Assessing Adverse Outcomes and Learning Needs in Canadian Psychiatric Independent Medical Examinations.

Despite the importance of independent medical examinations (IMEs), there is virtually no literature on the risks to the IME assessor nor the learning needs of psychiatrists in this area. To address this deficit, a retrospective chart review of nearly 38,000 cases from the Canadian Medical Protective Association (CMPA) identified 108 files involving complaints or legal actions against psychiatrists performing IMEs. Most complaints identified by the CMPA were to regulatory bodies, including biased opinion, inadequate assessment, inappropriately relying on a requester's information without independent evaluation, nonadherence to regulatory body policies, cursory documentation lacking relevant details, and communication breakdowns. A survey by the Canadian Academy of Psychiatry and the Law (CAPL) and the Canadian Psychiatric Association (CPA) had 306 Canadian psychiatrist respondents. About 37 percent of psychiatrists completing IMEs reported medico-legal consequences, including complaints to regulatory authorities. Only 40 percent of those doing IMEs and 20 percent of all psychiatrists had formal training in doing IMEs. The studies confirm that despite a low but important risk of medico-legal consequences, many psychiatrists performing IMEs do not have formalized training. Using the new CAPL Canadian Guidelines for Forensic Psychiatry Assessment and Report Writing is a step to reduce the risk of such evaluations.

Adverse events in radiation oncology: A case series from wake up safe, the pediatric anesthesia quality improvement initiative.

BACKGROUND: Radiation therapy in pediatric patients often requires anesthesia and poses environmental challenges. Monitoring must be done remotely to limit radiation exposure to the provider. Airway access can be limited by masks or frames. Care is often delivered in relatively inaccessible locations in the hospital. While individual institutions have reported their outcomes, this case series aims to review a multicenter registry of significant adverse events and make recommendations for improved care. METHODS: Wake Up Safe: The Pediatric Quality Improvement Initiative maintains a multisite, voluntary registry of pediatric perianesthetic significant adverse events. This was queried for reports from radiation oncology from January 1, 2010 to May 10, 2018. The database contained 3,379 significant adverse events from approximately 3.3 million anesthetics. All 33 institutions submitted data on a standardized form to a central data repository (Axio Research, Seattle Washington). Prior to each significant adverse events case submission, three anesthesiologists who were not involved in the event analyzed the event using a standardized root cause analysis method to identify the causal or contributing factor(s). RESULTS: Six significant adverse events were identified. In three, incorrect programming of a propofol infusion resulted in overdose. In case one, the 3-year-old female became hypotensive, requiring vasopressors and volume resuscitation. In the second, the 2-year-old female experienced airway obstruction and apnea requiring chin lift. In case three, the child suffered no consequences despite a noted overdose of propofol infusion. In case four, a 2-year-old female with recent respiratory infection suffered laryngospasm during an unmonitored transport to the recovery area. She developed profound oxygen desaturation with bradycardia treated with succinylcholine and chest compressions. In case five, a 6-year-old former premature child suffered laryngospasm at the conclusion of mask creation under general anesthesia with a laryngeal mask airway. The radiation mask delayed recognition of copious secretions. Finally, in case six, a 6-year-old undergoing stereotactic radiosurgery in a head halo suffered bronchospasm and unintended extubation during therapy which required multiple attempts at reintubation by multiple providers ultimately requiring cancellation of the treatment and transport to the intensive care unit. CONCLUSION: There were few radiation oncology significant adverse events, but analysis has led to the identification of several specific opportunities for improvement in pediatric anesthesia for radiation oncology.

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer.

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from six working groups, and a recent symposium co-sponsored by the ACS, American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology (ASCP), which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (e.g., management of screen positives and screening interval for screen negatives) of women after screening, age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16/18 infections.

Sex trade among young women attending family-planning clinics in Northern California.

OBJECTIVE: To describe the prevalence and nature of sex trade in a clinic-based sample of young women and to evaluate associations with sexual and reproductive health. METHODS: A cross-sectional survey was conducted with women aged 16-29 years (n=1277) presenting to family-planning clinics in Northern California, USA. RESULTS: Overall, 8.1% of respondents indicated a lifetime history of trading sex for money or other resources. Sex trade was associated with unintended pregnancy (adjusted risk ratio [ARR] 1.27; 95% confidence interval [CI], 1.09-1.48), multiple abortions (ARR 1.63; 95% CI, 1.19-2.23), STI diagnosis (ARR 1.46; 95% CI, 1.27-1.68), and unwanted sex (vaginal ARR 3.64; 95% CI, 2.39-5.56; anal ARR 4.99; 95% CI, 2.17-11.50). Of the women ever involved in sex trade, 12 (37.3%) reported that their first such experience was before they were 18 years of age. CONCLUSION: Approximately 1 in 12 participants had been involved in sex trade, illustrating the presence of patients with this history within the family-planning clinical setting. Sex trade was associated with multiple indicators of poor sexual and reproductive health. Family-planning clinics may represent an underused mechanism for engaging this high-risk population.

A family planning clinic partner violence intervention to reduce risk associated with reproductive coercion.

BACKGROUND: This study examined the efficacy of a family-planning-clinic-based intervention to address intimate partner violence (IPV) and reproductive coercion. STUDY DESIGN: Four free-standing urban family planning clinics in Northern California were randomized to intervention (trained family planning counselors) or standard of care. English-speaking and Spanish-speaking females ages 16-29 years (N = 906) completed audio computer-assisted surveys prior to a clinic visit and 12-24 weeks later (75% retention rate). Analyses included assessment of intervention effects on recent IPV, awareness of IPV services and reproductive coercion. RESULTS: Among women reporting past-3-months IPV at baseline, there was a 71% reduction in the odds of pregnancy coercion among participants in intervention clinics compared to participants in the control clinics that provided standard of care. Women in the intervention arm were more likely to report ending a relationship because the relationship was unhealthy or because they felt unsafe regardless of IPV status (adjusted odds ratio = 1.63; 95% confidence interval=1.01-2.63). CONCLUSIONS: Results of this pilot study suggest that this intervention may reduce the risk for reproductive coercion from abusive male partners among family planning clients and support such women to leave unsafe relationships.

Pregnancy coercion, intimate partner violence and unintended pregnancy.

BACKGROUND: Reproductive control including pregnancy coercion (coercion by male partners to become pregnant) and birth control sabotage (partner interference with contraception) may be associated with partner violence and risk for unintended pregnancy among young adult females utilizing family planning clinic services. STUDY DESIGN: A cross-sectional survey was administered to females ages 16-29 years seeking care in five family planning clinics in Northern California (N=1278). RESULTS: Fifty-three percent of respondents reported physical or sexual partner violence, 19% reported experiencing pregnancy coercion and 15% reported birth control sabotage. One third of respondents reporting partner violence (35%) also reported reproductive control. Both pregnancy coercion and birth control sabotage were associated with unintended pregnancy (AOR 1.83, 95% CI 1.36-2.46, and AOR 1.58, 95% CI 1.14-2.20, respectively). In analyses stratified by partner violence exposure, associations of reproductive control with unintended pregnancy persisted only among women with a history of partner violence. CONCLUSIONS: Pregnancy coercion and birth control sabotage are common among young women utilizing family planning clinics, and in the context of partner violence, are associated with increased risk for unintended pregnancy.

Acute kidney injury during liver transplantation as determined by neutrophil gelatinase-associated lipocalin.

Acute kidney injury (AKI) has significant prognostic implications for long-term outcomes in patients undergoing liver transplantation. In several retrospective studies, perioperative variables have been associated with AKI. These variables have been mainly associated with changes in creatinine concentrations over several days or months post-transplantation. To better define AKI, new markers have become available that help to identify patients at risk for renal injury within hours of a triggering insult. We prospectively enrolled liver transplant patients at our institutions to evaluate neutrophil gelatinase-associated lipocalin (NGAL), a marker of early renal injury, as a surrogate for AKI in patients undergoing liver transplantation. Blood was prospectively collected at predetermined time points from 59 patients at 2 institutions. The electronic anesthesia records and the hospital computer data system were reviewed for perioperative variables. Data collection included patient demographics, intraoperative variables such as fluid management, transfusion requirements, hemodynamics, and urine output. Subsequently, patients were grouped according to the presence of risk for developing AKI as defined by the RIFLE (risk, injury, failure, loss, and end-stage kidney disease) criteria. The difference between the NGAL concentration 2 hours after reperfusion and the baseline NGAL concentration was predictive of AKI in all patients, including patients with preexisting renal dysfunction. In patients with creatinine concentrations less than 1.5 mg/dL, a single NGAL determination 2 hours after reperfusion of the liver was associated with the development of AKI. Total occlusion of the inferior vena cava was associated with AKI. In conclusion, NGAL concentrations obtained during surgery were highly associated with postoperative AKI in patients undergoing liver transplantation. These findings will allow the design of larger interventional studies. Our findings regarding the impact of surgical techniques and glucose require validation in larger studies.

Psychiatric hospitalization and veterans with traumatic brain injury: a retrospective study.

OBJECTIVE: To determine risk factors for psychiatric hospitalization after traumatic brain injury (TBI) in veterans. SUBJECTS AND PROCEDURES: Medical records of 96 veterans with histories of TBI (17 mild, 33 moderate, and 46 severe) were reviewed for information concerning psychiatric history, including hospitalization and substance misuse. RESULTS: Subjects with a history of problematic drug and alcohol use had a significantly higher probability of psychiatric hospitalization than those without such a history. Gender, age, problematic alcohol use without problematic drug use, injury severity, time since injury, years of follow-up, and a history of psychiatric symptoms (including those attributed to general medical conditions) were not identified as significant risk factors. Ninety-one veterans (95%) had a history of psychiatric difficulty. In addition, the probability of post-TBI problematic drug and alcohol use, given a pre-TBI history of such use, was significantly higher than the probability given no history. CONCLUSIONS: Veterans with problematic drug and alcohol use are at increased risk for psychiatric hospitalization after TBI. In addition, the likelihood of problematic post-TBI drug and alcohol use was significantly greater for those with a preinjury history. Ninety-five percent of veterans in the current sample endorsed lifetime histories of psychiatric difficulty. These findings highlight the need for evidence-based means of psychiatric and/or substance abuse treatment of those with a history of TBI.

Mental disorder and threats made by noninstitutionalized people with weapons in the national comorbidity survey replication.

Controversy exists as to whether mental disorders are associated with a higher risk of violent behavior. Data from the nationally-representative National Comorbidity Survey Replication was examined. Multiple logistic regression was used to determine whether mood, anxiety, impulse control, and substance use disorders were associated with a higher rate of potentially violent behavior as assessed by threatening others with a gun or other weapon. After adjusting for sociodemographic factors, an association was found between mood, anxiety, impulse control, and substance use disorders and the rate of threatening others. A significant association was found between threats made against others with a gun and both substance use disorders (adjusted odds ratio [AOR] 2.27; 95% confidence interval [CI] 1.62-3.20) and impulse control disorders (AOR 2.67; 95% CI 1.95-3.66). Threats made against others with any other type of weapon were significantly associated with any anxiety (AOR 1.76; 95% CI 1.34-2.31), substance (AOR 2.63; 95% CI 1.87-3.71), or impulse control disorder (AOR 2.49; 95% CI 1.96-3.18). Of the disorders studied, social phobia, specific phobia, and impulse control disorders seemed to have their onset before the act of threatening others with weapons. This finding was also true for those who had attempted suicide. Further research is needed to determine whether treatment of mental disorders decreases the risk of violence in this population.

ASCCP patient management guidelines: Pap test specimen adequacy and quality indicators.

Our objective was to provide management guidelines according to Papanicolaou (Pap) test specimen adequacy based on literature review and expert opinion. A task force named by the American Society for Colposcopy and Cervical Pathology (ASCCP) conducted a literature review and discussed appropriate management. The Steering Committee of the ASCCP and other experts reviewed the guidelines. The guidelines recommend a repeated Pap test in 12 months for most women undergoing routine annual/biennial screening if the current Pap test is negative but either lacks an endocervical/ transformation zone component or is partially obscured. Indications for considering an earlier repeat are also provided. The preferred managementfor unsatisfactory Pap tests is a repeated Pap test within a short interval of 2 to 4 months. The management guidelines will help promote optimal and uniform follow-up of women according to Pap test specimen adequacy.

ASCCP Patient Management Guidelines: Pap Test Specimen Adequacy and Quality Indicators.

OBJECTIVES: To provide management guidelines according to Pap test specimen adequacy based on literature review and expert opinion. METHODS: A task force named by the American Society for Colposcopy and Cervical Pathology conducted a literature review and discussed appropriate management. The steering committee of the American Society for Colposcopy and Cervical Pathology and other experts reviewed the guidelines. RESULTS: The guidelines recommend a repeat Pap test in 12 months for most women who are undergoing routine annual/biennial screening if the current Pap test is negative but either lacks an endocervical/transformation zone component or is partially obscured. Indications for considering an earlier repeat are also provided. The preferred management for unsatisfactory Pap tests is a repeat Pap test within a short interval of 2 to 4 months. CONCLUSIONS: The management guidelines will help promote optimal and uniform follow-up of women's Pap tests, according to Pap test specimen adequacy.