Age as an Exclusion Criterion for Nonoperative Management in Simple Acute Appendicitis in Children.

OBJECTIVE: Nonoperative management (NOM) for simple acute appendicitis (SAA) is an acceptable mode of treatment in healthy children. Previous studies of NOM routinely excluded young children (< 5 years); however, the effect of age on NOM failure has not been directly assessed. Efficiency of NOM in young adults is questionable. Therefore, adolescents may also be at greater risk of NOM failure. Our aim was to investigate the effect of age on NOM failure. METHODS: This is a retrospective analysis of children with SAA who received NOM between January 1, 2019, and June 30, 2021, at our institution. NOM failure was defined by subsequent appendectomy. Age was assessed as a continuous variable, and we also compared different age subgroups. RESULTS: In this study, 151 children were included (60% male), mean age 11.2 ± 3.2 years (range: 5-17). Overall, 66 children (44%) failed NOM, 90% of them within the first year (median 7 weeks). Ten percent of the cohort were younger than 6 years of age and 33% of them failed NOM (p = 0.39). Per 1 year increase in age, the odds of NOM failure increased by 12% (p = 0.027). Children over 14 years of age had 2.46 times higher odds to fail NOM (p = 0.03). These higher odds remained after adjusting for appendiceal diameter and appendicolith. Linear regression showed a decrease by a factor of 12 at the time of NOM failure with every 1-year increase in age (ß = -12, p = 0.09). CONCLUSION: The risk of NOM failure in children increases with age; therefore, age should be considered when deciding on the optimal management of SAA, especially in adolescents. Effectiveness of NOM in children younger than 6 years is noninferior to older children and therefore should not be excluded.

Learning About and Destigmatizing Substance Use Disorders: a Video-Based Educational Module Using Simulated Patients.

OBJECTIVE: The authors developed and tested video clips depicting three paradigmatic substance use disorder (SUD) clinical scenarios, each portrayed by a different simulated patient interacting with the same clinician. METHODS: The authors embedded 21 short video clips (with a cumulative duration of 27 min) into a 2-h session on SUDs. The didactic was delivered online through synchronous videoconferencing with Zoom. The primary outcome compared learners' scores on the Attitudes and Confidence in the Treatment of Patients with Substance Use Disorders (ACT-SUDS) before and after participating in the didactic. RESULTS: Fifty-eight second-year medical students participated and completed the survey prior to the didactic; 42 (72%) of them completed the survey immediately after. Compared to baseline, ACT-SUDS increased after the didactic: from 3.7 ± 0.5 to 4.0 ± 0.4 (mean difference = 0.4 [95% confidence interval = 0.2-0.5], paired-t = 5.75, p < 0.001), as did each of its four subscales: confidence, enjoyment, SUD as a medical disorder, and attitudes toward Alcoholics Anonymous (AA; t ≥ 3.0, p ≤ 0.005). CONCLUSIONS: The video-based educational module proved easy to implement in the virtual classroom and led to measurable changes in perceptions and attitudes toward SUDs. The module is available to view or freely download and is amenable for adaptation by end-use instructors.

Ketamine vs midazolam: Mood improvement reduces suicidal ideation in depression.

OBJECTIVE: Studies demonstrate rapid antidepressant and anti-suicidal ideation effects of subanesthetic ketamine. The specific subcomponents of depression that are most closely tied to reduction of suicidal ideation with ketamine treatment are less explored. METHODS: Exploratory, post hoc analysis of data from a randomized clinical trial of ketamine vs midazolam in patients with major depressive disorder (MDD) and clinically significant suicidal ideation examined changes in factor analysis-derived symptom clusters from standard measures of depression (Hamilton Depression Rating Scale, HDRS; Beck Depression Inventory, BDI) and mood disturbance (Profile of Mood States, POMS), and their relationship to severity of suicidal ideation (Beck Scale for Suicidal Ideation; SSI). Ratings obtained before and one day after blinded intravenous infusion were decomposed into component factors or published subscales. Treatment effects on factors/subscales were compared between drugs, correlations with changes in suicidal ideation were tested, and stepwise regression was used to derive predictors of change in SSI. RESULTS: Factor scores for HDRS Psychic Depression, HDRS Anxiety, BDI Subjective Depression, POMS Depression and POMS Fatigue improved more with ketamine than midazolam. Stepwise regression showed across both drugs that improvement in HDRS Psychic Depression, POMS Depression, and HDRS Anxiety predicted 51.6% of the variance in reduction of suicidal ideation. LIMITATIONS: Secondary analysis of clinical trial data. CONCLUSIONS: Ketamine's rapid effects on suicidal ideation appear to be mostly a function of its effects on core mood and anxiety symptoms of MDD, with comparatively little contribution from neurovegetative symptoms with the potential exception of vigor/fatigue. TRIAL REGISTRATION: Data used in this secondary analysis came from ClinicalTrials.gov identifier: NCT01700829.

The rapid anti-suicidal ideation effect of ketamine: A systematic review.

In many countries suicide rates have been trending upwards for close to twenty years-presenting a public health crisis. Most suicide attempts and deaths are associated with psychiatric illness, usually a depressive disorder. Subanesthetic ketamine is the only FDA-approved antidepressant that works in hours not weeks-thus potentially transforming treatment of suicidal patients. We reviewed all randomized controlled trials of the effect of ketamine on suicidal ideation to determine if ketamine rapidly reduces suicidal ideation [SI] in depressed patients and how long the benefit persists after one dose and if the route of administration or dose affects the outcome. A systematic review was conducted as per PRISMA [preferred reporting items for systematic reviews and meta-analyses] criteria. PubMed search inclusive of "ketamine" and "suicide" yielded 358 results. Papers (N = 354) were then read by at least two authors, identifying 12 meeting eligibility requirements and eleven RCTs examining whether ketamine treatment ameliorated SI. Four of five RCTs examined racemic ketamine (0.5 mg/kg) given intravenously and found an advantage for ketamine over control for rapid reduction in SI in acutely depressed patients. Two studies examined intranasal esketamine in depressed suicidal patients and found no advantage over saline. One study examined outcome six weeks after a single intravenous dose of ketamine and found benefit for SI sustained relative to 24 h post-dose. Further research is warranted into: optimal dosing strategy, including number and frequency; and long-term efficacy and safety. Ultimately, it remains to be shown that ketamine's benefit for SI translates into prevention of suicidal behavior.

Peer mentorship as an adjunct intervention for the treatment of eating disorders: A pilot randomized trial.

OBJECTIVE: Peer mentorship has been shown to be helpful for other mental health conditions, but it has been understudied for patients with eating disorders. The goal of the present study was to evaluate the feasibility and efficacy of peer mentorship for individuals with eating disorders by conducting a randomized controlled trial (RCT). TRIAL DESIGN: Parallel three-arm pilot RCT with 1:1:1 allocation to peer mentorship, social support mentorship (active comparison intervention), and waiting list. METHOD: Sixty outpatients with anorexia nervosa (AN), bulimia nervosa (BN), or binge-eating disorder (BED) were randomly assigned to a condition. Outcome measures, including eating disorder symptoms and general psychopathology, were completed at baseline, mid-, and postintervention. RESULTS: Session attendance and acceptability ratings were higher in peer mentorship than social support mentorship. More participants in social support mentorship (39%) dropped out compared to peer mentorship (5%). In intent-to-treat analysis, peer mentorship showed greater reductions in body dissatisfaction and anxiety compared with both control groups. Compared with social support mentorship, peer mentorship had greater reductions in depression. Compared with waiting list, peer mentorship had greater reduction in binge eating days/week in patients with BN/BED and restriction days/week in patients with AN. Peer mentorship did not impact body mass index or reentry into higher level of care. DISCUSSION: This pilot RCT provides preliminary evidence that peer mentorship is effective for some cognitive and behavioral symptoms of eating disorders as an adjunct to outpatient treatment. Additional studies are needed to evaluate the efficacy of peer mentorship in absence of treatment.