Complex Population Research Articles

Solid Organ Transplantation for Children With Neurodevelopmental Disabilities—Ethical Considerations and a Call for Clarity

Pediatric transplant centers are faced with the difficult task of maximizing the benefit of organs donated for transplantation while also ensuring that all patients undergoing transplant evaluation are fairly considered for this life-saving therapy. Children with neurodevelopmental disabilities are a complex patient population that on occasion may face the need for a solid organ transplant. Several concerns exist regarding transplantation in this population, yet standard transplant inclusion and exclusion criteria do not exist. Here we explore important factors regarding organ transplantation for children with neurodevelopmental disorders, including patient outcomes, quality of life considerations, and the fundamental ethical principles underlying this complex medical decision-making.

PD29-02 BENCHMARKING BLADDER CANCER CARE: A REAL-LIFE POPULATION-BASED STUDY

You have accessJournal of UrologyCME1 Apr 2023PD29-02 BENCHMARKING BLADDER CANCER CARE: A REAL-LIFE POPULATION-BASED STUDY Nicolas Vanin-Moreno, Marlo Whitehead, and Robert Siemens Nicolas Vanin-MorenoNicolas Vanin-Moreno More articles by this author , Marlo WhiteheadMarlo Whitehead More articles by this author , and Robert SiemensRobert Siemens More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003315.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) is a complex oncological surgical procedure and population studies of routine surgical care have suggested suboptimal results compared to high-volume centers of excellence. A previous Canadian bladder cancer quality-of-care consensus led to adoption of multiple key quality-of-care indicators with associated benchmarks created utilizing available evidence and expert opinion to inform and measure future performance. Herein we report real-life benchmark performance for the management of muscle invasive bladder cancer (MIBC) relative to expert opinion guidance. METHODS: This is a population-based, retrospective, cohort study that used the Ontario Cancer Registry (OCR) to identify all incident patients who underwent RC from 2009 and 2013. Electronic records of treatment from 1,573 patients were linked to OCR; pathology records were obtained for all cases and reviewed by a team of trained data abstractors. The primary objective was to describe benchmarks for identified indicators first as median values obtained across hospitals or providers as well as a “pared-mean” approach to identify a benchmark population of "top performance" as defined as the best outcome accomplished for at least 10 percent of the population. RESULTS: Overall, performance in Ontario across all indicators fell short of expert-opinion determined benchmarks. Annual surgical volume by each surgeon performing a RC (benchmark>6, percent of institutions meeting benchmark =20%), percent of patients with MIBC referred pre-operatively to Medical Oncology (MO; benchmark >90%, percent of institutions meeting benchmark =2%) and Radiation Oncology (RO; benchmark >50%, percent of institutions meeting benchmark =0%), time to cystectomy within 6 weeks of TURBT in patients without neoadjuvant chemotherapy (benchmark <6 weeks, percent of institutions meeting benchmark =0%), percent of patients with adequate lymph node dissection (defined as >14 nodes, benchmark >85%, percent of institutions meeting benchmark =0%), percent of patients with positive margins post RC (benchmark <10%, percent of institutions meeting benchmark =46%), and 90 day mortality (benchmark <5%, percent of institutions meeting benchmark =37%) fell considerably short. Simply evaluating benchmarks across the province as median performance significantly under-estimated benchmarks that were possible by top-performing hospitals. CONCLUSIONS: Performance through the majority of BC quality of care indicators fall short of benchmarks proposed by expert-opinion. Different methodologies such as a pared-mean approach of top performers may provide more realistic benchmarking. Source of Funding: This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Parts of this material are based on data and information compiled and provided by CIHI. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e824 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicolas Vanin-Moreno More articles by this author Marlo Whitehead More articles by this author Robert Siemens More articles by this author Expand All Advertisement PDF downloadLoading ...

The Rib Fracture Map in Patients with High-Energy Mechanisms of Injury.

The objective of this study was to use a novel rib unfurling technology to investigate the locations of multiple rib fractures occurring from high-energy trauma to discern if there are reproducible rib fracture patterns. Patients between the ages of 18 and 48 presenting to a Level 1 academic trauma center with ≥ 2 rib fractures following a high-energy mechanism of injury between 2017 and 2019 were identified. Curved planar reformatting of CT scans was used to create two-dimensional unfurled rib images by flattening out the view of the ribs from a CT scan. Rib fractures were placed on a template map using a standardized measurement method and subsequent frequency and heat maps were created. Among 100 consecutive patients, 534 fractures on 454 ribs were identified. The most common high-energy mechanism of injury was motor vehicle accidents (41%). Flail chest occurred in 8% of patients. The mean number of ribs fractured per patient was 4.54 ± 3.14 and included a mean of 5.34 ± 4.38 total fractures. Among all fractures, 50.9% were located on ribs 4 through 7. The most common fracture location was located in the lateral or anterolateral zone of the ribcage. Patients with multiple rib fractures from high-energy trauma have rib fractures with locations of common occurrence. An understanding of location and frequency of rib fractures can help inform surgical approaches, prognosis, indications, classifications, and implant design in the management of a complex population of patients with chest wall injury following trauma. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Utilization of Stellate Ganglion Block in the Treatment of Long-COVID: A Case Series

BACKGROUND: With the recent COVID-19 pandemic, chronic pain physicians undoubtedly face the challenge of treating long-COVID within the already complex chronic pain patient population. Sympathetic blockade of the stellate ganglion has historically been utilized as a diagnostic and therapeutic tool in confirming and targeting the sympathetically mediated component of many chronic pain conditions, but its role in treating long-COVID symptoms has yet to be thoroughly studied or elucidated. CASE SERIES: We present a unique case series where the utilization of stellate ganglion blockade in one case and use of stellate ganglion blockade followed by rhizotomy in another were successful in sustained and near-complete relief of all initial long-COVID symptoms during a 3-month follow-up period. CONCLUSIONS: Our case series presents promising results on the role of stellate ganglion blockade in the sustained and near-complete relief of multiple long-COVID symptoms during the longest known follow-up period to date. KEY WORDS: COVID-19, dysautonomia, long-COVID, rhizotomy, stellate ganglion block

Life-cycle analysis of an endangered migratory goose to assess the impact of conservation actions on population recovery

Evaluating the effectiveness of conservation actions is challenging for migratory species because a population can be impacted anywhere along its route. Conservation actions for the critically endangered Fennoscandian lesser white-fronted goose population include culling of red foxes in the breeding area and habitat improvements and reduction of illegal hunting in the non-breeding areas. One goal of the predator control strategy is to prevent adult birds from using an autumn migration route through western Asia, where mortality is believed to be higher than on the migration route through eastern Europe. We used 23 years of count data obtained at different staging areas to parameterize a seasonal state-space model describing the full-annual cycle dynamics of this population and evaluate whether the recent population recovery was linked to these conservation efforts. The results did not provide evidence that predator control influenced population recovery, as survival on the European route did not appear higher than on the allegedly riskier Asian route. However, adult survival at staging areas on both routes and at wintering sites may have improved in the last decade, suggesting a positive effect of the other conservation initiatives. These results emphasize the importance of including the non-breeding dynamics in population assessments of migratory species and highlight the challenge of evaluating the efficacy of separate conservation actions when a proper experimental design is unfeasible. Our study, which is a unique case of cross-national, coordinated conservation efforts, exemplifies how to model complex population dynamics to assess the influence of costly conservation initiatives.

Lost in transition? Community residential facility staff and stakeholder perspectives on previously incarcerated older adults’ transitions into long-term care

BackgroundEstablishing an effective continuum of care is a pivotal part of providing support for older populations. In contemporary practice; however, a subset of older adults experience delayed entry and/or are denied access to appropriate care. While previously incarcerated older adults often face barriers to accessing health care services to support community reintegration, there has been limited research on their transitions into long-term care. Exploring these transitions, we aim to highlight the challenges of securing long-term care services for previously incarcerated older adults and shed light on the contextual landscape that reinforces the inequitable care of marginalized older populations across the care continuum.MethodsWe performed a case study of a Community Residential Facility (CRF) for previously incarcerated older adults which leverages best practices in transitional care interventions. Semi-structured interviews were conducted with CRF staff and community stakeholders to determine the challenges and barriers of this population when reintegrating back into the community. A secondary thematic analysis was conducted to specifically examine the challenges of accessing long-term care. A code manual representing the project themes (e.g., access to care, long-term care, inequitable experiences) was tested and revised, following an iterative collaborative qualitative analysis (ICQA) process.ResultsThe findings indicate that previously incarcerated older adults experience delayed access and/or are denied entry into long-term care due to stigma and a culture of risk that overshadow the admissions process. These circumstances combined with few available long-term care options and the prominence of complex populations already in long-term care contribute to the inequitable access barriers of previously incarcerated older adults seeking entry into long-term care.ConclusionsWe emphasize the many strengths of utilizing transitional care interventions to support previously incarcerated older adults as they transition into long-term care including: 1) education & training, 2) advocacy, and 3) a shared responsibility of care. On the other hand, we underscore that more work is needed to redress the layered bureaucracy of long-term care admissions processes, the lack of long-term care options and the barriers imposed by restrictive long-term care eligibility criteria that sustain the inequitable care of marginalized older populations.

Population of the Bratsk-Ust-Ilimsk Complex: The Making and Current Demographic Situation

The article deals with the historical and current problems of the population of the Bratsk-Ust-­Ilimsk territorial production complex, located in the Middle Angara region of the Irkutsk region. The main stages of the settlement of the territory associated with the economic development of the region are singled out. The author notes the special role of the state in attracting and resettling the population, providing financial, material and other assistance to migrants. The author focuses on the formation of the population of the Bratsk-Ust-­Ilim complex in the Soviet period, reveals the relationship between the processes of industrial development of the region and demographic processes. This is confirmed by the dynamics of the population, which is closely related to the main stages in the formation of the territorial production complex. The article examines the features of the natural and mechanical movement of the population, their share in the dynamics of the population, the impact of the industrial complex on the urban development of the region, which led to a sharp reduction in the rural population. The article analyzes the current demographic situation, characterized by a large migration outflow and natural population decline, which ultimately affected the progressive decline in the total population of the territorial production complex.

Comparative effectiveness of evidence-based psychotherapies for PTSD delivered in VA residential PTSD treatment.

Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are first-line treatments for posttraumatic stress disorder (PTSD). There have been few direct comparisons of CPT and PE intended to determine their comparative effectiveness, none of which have examined outcomes among military veterans receiving these treatments in a residential setting such as the Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs). Such work is essential given that these veterans are among the most complex and severely symptomatic patients with PTSD treated in VA. In this study we compared changes in PTSD and depressive symptoms across admission, discharge, four months and 12 months following discharge among veterans who received CPT or PE within VA RRTPs. Using linear mixed models conducted on program evaluation data derived from the electronic medical record and follow-up surveys, we compared self-reported PTSD and depressive symptom outcomes among 1130 veterans with PTSD who were treated with individual CPT (n = 832, 73.5%) or PE (n = 297, 26.5%) in VA PTSD RRTPs in fiscal years 2018-2020. PTSD and depressive symptom severity did not significantly differ at any time points. The CPT and PE groups both showed large-sized reductions in PTSD (CPT d = 1.41, PE d = 1.51) and depression (CPT d = 1.01, PE d = 1.09) from baseline to 12-month follow-up. Outcomes for PE and CPT do not differ among a highly complex population of veterans with severe PTSD and several comorbid conditions that can make it difficult to engage in treatment.

Prevalence, Trends, and Factors Associated with Teen Motherhood in Nigeria: An Analysis of the 2008–2018 Nigeria Demographic and Health Surveys

Background: Teen pregnancy and childbearing are common in Nigeria, and understanding the complexities, such as sociodemographics and economic factors including sexual and reproductive health knowledge and awareness among adolescents over time can trigger innovative approaches and interventions. This study intends to capture the patterns and associated factors of teen motherhood among sexually active adolescents (15–19 years) between 2008 and 2018. Methods: The study data was extracted from 2008, 2013, and 2018 Nigeria Demographic and Health Surveys. Descriptive analysis was presented using frequencies and percentages; multivariable analysis was conducted using log-binomial logistic regression at a p-value <0.05. All analyses were performed using Stata 15.0, weighted and adjusted for the complex survey design and population size. Results: The prevalence of teen motherhood increased between the three successive survey waves (50.9% vs. 52.4% vs. 55.2%) from 2008, 2013, and 2018. Although, the pooled adjusted analysis revealed no significant change over the 10-year period. Knowledge of modern contraceptive methods, primary education, non-Catholic Christians, residing in the South-South region, and those currently or formerly married were associated with increased risk of teen motherhood. There was an inverse relationship between teen motherhood and wealth status; lower wealth status was associated with high adolescent pregnancy and childbearing. Conclusion: This study revealed an increase in the proportion of teen pregnancy and childbearing in Nigeria. Notably, there exist variations across age groups, geographic location, educational level, religious belief, marital and economic status. Interventions that ensure comprehensive sexuality education, girl child education, and economic empowerment especially for school dropouts are advocated to reduce teen motherhood.

Evolutionary game theory and the adaptive dynamics approach: adaptation where individuals interact.

Evolutionary game theory and the adaptive dynamics approach have made invaluable contributions to understanding how gradual evolution leads to adaptation when individuals interact. Here, we review some of the basic tools that have come out of these contributions to model the evolution of quantitative traits in complex populations. We collect together mathematical expressions that describe directional and disruptive selection in class- and group-structured populations in terms of individual fitness, with the aims of bridging different models and interpreting selection. In particular, our review of disruptive selection suggests there are two main paths that can lead to diversity: (i) when individual fitness increases more than linearly with trait expression; (ii) when trait expression simultaneously increases the probability that an individual is in a certain context (e.g. a given age, sex, habitat, size or social environment) and fitness in that context. We provide various examples of these and more broadly argue that population structure lays the ground for the emergence of polymorphism with unique characteristics. Beyond this, we hope that the descriptions of selection we present here help see the tight links among fundamental branches of evolutionary biology, from life history to social evolution through evolutionary ecology, and thus favour further their integration. This article is part of the theme issue 'Half a century of evolutionary games: a synthesis of theory, application and future directions'.

How Do Diet Patterns, Single Foods, Prebiotics and Probiotics Impact Gut Microbiota?

The human gastrointestinal tract hosts a complex and dynamic population of commensal bacterial species, which have coevolved with the host, generating a symbiotic relationship. Some compounds present in foods, such as polyols, prebiotic fibers, or phenolic compounds, are poorly metabolized and absorbed by the host before the transformation guided by the colonic microbiota. By influencing gut microbiota, diet plays a fundamental role in understanding the beneficial effects of the gut microbiota on the host, including its long-term metabolism. The idea that probiotics can act not only by influencing the colonizing microbiota opens the door to a wider range of probiotic possibilities, encouraging innovation in the field. Furthermore, it has been shown both that some probiotics increase phagocytosis or the activity of natural killer cells. Current prebiotics are mainly based on carbohydrates, but other substances, such as polyphenols and polyunsaturated fatty acids, could exert prebiotic effects. A prebiotic substance has been defined as ‘a substrate that is selectively used by host microorganisms that confer a health benefit’, and so can interact with the gut microbiota through competition for nutrients, antagonism, cross-feeding, and support for microbiota stability. Influencing its composition in terms of richness and diversity, food components have a key impact on the intestinal microbiota. Eating habits can strongly influence the composition of the intestinal microbiota. A healthy intestinal microbiota is essential for maintaining general health, and diet is one of the major modulators of this fascinating world of microorganisms. This must give us one more reason to adopt a healthy lifestyle.

Telehealth as a Tool to Improve Access and Reduce No-Show Rates in a Large Safety-Net Population in the USA.

Low-income populations are at higher risk of missing appointments, resulting in fragmented care and worsening disparities. Compared to face-to-face encounters, telehealth visits are more convenient and could improve access for low-income populations. All outpatient encounters at the Parkland Health between March 2020 and June 2022 were included. No-show rates were compared across encounter types (face-to-face vs telehealth). Generalized estimating equations were used to evaluate the association of encounter type and no-show encounters, clustering by individual patient and adjusting for demographics, comorbidities, and social vulnerability. Interaction analyses were performed. There were 355,976 unique patients with 2,639,284 scheduled outpatient encounters included in this dataset. 59.9% of patients were of Hispanic ethnicity, while 27.0% were of Black race. In a fully adjusted model, telehealth visits were associated with a 29% reduction in odds of no-show (aOR 0.71, 95% CI: 0.70-0.72). Telehealth visits were associated with significantly greater reductions in probability of no-show among patients of Black race and among those who resided in the most socially vulnerable areas. Telehealth encounters were more effective in reducing no-shows in primary care and internal medicine subspecialties than surgical specialties or other non-surgical specialties. These data suggest that telehealth may serve as a tool to improve access to care in socially complex patient populations.

Social copying drives a tipping point for nonlinear population collapse

Sudden changes in populations are ubiquitous in ecological systems, especially under perturbations. The agents of global change may increase the frequency and severity of anthropogenic perturbations, but complex populations' responses hamper our understanding of their dynamics and resilience. Furthermore, the long-term environmental and demographic data required to study those sudden changes are rare. Fitting dynamical models with an artificial intelligence algorithm to population fluctuations over 40 y in a social bird reveals that feedback in dispersal after a cumulative perturbation drives a population collapse. The collapse is well described by a nonlinear function mimicking social copying, whereby dispersal made by a few individuals induces others to leave the patch in a behavioral cascade for decision-making to disperse. Once a threshold for deterioration of the quality of the patch is crossed, there is a tipping point for a social response of runaway dispersal corresponding to social copying feedback. Finally, dispersal decreases at low population densities, which is likely due to the unwillingness of the more philopatric individuals to disperse. In providing the evidence of copying for the emergence of feedback in dispersal in a social organism, our results suggest a broader impact of self-organized collective dispersal in complex population dynamics. This has implications for the theoretical study of population and metapopulation nonlinear dynamics, including population extinction, and managing of endangered and harvested populations of social animals subjected to behavioral feedback loops.

Characterization of 25 new microsatellite markers for the green turtle (Chelonia mydas) and cross-species amplification in other marine turtle species

The green sea turtle, Chelonia mydas, is a migratory species with a strong natal homing behavior leading to a complex population structure worldwide. The species has suffered severe declines in local populations; it is therefore crucial to understand its population dynamics and genetic structure to adopt appropriate management policies. Here, we describe the development of 25 new microsatellite markers specific to C. mydas and suitable for these analyses. They were tested on 107 specimens from French Polynesia. An average allelic diversity of 8 alleles per locus was reported and observed heterozygosity ranged from 0.187 to 0.860. Ten loci were significantly deviant from the Hardy-Weinberg equilibrium, and 16 loci showed a moderate to high level of linkage disequilibrium (4-22%). The overall Fis was positive (0.034, p-value < 0.001), and sibship analysis revealed 12 half- or full-sibling dyads, suggesting possible inbreeding in this population. Cross-amplification tests were performed on two other marine turtle species, Caretta caretta and Eretmochelys imbricata. All loci successfully amplified on these two species, though 1 to 5 loci were monomorphic. These new markers will not only be relevant for further analyses on the population structure of the green turtle and the two other species, but they will also be invaluable for parentage studies, for which a high number of polymorphic loci are necessary. This can provide important insight into male reproductive behavior and migration, an aspect of sea turtle biology that is of critical importance for the conservation of the species.

Disparate population and holobiont structure of pocilloporid corals across the Red Sea gradient demonstrate species-specific evolutionary trajectories.

Global habitat degradation heightens the need to better understand patterns of genetic connectivity and diversity of marine biota across geographical ranges to guide conservation efforts. Corals across the Red Sea are subject to pronounced environmental differences, but studies so far suggest that animal populations are largely connected, excepting evidence for a genetic break between the northern-central and southern regions. Here, we investigated population structure and holobiont assemblage of two common pocilloporid corals, Pocillopora verrucosa and Stylophora pistillata, across the Red Sea. We found little evidence for population differentiation in P. verrucosa, except for the southernmost site. Conversely, S. pistillata exhibited a complex population structure with evidence for within-reef and regional genetic differentiation, in line with differences in their reproductive mode (P. verrucosa is a broadcast spawner and S. pistillata is a brooder). Analysis for genomic loci under positive selection identified 85 sites (18 of which were in coding sequences) that distinguished the southern P. verrucosa population from the remainder of the Red Sea population. By comparison, we found 128 loci (24 of which were residing in coding sequences) in S. pistillata with evidence for local adaptation at various sites. Functional annotation of the underlying proteins revealed putative roles in the response to stress, lipid metabolism, transport, cytoskeletal rearrangement, and ciliary function (among others). Microbial assemblages of both coral species showed pervasive association with microalgal symbionts from the genus Symbiodinium (former clade A) and bacteria from the genus Endozoicomonas that exhibited significant differences according to host genotype and environment. The disparity of population genetic and holobiont assemblage patterns even between closely related species (family Pocilloporidae) highlights the need for multispecies investigations to better understand the role of the environment in shaping evolutionary trajectories. It further emphasizes the importance of networks of reef reserves to achieve conservation of genetic variants critical to the future survival of coral ecosystems.

The Influence of Extracorporeal Membrane Oxygenation on Antibiotic Pharmacokinetics.

Extracorporeal membrane oxygenation (ECMO) is becoming increasingly utilized to support critically ill patients who experience life-threatening cardiac or pulmonary compromise. The provision of this intervention poses challenges related to its complications and the optimization of medication therapy. ECMO's mechanical circulatory support is facilitated via various devices and equipment that have been shown to sequester lipophilic- and protein-bound medications, including anti-infectives. Since infectious outcomes are dependent on achieving specific anti-infectives' pharmacodynamic targets, the understanding of these medications' pharmacokinetic parameters in the setting of ECMO is important to clinicians. This narrative, non-systematic review evaluated the findings of the most recent and robust pharmacokinetic analyses for commonly utilized anti-infectives in the setting of ECMO. The data from available literature indicates that anti-infective pharmacokinetic parameters are similar to those observed in other non-ECMO critically ill populations, but considerable variability in the findings was observed between patients, thus prompting further evaluation of therapeutic drug monitoring in this complex population.

Ethnopolitical concepts of national identity: world experience and Kazakhstan's model

The problem of self-determination of a nation is an urgent topic in ethnopolitics, since it is a complex concept that includes national and cultural identity and civic consciousness, patriotism and statesmanship, culture in the sphere of social harmony and interethnic relations. For multi-ethnic states with a complex population, the formation and strengthening of a creative national identity within the country is a pledge of friendship and solidarity in society, a way of integration into the national idea and national development. However, the complexity and internal inconsistency of the formation of national identity is a more serious task, therefore, various concepts and models arise in world political practice. It is very important to be able to conduct their comparative analysis, generalize and receive appropriate lessons. The authors of this article consider the concepts of «national identity» from the point of view of various scientific schools of the world (French, German, etc.). The role of the considered forms of identity in the formation and development of modern society is also analyzed. The article analyzes the features of ethnic identity, world experience and the Kazakh model, considers the problem of formation and preservation of national and cultural identity from the standpoint of ethnopolitical concepts. Topical issues of the implementation of national policy and the formation of national-civic identity in multiethnic states are raised, proposals are given that contribute to the development of work in this direction. Keywords: national policy, ethnos, nation, nation, diaspora, cooperation, interethnic relations, national peculiarities.

Early Outcomes of Repetitive Transcranial Magnetic Stimulation in Complex Clinical Population

IntroductionRepetitive Transcranial Magnetic Stimulation (rTMS) is a new emerging neuromodulation treatment that has been tried for multiple psychiatric conditions [1, 2]. Its major approved application is treatment-resistant depression (TRD) [1]. At the same time there is a perceived potential for its use for other clinical conditions, primarily other mood and anxiety disorders [2]. At Homewood Health Centre we have been using rTMS as an adjunct treatment for patients with TRD and multiple comorbidities.ObjectivesTo evaluate the effectiveness and feasibility of rTMS in complex clinical populations.MethodsObservational study. Quick Inventory of Depressive Symptomatology (QIDS). Generalized Anxiety Disorder Questionnaire (GAD-7). Descriptive statistics.ResultsWe have treated 30 patients, 12 women (40%) and 18 men (60%), with average age of 42.0±15.6 years. All patients had a primary diagnosis of major depressive disorder. The standard questionnaires were used to quantify the severity of depressive symptoms (QIDS) and anxiety (GAD-7). The average baseline scores for depression and anxiety were 16.1±4.9 and 15.0±4.4, respectively. The patients received an average of 28.1±5.1 treatments. All patients but one received the full course of treatment as planned. The average end-of-treatment (EoT) scores for severity of depressive symptoms and anxiety were 9.6±6.5 and 7.3±5.3, respectively. The rates of improvement and remission for depressive symptoms were 66.7% and 36.7%, respectively. The rates of improvement and remission for anxiety symptoms were 76.9% and 30.8%, respectively.Image:ConclusionsOur data indicate that rTMS provides significant improvement and recovery rates in complex clinical populations and is well-tolerated. While further research is required, we recommend wider implementation of rTMS for treatment of mood and anxiety disorders.

Evaluation of Safety Measures at a Medical Summer Camp During the SARS-CoV-2 Pandemic.

SARS-CoV-2 poses challenges for the safe delivery of a camp experience with a medically complex camper population. Multiple studies have investigated the effect of nonpharmaceutical interventions for preventing SARS-CoV-2 transmission in traditional summer camp settings, but none in the medical summer camp settings. Our objective was to describe and evaluate the nonpharmaceutical interventions on SARS-CoV-2 transmission rate in a medical summer camp setting. This was a single-institution cross-sectional study conducted between June 2021 and August 2021 in a rural summer camp setting in upstate New York. Nonpharmaceutical interventions consisted of prearrival guidance on low-risk activities, obtaining negative SARS-CoV-2 polymerase chain reaction results within 72 h prior to arrival, adult SARS-CoV-2 vaccine mandate, universal masking mandate, small cohorts, daily symptom screening, and rapid testing on site. Primary cases were defined as an individual with a positive SARS-CoV-2 test result of any type while at camp or 2 wk after departure from camp without any known exposure at camp; secondary cases were defined as cases from potential exposures within camp. Two hundred and ninety-three campers were included. Nine individuals were tested owing to potentially infectious symptoms while at camp. Thirty-four campers were tested because they arrived from a county with an a priori intermediate level of SARS-CoV-2 community spread. Zero on-site rapid tests were positive for SARS-CoV-2. We describe the implementation of multilayered nonpharmaceutical interventions at a medical summer camp during the SARS-CoV-2 pandemic.

Silent Screams; Lily's Story

Silent Screams; Lily's Story Eva V. Regel "Trauma is personal. It does not disappear if it is not validated. When it is ignored or invalidated, the silent screams continue internally heard only by the one held captive. When someone enters the pain and hears the scream, healing can begin." —Danielle Bernock, "Emerging Wings; A true story of Lies, Pain and the Love that Heals." Some patients stay with you long after they leave. They appear in your mind when you walk by the hospital room they occupied or when someone mentions their name. There is [End Page 19] something about the narrative of their life and illness that makes you hold on to them. Lily is one such patient for me. Lily was a 45-year-old paraplegic woman who was well known to many providers in the hospital. She had a complex trauma history (childhood physical and sexual abuse, intimate partner violence, domestic violence), homelessness, and multiple psychiatric admissions. In addition, she had a complex medical history, including chronic pain issues and substance use disorder. Many providers considered her to be a "very difficult" or "challenging" patient because she would "dictate" her care, had low distress tolerance and would have explosive angry outbursts requiring frequent visits from Police and Security. To top it off, after months of a challenging stay on a unit, she would eventually leave against medical advice. Everyone involved in her care felt that discharge to a safe setting such as a skilled nursing facility would be her best option. Yet, she was a very "hard" sell to any facility because of her behavioral issues, relatively young age, extensive history of drug use, and medication non-compliance. Even though the unit I worked in was familiar with "difficult" patients like Lily, the floor staff was anxious and concerned about the effect Lily would have on patients, staff, and providers. The combined anticipatory anxiety worsened after we were told that Lily left against medical advice three days before her admission to our unit as a reaction to the staff's attempt to develop a behavioral plan. I remember the day I met Lily. I was working as the clinical social worker on the floor, helping patients with adjustment to coping with hospitalization, addressing mental health issues that usually exacerbate in the acute care setting, and providing support to the staff caring for a psychosocially complex patient population. It was the second day after Lily arrived on the floor, and Police and Security had already come up three times. As I walked out of another patient's room, a bedside nurse stopped me in the hallway. "Can you please talk to her? … Please, just talk to her, or sit with her. I just need a break. I have been in that room since I started my shift. I am exhausted." The nurse had an exasperated and pleading look, and even though I was rushing to a meeting, I decided to meet with Lily instead. When I walked into her room, I saw a thin, small-framed woman with brown hair pulled back into a tight bun. She had freckles peppered all over her round face, neck, and chest. Her features were delicate and small, and her almond-shaped green eyes were her most prominent feature. She was wearing a white tee and jeans. She was sitting in her wheelchair; her makeup bag was lying on the table next to her. I introduced myself and my role on the team, trying not to stumble under a very heavy glare. "Tell them to leave me alone. That nurse is always in my room. Spying. I might not be able to walk, but I can still use my hands. I can call if I need help." And so I did. And when I came back, Lily and I talked a little about her life. And the next day, we talked a little more. And then again. Lily was giving me small glimpses of who she was and the events in her life. Then, one day, in the middle of the conversation about her day and telling me how much she hated to be confined to her hospital room, she looked...