Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department.

INTRODUCTION: Restraint use in the emergency department (ED) can pose significant risks to patients and health care workers. We evaluate the effectiveness of Code De-escalation- a standardized, team-based approach for management and assessment of threatening behaviors- in reducing physical restraint use and workplace violence in a community ED. METHODS: A retrospective observational study of a pathway on physical restraint use among patients placed on an involuntary psychiatric hold in a community ED. This pathway includes a built-in step for the team members to systematically assess perceptions of threats from the patient behavior and threats perceived by the patient. Our primary outcome was the change in the rate of physical restraint use among patients on an involuntary psychiatric hold. Our secondary outcome was the change in the rate of workplace violence events involving all ED encounters. We evaluated our outcomes by comparing all encounters in a ten-month period before and after implementation, and compared our results to rates at neighboring community hospitals within the same hospital network. RESULTS: Pre intervention there were 434 ED encounters involving a psychiatric hold, post-intervention there were 535. We observed a significant decrease in physical restraint use, from 7.4% to 3.7% (ARR 0.028 [95% CI 0.002-0.055], p < 0.05). This was not seen at the control sites. CONCLUSIONS: A standardized de-escalation algorithm can be effective in helping ED's decrease their use of physical restraints in management of psychiatric patients experiencing agitation.

Quantitative tract-specific measures of uncinate and cingulum in major depression using diffusion tensor imaging.

Previous findings suggested the role of the prefrontal cortex, hippocampus, and cingulate gyrus in major depressive disorders (MDD), but the white matter microstructural abnormalities of the fibers connecting these brain structures are not known. The purpose of this study was to test the hypothesis that white matter abnormalities are present in association fibers of the uncinate fasciculus (UF) and cingulum bundle (CB) among MDD subjects. A total of 21 MDD subjects aged between 30 and 65 years and 21 age-matched healthy controls (HC) were recruited. All subjects were right-handed and without history of diabetes or other cardiac diseases. We extracted quantitative tract-specific measures based on diffusion tensor imaging tractography to examine both diffusivity and geometric properties of the UF and CB. Significantly decreased fractional anisotropy (FA) and increased radial diffusivity of the right UF were observed in MDD patients compared with HC (p<0.05), while their geometric characteristics remained relatively unchanged. Among MDD subjects, depression severity had a significant negative correlation with normalized number of fibers (NNF) in the right UF (r=-0.53, p=0.02). We also found significant age effect (oldR) in both groups in the FA measure of the CB. Our study demonstrates novel findings of white matter microstructural abnormalities of the right UF in MDD. In the MDD group, the severity of depression is associated with reduced NNF in the right UF. These findings have implications for both clinical manifestations of depression as well as its pathophysiology.

Pediatricians' attitudes toward resuscitation in children with chronic illnesses.

OBJECTIVE: Do not attempt resuscitation (DNAR) orders are becoming more common in children with chronic illnesses. In this study, we compare pediatricians' attitudes about DNAR orders in four venues. Our hypotheses are: 1) venue matters: acceptance of DNAR varies by where the arrest occurs; 2) specialty affiliation matters: acceptance of DNAR varies by pediatric specialization; and 3) the personal influences the professional: pediatricians are more likely to respect and recommend a DNAR if they would choose DNAR for their own child. METHODS: Surveys were sent to 150 pediatricians in each of four sections of the American Academy of Pediatrics: children with disabilities, critical care, emergency medicine, and school health. The survey included four hypothetical vignettes about DNAR in various venues (pediatric intensive care unit, chronic care facility, emergency department, and school) followed by three questions: 1) would you respect the family's choice for DNAR? 2) Would you recommend DNAR to the family? 3) Would you choose DNAR for your own child? Results were analyzed using SPSS software. RESULTS: Two hundred seventy-nine of 560 eligible surveys (50%) were returned. The majority of respondents were men (62%), white (85%), Christian (61%), and fellowship trained (70%). In three of the scenarios (pediatric intensive care unit, emergency department, and school), most pediatricians were willing to respect (>90%), recommend (>85%), and choose a DNAR for their own child (>75%). For a ventilator-dependent child living in a chronic care facility, respondents were significantly less likely to respect (81%, p < 0.001), recommend (76%, p < 0.001), or want a DNAR for their own child (68%, p < 0.001). In a multivariate analysis, no demographic characteristic consistently correlated with physicians' decisions. However, pediatricians' preferences for DNAR for their own child correlated with recommending DNAR (p < 0.001) for their patients. CONCLUSION: DNAR decisions have become well accepted in the pediatric community for both end-of-life and poor quality of life cases.

Functional grouping and cortical-subcortical interactions in emotion: a meta-analysis of neuroimaging studies.

We performed an updated quantitative meta-analysis of 162 neuroimaging studies of emotion using a novel multi-level kernel-based approach, focusing on locating brain regions consistently activated in emotional tasks and their functional organization into distributed functional groups, independent of semantically defined emotion category labels (e.g., "anger," "fear"). Such brain-based analyses are critical if our ways of labeling emotions are to be evaluated and revised based on consistency with brain data. Consistent activations were limited to specific cortical sub-regions, including multiple functional areas within medial, orbital, and inferior lateral frontal cortices. Consistent with a wealth of animal literature, multiple subcortical activations were identified, including amygdala, ventral striatum, thalamus, hypothalamus, and periaqueductal gray. We used multivariate parcellation and clustering techniques to identify groups of co-activated brain regions across studies. These analyses identified six distributed functional groups, including medial and lateral frontal groups, two posterior cortical groups, and paralimbic and core limbic/brainstem groups. These functional groups provide information on potential organization of brain regions into large-scale networks. Specific follow-up analyses focused on amygdala, periaqueductal gray (PAG), and hypothalamic (Hy) activations, and identified frontal cortical areas co-activated with these core limbic structures. While multiple areas of frontal cortex co-activated with amygdala sub-regions, a specific region of dorsomedial prefrontal cortex (dmPFC, Brodmann's Area 9/32) was the only area co-activated with both PAG and Hy. Subsequent mediation analyses were consistent with a pathway from dmPFC through PAG to Hy. These results suggest that medial frontal areas are more closely associated with core limbic activation than their lateral counterparts, and that dmPFC may play a particularly important role in the cognitive generation of emotional states.

An empirical investigation of physicians' attitudes toward intrasibling kidney donation by minor twins.

BACKGROUND: A United States consensus group on the live donor concluded that minors (<18 years) can ethically serve as live solid organ donors in exceptional circumstances. More recent international guidelines reject this position. Recent United Network of Organ Sharing data show that minors serve as living donors, albeit infrequently. We examined the attitudes of US physicians toward minors as living donors. METHODS: Four hundred members of the American Society of Transplantation and 160 physicians from the American Academy of Pediatrics Section of Nephrology or Bioethics were surveyed. The physicians were asked whether minors should be permitted to serve as living donors and how their opinion would change depending on the twins' zygosity, age, and increased waitlist time. RESULTS: One hundred seventy of 436 eligible participants (39%) returned surveys. Thirty-two and 39% of respondents would permit a kidney donation between 15-year-old fraternal and identical twins, respectively (P=NS). If the wait time increased from 1 to 6 years, willingness increased to 39% and 45%, respectively (P=NS). Pediatric bioethicists were the most reluctant to prohibit minors as living donors. CONCLUSION: Approximately one-third of US physicians would permit children to serve as donors. Lengthening the wait time is associated with a trend toward greater willingness to permit minor donations. Current policies that give preferential status for a deceased donor organ to minors may help minimize donations by their minor siblings. Nontransplant physicians need education about donor risks to ensure that donations are in the best interest of pediatric donors and recipients.

Empirical data about women's attitudes toward a biobank focused on pregnancy outcomes.

The Chicago Lying-in Pregnancy Program (CLIPP) is a biobank designed to collect biological samples from pregnant women to study issues related to pregnancy. Despite the large number of biobanking initiatives in obstetric populations around the world, there is no published research that examines what pregnant women understand about enrollment into such programs and what their attitudes and beliefs are toward the research and its potential outcomes. Postpartum women 18 years or older who delivered at the University of Chicago Hospitals and had live infants on the General Care Nursery service were approached about participating in a survey about the CLIPP biobank and about a hypothetical pediatric biobank. Ninety-three women who had been recruited to participate in CLIPP agreed to participate in this research. Sixty-three women (68%) had previously agreed to participate in CLIPP; and 30 (32%) had refused. Both participants and non-participants understood that CLIPP had the main goal of advancing science, although almost one-half of the respondents thought that participation in CLIPP would benefit the individual participants. Eighty-five (92%) correctly believed that the research team would keep the medical information private. There was widespread optimism that the research would yield significant results. Importantly, there was no difference in these beliefs between those who enrolled and those who did not enroll in CLIPP. While education and socioeconomic status correlated with greater understanding about the methods and goals of the program, greater understanding did not correlate with willingness to participate. Our survey found widespread willingness to enroll in a pregnancy-focused biobank and optimism that the results will yield significant benefits.

Empirical data about women's attitudes towards a hypothetical pediatric biobank.

Researchers at the University of Chicago sought institutional review board (IRB) approval to establish both an obstetrical biobank (Chicago Lying-in Pregnancy Program [CLIPP]) and a pediatric biobank (KidsGene). Before KidsGene was approved, the IRB requested additional ethical review. The research ethics consultation service noted that no empirical data existed about parental attitudes towards this type of project. Postpartum women 18 years or older who delivered at the University of Chicago Hospitals and had live infants on the General Care Nursery service were approached about participating in a survey about the CLIPP biobank and about a hypothetical pediatric biobank. Two hundred thirty-nine women were consented and completed most or all of the survey. Eighty-two percent self-classified as Black and seven percent were Caucasians. Caucasians were the most willing to enroll their children hypothetically into a pediatric biobank with non-Black minorities being the most uncertain about what they would do. Almost half of the women thought that the research had the main goal of advancing science although a similar number expressed the belief that the research had the main goal of helping their individual child. Women supported use of the samples for a wide array of pediatric conditions. Comprehension of research practices, trust in medical researchers, and a belief that the research findings would be used fairly correlated with enrollment. Our survey found that most women support biobank development for research purposes. Most respondents expressed optimism that the results will yield significant benefits and that the benefits will be distributed fairly.