Patients with posttraumatic stress disorder (PTSD) exhibit smaller regional brain volumes in commonly reported regions including the amygdala and hippocampus, regions associated with fear and memory processing. In the current study, we have conducted a voxel-based morphometry (VBM) meta-analysis using whole-brain statistical maps with neuroimaging data from the ENIGMA-PGC PTSD working group.

T1-weighted structural neuroimaging scans from 36 cohorts (PTSD n = 1309; controls n = 2198) were processed using a standardized VBM pipeline (ENIGMA-VBM tool). We meta-analyzed the resulting statistical maps for voxel-wise differences in gray matter (GM) and white matter (WM) volumes between PTSD patients and controls, performed subgroup analyses considering the trauma exposure of the controls, and examined associations between regional brain volumes and clinical variables including PTSD (CAPS-4/5, PCL-5) and depression severity (BDI-II, PHQ-9).

PTSD patients exhibited smaller GM volumes across the frontal and temporal lobes, and cerebellum, with the most significant effect in the left cerebellum (Hedges’ g = 0.22, pcorrected = .001), and smaller cerebellar WM volume (peak Hedges’ g = 0.14, pcorrected = .008). We observed similar regional differences when comparing patients to trauma-exposed controls, suggesting these structural abnormalities may be specific to PTSD. Regression analyses revealed PTSD severity was negatively associated with GM volumes within the cerebellum (pcorrected = .003), while depression severity was negatively associated with GM volumes within the cerebellum and superior frontal gyrus in patients (pcorrected = .001).

PTSD patients exhibited widespread, regional differences in brain volumes where greater regional deficits appeared to reflect more severe symptoms. Our findings add to the growing literature implicating the cerebellum in PTSD psychopathology.

Duchenne muscular dystrophy is a devastating neuromuscular disorder characterized by the loss of dystrophin, inevitably leading to cardiomyopathy. Despite publications on prophylaxis and treatment with cardiac medications to mitigate cardiomyopathy progression, gaps remain in the specifics of medication initiation and optimization.

This document is an expert opinion statement, addressing a critical gap in cardiac care for Duchenne muscular dystrophy. It provides thorough recommendations for the initiation and titration of cardiac medications based on disease progression and patient response. Recommendations are derived from the expertise of the Advance Cardiac Therapies Improving Outcomes Network and are informed by established guidelines from the American Heart Association, American College of Cardiology, and Duchenne Muscular Dystrophy Care Considerations. These expert-derived recommendations aim to navigate the complexities of Duchenne muscular dystrophy-related cardiac care.

Comprehensive recommendations for initiation, titration, and optimization of critical cardiac medications are provided to address Duchenne muscular dystrophy-associated cardiomyopathy.

The management of Duchenne muscular dystrophy requires a multidisciplinary approach. However, the diversity of healthcare providers involved in Duchenne muscular dystrophy can result in variations in cardiac care, complicating treatment standardization and patient outcomes. The aim of this report is to provide a roadmap for managing Duchenne muscular dystrophy-associated cardiomyopathy, by elucidating timing and dosage nuances crucial for optimal therapeutic efficacy, ultimately improving cardiac outcomes, and improving the quality of life for individuals with Duchenne muscular dystrophy.

This document seeks to establish a standardized framework for cardiac care in Duchenne muscular dystrophy, aiming to improve cardiac prognosis.

Limited evidence investigates how knowledge, misconceptions, and beliefs about palliative care vary across patients with cancerous versus non-cancerous chronic disease. We examined the knowledge of and misconceptions about palliative care among these groups.

We used weighted data from the National Cancer Institute Health Information National Trends Survey 5 (Cycle 2) for nationally representative estimates and logistic regression to adjust for respondent characteristics. We identified respondents who reported having (1) cancer ([n = 585]; breast, lung, and colorectal), (2) chronic conditions ([n = 543]; heart failure, lung disease, or chronic obstructive pulmonary disorder), or (3) neither cancer nor other chronic conditions (n = 2,376).

Compared to cancer respondents, chronic condition respondents were more likely to report being Black or Hispanic, report a disability, and have lower socioeconomic status. In the sample, 65.6% of cancer respondents and 72.8% chronic conditions respondents reported they had never heard of palliative care. Chronic condition respondents were significantly (p < 0.05) less likely to report high palliative care knowledge than cancer respondents (9.1% vs. 16.6%, respectively). In adjusted analyses, cancer respondents had greater odds of high palliative care knowledge (odd ratio [OR] = 1.70; 95% confidence interval [CI] = 1.01, 2.86) compared to respondents with neither cancer nor chronic disease; chronic condition respondents did not have increased odds (OR = 0.96; CI = 0.59, 1.54).

Disparities in palliative care knowledge exist among people with non-cancerous chronic disease compared to cancer. Supportive educational efforts to boost knowledge about palliative care remains urgent and is critical for promoting equity, particularly for underserved people with chronic illnesses.

Understanding the cognitive determinants of healthcare worker (HCW) behavior is important for improving the use of infection prevention and control (IPC) practices. Given a patient requiring only standard precautions, we examined the dimensions along which different populations of HCWs cognitively organize patient care tasks (ie, their mental models).

HCWs read a description of a patient and then rated the similarities of 25 patient care tasks from an infection prevention perspective. Using multidimensional scaling, we identified the dimensions (ie, characteristics of tasks) underlying these ratings and the salience of each dimension to HCWs.

Adult inpatient hospitals across an academic hospital network.

In total, 40 HCWs, comprising infection preventionists and nurses from intensive care units, emergency departments, and medical-surgical floors rated the similarity of tasks. To identify the meaning of each dimension, another 6 nurses rated each task in terms of specific characteristics of tasks.

Each HCW population perceived patient care tasks to vary along 3 common dimensions; most salient was the perceived magnitude of infection risk to the patient in a task, followed by the perceived dirtiness and risk of HCW exposure to body fluids, and lastly, the relative importance of a task for preventing versus controlling an infection in a patient.

For a patient requiring only standard precautions, different populations of HCWs have similar mental models of how various patient care tasks relate to IPC. Techniques for eliciting mental models open new avenues for understanding and ultimately modifying the cognitive determinants of IPC behaviors.

Maximization of response with minimization of adverse effects is central to successful oncology chemotherapy. Since psychiatric comorbidity is significant in cancer patients, psychotropic co-administration with chemotherapy requires assessment of drug-drug interactions and cumulative adverse effects. Arsenic trioxide (ATO), indicated for treatment of relapsed acute promyelocytic leukemia (APL), prolongs QTc and has “black-box” warning regarding co-administration with medications with potential QTc prolongation. ATO administration is to be held if QTc > 500 milliseconds. This case describes ATO and olanzapine co-administration.

Case analysis with literature review.

43-year-old Caucasian male presented with relapsed APL characterized by non-traumatic bruising, anemia, and thrombocytopenia confirmed by bone marrow biopsy. Psychiatric comorbidity included Obsessive-Compulsive Disorder, Panic Disorder, and Bipolar NOS treated with fluvoxamine and benzodiazepines. Chemotherapy consisted of ATO, 0.15 mg/kg IV infusion over 2 hours. Fluvoxamine and fluconazole were discontinued early in treatment; olanzapine (2.5 mg bid) initiated thereafter effectively controlled obsessive-compulsive/affective features. Serial EKGs were performed; serum K and Mg were monitored daily and supplemented with intention of maintaining K>4.0 and Mg>1.8. EKG findings revealed: mean QTc on fluvoxamine and fluconazole, before ATO, 447 (431-464); mean QTc after ATO initiation, before discontinuation of fluvoxamine and fluconazole, 474 (445-500); mean QTc after discontinuation of fluvoxamine and fluconazole, while on ATO, 466 (441-496); mean QTc after olanzapine initiation, while on ATO, 479 (450-497). No adverse cardiovascular events occurred during treatment with ATO.

This case suggests olanzapine can be safely co-administered with ATO. Further studies are indicated.

Access to mental health treatment is often negatively impacted by cultural bias. This may relate to non-acceptance of psychiatric diagnoses as true illnesses, perceived shame by patient or family, or even fear of ostracism. As a result, treatable patients remain untreated with unnecessary morbidity, direct costs, indirect costs, and potential mortality. This case addresses depression and overdose in a Chinese patient.

Case analysis with literature review.

20-year-old Chinese single female was admitted for multidrug overdose (zolpidem/acetaminophen/clonazepam). When seen in psychiatric consultation, patient met DSM-IV criteria for Bipolar Disorder NOS, Anxiety Disorder NOS, and Polysubstance Dependence and was upset that overdose was unsuccessful. Patient described how parents were focused on performance success and would not accept her emotionality or depression stating “Depression, failure and suicide are not acceptable in China.” Patient summarized parental response to overdose: “they threw me in the basement with a basin where I kept vomiting for one day…then they thought that it was serious enough. They would come to the basement periodically and ask why I couldn't stop crying. They said it was my fault.” Mother instructed medical team patient needed to “sleep, eat, and exercise” and insisted patient be told she was responsible for hospital bill and her decision. After treatment with N-acetylcysteine, elevated transaminases stabilized and the patient was transferred to an inpatient psychiatric hospital.

Cultural themes focusing on success and lack of acceptance of psychiatric illness can lead to increased morbidity and potential mortality.

The objective of this study was to determine if modification of the Simple Triage and Rapid Treatment (START) system by the addition of an Orange category, intermediate between the most critically injured (Red) and the non-critical, non-ambulatory injured (Yellow), would reduce over- and under-triage rates in a simulated mass-casualty incident (MCI) exercise.

A computer-simulation exercise of identical presentations of an MCI scenario involving a 2-train collision, with 28 case scenarios, was provided for triaging to two groups: the Fire Department of the City of New York (FDNY; n = 1,347) using modified START, and the Emergency Medical Services (EMS) providers from the Eagles 2012 EMS conference (Lafayette, Louisiana USA; n = 110) using unmodified START. Percent correct by triage category was calculated for each group. Performance was then compared between the two EMS groups on the five cases where Orange was the correct answer under the modified START system.

Overall, FDNY-EMS providers correctly triaged 91.2% of cases using FDNY-START whereas non-FDNY-Eagles providers correctly triaged 87.1% of cases using unmodified START. In analysis of the five Orange cases (chest pain or dyspnea without obvious trauma), FDNY-EMS performed significantly better using FDNY-START, correctly triaging 86.3% of cases (over-triage 1.5%; under-triage 12.2%), whereas the non-FDNY-Eagles group using unmodified START correctly triaged 81.5% of cases (over-triage 17.3%; under-triage 1.3%), a difference of 4.9% (95% CI, 1.5-8.2).

The FDNY-START system may allow providers to prioritize casualties using an intermediate category (Orange) more properly aligned to meet patient needs, and as such, may reduce the rates of over-triage compared with START. The FDNY-START system decreases the variability in patient sorting while maintaining high field utility without needing computer assistance or extensive retraining. Comparison of triage algorithms at actual MCIs is needed; however, initial feedback is promising, suggesting that FDNY-START can improve triage with minimal additional training and cost.

ArshadFH , WilliamsA , AsaedaG , IsaacsD , KaufmanB , Ben-EliD , GonzalezD , FreeseJP , HillgardnerJ , WeakleyJ , HallCB , WebberMP , PrezantDJ . A Modified Simple Triage and Rapid Treatment Algorithm from the New York City (USA) Fire Department. Prehosp Disaster Med. 2015;30(2):1-6.

Individuals with anxiety disorders often remain symptomatic despite treatment with a first-line pharmacologic agent. More research examining pharmacotherapy augmentation strategies to improve outcomes is needed.

In an 8-week, open-label, prospective augmentation study, we examined the efficacy and tolerability of the novel antipsychotic agent aripiprazole for adult outpatients with generalized anxiety disorder (n=13) or panic disorder (n=10) who remained symptomatic despite treatment for at least 8 weeks with an adequate (or maximally tolerated) dose of typical pharmacotherapy.

Aripiprazole augmentation was associated with a significant reduction in Clinical Global Impressions-Severity scores (paired t=4.41, df=22, P<.001) in the intent-to-treat sample of 23 individuals. Three subjects (13%) discontinued due to sedation, chest discomfort, and restlessness, respectively.

These data provide preliminary evidence that aripiprazole may be a useful augmentation strategy for individuals with generalized anxiety disorder or panic disorder who show a limited response to initial pharmacotherapy.