not Affected by the Implementation of a Wellness Curriculum

Introduction: While burnout is occupation-specific, depression affects individuals comprehensively. Research on interventions for depression in emergency medicine (EM) residents is limited. Objectives: We sought to obtain longitudinal data on positive depression screens in EM residents, assess their association with burnout, and determine whether implementation of a wellness curriculum affected the rate of positive screens. Methods: In February 2017, we administered the Maslach Burnout Inventory and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire two-question depression screen at 10 EM residencies. At five intervention sites, a year-long wellness curriculum was then introduced while five control sites agreed not to introduce new wellness initiatives during the study period. Study instruments were re-administered in August 2017 and February 2018. Results: Of 382 residents, 285 participated in February 2017; 40% screened positive for depression. In August 2017, 247/386 residents participated; 27.9% screened positive for depression. In February 2018, 228/386 residents participated; 36.2% screened positive. A positive depression screen was associated with higher burnout. There were similar rates of positive screens at the intervention and control sites. Conclusion: Rates of positive depression screens in EM residents ranged between 27.9% and 40%. Residents with a positive screen reported higher levels of burnout. Rates of a positive screen were unaffected by introduction of a wellness curriculum.

Mental Health History and DECIDE (Decision-Making Education for Choices in Diabetes Everyday) Diabetes Support Program Outcomes Among African Americans With Type 2 Diabetes

Purpose The purpose of this study was to determine behavioral and clinical outcomes of the DECIDE (Decision-Making Education for Choices in Diabetes Everyday) diabetes support program trial participants with and without a mental health (MH) history by treatment arm. Methods A secondary analysis was conducted of data from the DECIDE trial sample of urban African American adults with type 2 diabetes (T2DM; N = 137) who received the DECIDE diabetes support program in 1 of 3 delivery formats: self-study (n = 46), individual (n = 45), and group (n = 46). Positive screen on the Patient Health Questionnaire-2 and/or reported MH diagnosis were coded as MH history. Self-management, knowledge, problem-solving, and A1C data at baseline and 1 week and 6 months postintervention were analyzed for participants with and without MH history. Results Prevalence of MH history was 37% in the sample. Among those with no MH history, knowledge and problem-solving improved at 6 months postintervention in all intervention arms. For those with MH history, knowledge and problem-solving improved in the self-study and individual arms but not in the group arm. Clinically but not statistically significant changes in A1C were observed at 6 months. Conclusions In an urban minority T2DM sample, those with an MH history benefited from the intervention, but delivery format mattered, with robust improvements when participants with an MH history received self-directed or one-on-one formats rather than group.

Women’s acceptability of and experience with primary human papillomavirus testing for cervix screening: HPV FOCAL trial cross-sectional online survey results

ObjectiveTo study participant’s acceptability of and attitudes towards human papillomavirus (HPV) testing compared with cytology for cervical cancer screening and what impact having an HPV positive result may have in future acceptability of screening.DesignCross-sectional online survey of clinical trial participants.SettingPrimary care, population-based Cervix Screening Program, British Columbia, Canada.ParticipantsA total of 5532 participants from the HPV FOCAL trial, in which women received HPV and cytology testing at study exit, were included in the analysis. Median age was 54 years. The median time of survey completion was 3 years after trial exit.Outcome measuresAcceptability of HPV testing for primary cervical cancer screening (primary); attitudes and patient perceptions towards HPV testing and receipt of HPV positive screen results (secondary).ResultsMost respondents (63%) were accepting of HPV testing, with the majority (69%) accepting screening to begin at age 30 years with HPV testing. Only half of participants (54%) were accepting of an extended screening interval of 4–5 years. In multivariable logistic regression, women who received an HPV positive screen test result during the trial (OR=1.41 95% CI 1.11 to 1.80) or were older (OR=1.01, 95% CI 1.00 to 1.02) were more likely to report HPV testing as acceptable.ConclusionsIn this evaluation of acceptability and attitudes regarding HPV testing for cervix screening, most are accepting of HPV testing for screening; however, findings indicate heterogeneity in concerns and experiences surrounding HPV testing and receipt of HPV positive results. These findings provide insights for the development of education, information and communication strategies during implementation of HPV-based cervical cancer screening.Trial registration numbersISRCTN79347302 and NCT00461760.