Functional impairment in daily activities, such as work and socializing, is part of the diagnostic criteria for major depressive disorder and most anxiety disorders. Despite evidence that symptom severity and functional impairment are partially distinct, functional impairment is often overlooked. To assess whether functional impairment captures diagnostically relevant genetic liability beyond that of symptoms, we aimed to estimate the heritability of, and genetic correlations between, key measures of current depression symptoms, anxiety symptoms, and functional impairment.

In 17,130 individuals with lifetime depression or anxiety from the Genetic Links to Anxiety and Depression (GLAD) Study, we analyzed total scores from the Patient Health Questionnaire-9 (depression symptoms), Generalized Anxiety Disorder-7 (anxiety symptoms), and Work and Social Adjustment Scale (functional impairment). Genome-wide association analyses were performed with REGENIE. Heritability was estimated using GCTA-GREML and genetic correlations with bivariate-GREML.

The phenotypic correlations were moderate across the three measures (Pearson’s r = 0.50–0.69). All three scales were found to be under low but significant genetic influence (single-nucleotide polymorphism-based heritability [h2SNP] = 0.11–0.19) with high genetic correlations between them (rg = 0.79–0.87).

Among individuals with lifetime depression or anxiety from the GLAD Study, the genetic variants that underlie symptom severity largely overlap with those influencing functional impairment. This suggests that self-reported functional impairment, while clinically relevant for diagnosis and treatment outcomes, does not reflect substantial additional genetic liability beyond that captured by symptom-based measures of depression or anxiety.

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.

Resilience of the healthcare system has been described as the ability to absorb, adapt, and respond to stress while maintaining the provision of safe patient care. We quantified the impact that stressors associated with the COVID-19 pandemic had on patient safety, as measured by central line-associated bloodstream infections (CLABSIs) reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network.

Acute care hospitals were mandated to report markers of resource availability (staffing and hospital occupancy with COVID-19 inpatients) to the federal government between July 2020 and June 2021. These data were used with community levels of COVID-19 to develop a statistical model to assess factors influencing rates of CLABSIs among inpatients during the pandemic.

After risk adjustment for hospital characteristics, measured stressors were associated with increased CLABSIs. Staff shortages for more than 10% of days per month were associated with a statistically significant increase of 2 CLABSIs per 10,000 central line days versus hospitals reporting staff shortages of less than 10% of days per month. CLABSIs increased with a higher inpatient COVID-19 occupancy rate; when COVID-19 occupancy was 20% or more, there were 5 more CLABSIs per 10,000 central line days versus the referent (less than 5%).

Reporting of data pertaining to hospital operations during the COVID-19 pandemic afforded an opportunity to evaluate resilience of US hospitals. We demonstrate how the stressors of staffing shortages and high numbers of patients with COVID-19 negatively impacted patient safety, demonstrating poor resilience. Understanding stress in hospitals may allow for the development of policies that support resilience and drive safe care.

Engaging patients, caregivers, and other stakeholders to help guide the research process is a cornerstone of patient-centered research. Lived expertise may help ensure the relevance of research questions, promote practices that are satisfactory to research participants, improve transparency, and assist with disseminating findings.

Traditionally engagement has been conducted face-to-face in the local communities in which research operates. Decentralized platform trials pose new challenges for the practice of engagement. We used a remote model for stakeholder engagement, relying on Zoom meetings and blog communications.

Here we describe the approach used for research partnership with patients, caregivers, and clinicians in the planning and oversight of the ACTIV-6 trial and the impact of this work. We also present suggestions for future remote engagement.

The ACTIV-6 experience may inform proposed strategies for future engagement in decentralized trials.

Paramedics are a vital component of the Emergency Medical Services (EMS) workforce and the United States health care system. The continued provision of high-quality care demands constantly improving education at accredited institutions. To date, only limited characteristics of paramedic education in the United States have been documented and studied in the literature. The objective of this study was to describe the educational infrastructure of accredited paramedic programs in the United States in 2018.

This is a retrospective, cross-sectional evaluation of the 2018 paramedic program annual report from The Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP; Rowlett, Texas USA). The dataset includes detailed program metrics. Additionally, questions concerning program characteristics, demographics, and resources were asked as part of the evaluation. Resource availability was assessed via the Resource Assessment Matrix (RAM) with a benchmark of 80%. Included in the analysis are all paramedic programs with students enrolled. Descriptive statistics were calculated (median, [interquartile range/IQR]).

A total of 677 programs submitted data (100% response rate). Of these, 626 met inclusion criteria, totaling 17,422 students. Program annual enrollment varied greatly from one to 362 with most programs having small sizes (18 students [IQR 12-30]). Program duration was 12 months [IQR 12-16] with total hours of instruction being approximately 1,174 [IQR 1069-1304], 19% of which were dedicated to clinical experience. Full-time faculty sizes were small (two faculty members [IQR 1-3]) with most programs (80%) having annual operating budgets below USD$500,000. For programs with an annual budget below USD$100,000 (34% of programs), annual enrollment was approximately 14 students [IQR 9-21]. Degrees conferred by programs included certificates (90%), associate degrees (55%), and bachelor’s degree (2%). Simulation access was assessed with nearly all (100%) programs reporting simple task trainers and 84% of programs investing in advanced simulation manikins. Seventy-eight percent of programs met the RAM benchmark.

Most paramedic educational programs in the United States have small annual enrollments with low numbers of dedicated faculty and confer certificates and associate degrees. Nearly one-quarter of paramedic educational programs are not adequately resourced. This study is limited by self-reported data to the national accreditation agency. Future work is needed to identify program characteristics that are associated with high performance.

In the absence of pyuria, positive urine cultures are unlikely to represent infection. Conditional urine reflex culture policies have the potential to limit unnecessary urine culturing. We evaluated the impact of this diagnostic stewardship intervention.

We conducted a retrospective, quasi-experimental (nonrandomized) study, with interrupted time series, from August 2013 to January 2018 to examine rates of urine cultures before versus after the policy intervention. We compared 3 intervention sites to 3 control sites in an aggregated series using segmented negative binomial regression.

The study included 6 acute-care hospitals within the Veterans’ Health Administration across the United States.

Adult patients with at least 1 urinalysis ordered during acute-care admission, excluding pregnant patients or those undergoing urological procedures, were included.

At the intervention sites, urine cultures were performed if a preceding urinalysis met prespecified criteria. No such restrictions occurred at the control sites. The primary outcome was the rate of urine cultures performed per 1,000 patient days. The safety outcome was the rate of gram-negative bloodstream infection per 1,000 patient days.

The study included 224,573 urine cultures from 50,901 admissions in 24,759 unique patients. Among the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the preintervention period (5.9% decrease; P = 0.8) but did decrease by 21% relative to control sites (P < .01). We detected no significant difference in the rates of gram-negative bloodstream infection among intervention or control sites (P = .49).

Conditional urine reflex culture policies were associated with a decrease in urine culturing without a change in the incidence of gram-negative bloodstream infection.

An improved understanding of diagnostic and treatment practices for patients with rare primary mitochondrial disorders can support benchmarking against guidelines and establish priorities for evaluative research. We aimed to describe physician care for patients with mitochondrial diseases in Canada, including variation in care.

We conducted a cross-sectional survey of Canadian physicians involved in the diagnosis and/or ongoing care of patients with mitochondrial diseases. We used snowball sampling to identify potentially eligible participants, who were contacted by mail up to five times and invited to complete a questionnaire by mail or internet. The questionnaire addressed: personal experience in providing care for mitochondrial disorders; diagnostic and treatment practices; challenges in accessing tests or treatments; and views regarding research priorities.

We received 58 survey responses (52% response rate). Most respondents (83%) reported spending 20% or less of their clinical practice time caring for patients with mitochondrial disorders. We identified important variation in diagnostic care, although assessments frequently reported as diagnostically helpful (e.g., brain magnetic resonance imaging, MRI/MR spectroscopy) were also recommended in published guidelines. Approximately half (49%) of participants would recommend “mitochondrial cocktails” for all or most patients, but we identified variation in responses regarding specific vitamins and cofactors. A majority of physicians recommended studies on the development of effective therapies as the top research priority.

While Canadian physicians’ views about diagnostic care and disease management are aligned with published recommendations, important variations in care reflect persistent areas of uncertainty and a need for empirical evidence to support and update standard protocols.

To determine the typical microbial bioburden (overall bacterial and multidrug-resistant organisms [MDROs]) on high-touch healthcare environmental surfaces after routine or terminal cleaning.

Prospective 2.5-year microbiological survey of large surface areas (>1,000 cm2).

MDRO contact-precaution rooms from 9 acute-care hospitals and 2 long-term care facilities in 4 states.

Samples from 166 rooms (113 routine cleaned and 53 terminal cleaned rooms).

Using a standard sponge-wipe sampling protocol, 2 composite samples were collected from each room; a third sample was collected from each Clostridium difficile room. Composite 1 included the TV remote, telephone, call button, and bed rails. Composite 2 included the room door handle, IV pole, and overbed table. Composite 3 included toileting surfaces. Total bacteria and MDROs (ie, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci [VRE], Acinetobacter baumannii, Klebsiella pneumoniae, and C. difficile) were quantified, confirmed, and tested for drug resistance.

The mean microbial bioburden and range from routine cleaned room composites were higher (2,700 colony-forming units [CFU]/100 cm2; ≤1–130,000 CFU/100 cm2) than from terminal cleaned room composites (353 CFU/100 cm2; ≤1–4,300 CFU/100 cm2). MDROs were recovered from 34% of routine cleaned room composites (range ≤1–13,000 CFU/100 cm2) and 17% of terminal cleaned room composites (≤1–524 CFU/100 cm2). MDROs were recovered from 40% of rooms; VRE was the most common (19%).

This multicenter bioburden summary provides a first step to determining microbial bioburden on healthcare surfaces, which may help provide a basis for developing standards to evaluate cleaning and disinfection as well as a framework for studies using an evidentiary hierarchy for environmental infection control.

Infect Control Hosp Epidemiol 2016;1426–1432