Adopting a Novel Approach to Prevent and Address Patient Mistreatment of Staff in a Community Mental Health Center

Verbal mistreatment of staff by patients is common in health care settings. Experiencing or witnessing mistreatment can have harmful psychological impacts, affecting well-being and clinical practice. As part of an effort to become an antiracist organization, an academic community mental health center based in Connecticut developed an initiative to address verbal mistreatment. Training in the Expect, Recognize, Address, Support, Establish (ERASE) framework was provided to 140 staff members. This training and subsequent actions to enhance the culture of safety were perceived as helpful by staff. Further development of the initiative is proceeding as the center's primary performance improvement program.

Undoing Institutional and Racial Trauma Through Interprofessional, Trauma-Informed Education

Trauma-informed care is a transdisciplinary framework that existed well before 2020, but it is now more imperative to teach it and incorporate it into medical education. This paper describes a novel interprofessional curriculum and its focus on trauma-informed care-notably, including institutional and racial trauma-that was implemented by Yale University for medical, physician associate, and advanced practice registered nursing students.

Geriatric Psychiatry Across the Spectrum: Medical Student, Resident, and Fellow Education

The older adult population in the United States is poised to reach 83.7 million by 2050, and up to 20% will suffer from cognitive and mental illnesses. We do not have the workforce available to meet this need; therefore, general psychiatrists will care for many older psychiatric patients. Enhancing learning opportunities during general medical education and residency could improve the knowledge of general psychiatrists and encourage recruitment into geriatric psychiatry. This article outlines geriatric psychiatry education in medical school, residency, and geriatric psychiatry fellowship with suggestions for recruitment into the field, along with recommendations for enhanced learning for general psychiatrists.

Insomnia and Other Sleep Disorders in Older Adults

Sleep disruption is common in older adults and is associated with many poor health outcomes. It is vital for providers to understand insomnia and other sleep disorders in this population. This article outlines age-related changes in sleep, and medical, psychiatric, environmental, and psychosocial factors that may impact sleep. It addresses the evaluation of sleep symptoms and diagnosis of sleep disorders. It aims to examine the evidence for non-pharmacological and pharmacologic treatment options for insomnia while weighing factors particularly germane to the aging adult..

Addressing Mistreatment of Providers by Patients and Family Members as a Patient Safety Event

OBJECTIVE

Mistreatment of health care providers (HCPs) is associated with burnout and lower-quality patient care, but mistreatment by patients and family members is underreported. We hypothesized that an organizational strategy that includes training, safety incident reporting, and a response protocol would increase HCP knowledge, self-efficacy, and reporting of mistreatment.

METHODS

In this single-center, serial, cross-sectional study, we sent an anonymous survey to HCPs before and after the intervention at a 213-bed tertiary care university children's hospital between 2018 and 2019. We used multivariable logistic regression to examine the effect of training on the outcomes of interest and whether this association was moderated by staff role.

RESULTS

We received 309 baseline surveys from 72 faculty, 191 nurses, and 46 residents, representing 39.1%, 27.1%, and 59.7%, respectively, of eligible HCPs. Verbal threats from patients or family members were reported by 214 (69.5%) HCPs. Offensive behavior was most commonly based on provider age (85, 28.5%), gender (85, 28.5%), ethnicity or race (55, 18.5%), and appearance (43, 14.6%) but varied by role. HCPs who received training had a higher odds of reporting knowledge, self-efficacy, and experiencing offensive behavior. Incident reporting of mistreatment increased threefold after the intervention.

CONCLUSIONS

We report an effective organizational approach to address mistreatment of HCPs by patients and family members. Our approach capitalizes on existing patient safety culture and systems that can be adopted by other institutions to address all forms of mistreatment, including those committed by other HCPs.

Addressing Mistreatment by Patients in Geriatric Subspecialties: A New Framework

Mistreatment by patients is unfortunately common in clinical medicine, including geriatric subspecialties. Despite the prevalence of this problem, there are few standardized approaches for addressing it at both interpersonal and institutional levels. The "ERASE" framework is a novel, practical approach for addressing mistreatment by patients. "ERASE" includes Expecting and preparing for mistreatment by patients, Recognizing mistreatment, Addressing mistreatment in real time, Supporting members of the healthcare team who have been mistreated, and Establishing a positive institutional culture. The framework may prove particularly helpful and applicable to providers specializing in geriatrics and can be used by administrators, educators, and all members of the healthcare team to promote safe, dignified clinical care and learning environments.

Predictors for Matriculation into Geriatric Psychiatry Fellowship: Data from a 2019-2020 National Survey of U.S. Program Directors

OBJECTIVE

With the number of geriatric psychiatry fellows declining from a peak of 106 during 2002-2003 to 48 during 2020-2021, this study aims to investigate characteristics of the geriatric psychiatry training requirement across U.S. psychiatry residency programs and to identify specific factors which may influence residents to pursue geriatric psychiatry subspecialty training.

METHODS

The authors queried the American Medical Association's Fellowship and Residency Electronic Interactive Database Access system to compile a list of program directors from the Accreditation Council for Graduate Medical Education sponsored general adult psychiatry residency programs. Program directors were emailed an anonymous multiple-choice survey to ascertain specific characteristics of their program's geriatric psychiatry training experiences. This study's primary outcome was the percentage of residents entering geriatric psychiatry fellowship after completion of general psychiatry training. Linear regression analysis determined which variables may be associated with this primary outcome.

RESULTS

Of 248 surveyed, 60 programs (24%) responded to the survey. Only one of the independent variables revealed a statistically significant association with the percent of residents that became geriatric psychiatry fellows: the number of geriatric psychiatrists at the residents' home institution (p=0.002).

CONCLUSIONS

Consistent with previous data, the presence of geriatric psychiatry faculty members is strongly associated with the decision to pursue subspecialty training in geriatric psychiatry.

Teamwork in the time of COVID-19

Strong and effective clinical teamwork has been shown to improve medical outcomes and reduce medical errors. Incorporating didactic and clinical activities into undergraduate medical education in which students work in teams will develop skills to prepare them to work in clinical teams as they advance through their education and careers. At the Yale School of Medicine, we foster the development of team skills in the classroom through team-based learning (TBL) and in clinical settings with the Interprofessional Longitudinal Clinical Experience (ILCE). Both TBL and ILCE require students work in close physical proximity. The COVID-19 pandemic forced us to immediately adapt our in-person activities to an online format and then develop clinical and interprofessional experiences that adhere to social distancing guidelines. Here we describe our approaches to solving these problems and the experiences of our students and faculty.

The American Association for Geriatric Psychiatry's Trainee Programs: Participant Characteristics and Perceived Benefits

OBJECTIVE

The number of physicians trained in geriatric psychiatry is dwindling. The American Association for Geriatric Psychiatry (AAGP) developed novel educational programs designed to foster interest in the field. The objective of this study was to compare participant characteristics and perceived benefits of two AAGP educational programs for trainees: Stepping Stones (1997-2007) and the Scholars Program (2010-2016).

METHODS

Web-based surveys were distributed to former participants of the Stepping Stones and Scholars Programs. Characteristics of participants in the two programs were compared using χ2, t tests, or Mann-Whitney U tests, as appropriate. The five-point Likert scale responses for each perceived benefit were compared using t tests, when normally distributed, or Mann-Whitney U tests as appropriate.

RESULTS

Of the 476 Stepping Stones participants, 132 (27.8%) responded to the survey, while 64 (29.0%) of the 221 Scholars Program participants responded to the survey. Participant characteristics differed only in age. Compared to Stepping Stones participants, Scholars Program participants endorsed greater advancement of their scholarly work, more support and recognition from their home institution, and increased networking opportunities.

CONCLUSION

Innovative approaches to addressing the geriatric psychiatry workforce shortage are critical. The member-funded AAGP Scholars Program offers several advantages over its predecessor Stepping Stones. Highlighted by the addition of medical student participants, a carefully matched mentoring program, and a required scholarly project, the Scholars Program is poised to enhance recruitment into geriatric psychiatry subspecialty training, although its impact on recruitment should be investigated directly in future research.

Suspending Medical Student Clerkships Due to COVID-19

Medical schools around the world have been grappling with how to adapt undergraduate medical curricula in the face of the COVID-19 pandemic. Our institution made the decision to suspend all clinical clerkships the day before the Association of American Medical Colleges (AAMC) recommended to US medical schools a similar suspension of "medical student participation in any activities that involved patient contact." This manuscript describes the rapid evolution in our decision-making as we weighed various information, values, and priorities in the face of the emerging public health crisis. We discuss how a compromised learning environment and concerns about student, patient, and the public health led to the suspension. We also consider next steps as we move forward in this uncertain time.

The AAGP Scholars Program: Predictors of Pursuing Geriatric Psychiatry Fellowship Training

OBJECTIVE

The American Association for Geriatric Psychiatry (AAGP) Scholars Program was developed to recruit trainees into geriatric psychiatry fellowships and is considered a pipeline for fellowship recruitment. Nonetheless, the number of trainees entering geriatric psychiatry fellowship is declining, making it important to identify modifiable factors that may influence trainees' decisions to pursue fellowship. We analyzed survey data from Scholars Program participants to identify demographic characteristics, attitudes toward program components, and behaviors after the program that were independently associated with the decision to pursue fellowship.

METHODS

Web-based surveys were distributed to all 289 former Scholars participants (2010-2018), whether or not they had completed geriatric psychiatry fellowships. We conducted a hierarchical binary logistic regression analysis to examine demographics, program components, and behaviors after the program associated with deciding to pursue geriatric psychiatry fellowship.

RESULTS

Sixty-one percent of Scholars decided to pursue geriatric psychiatry fellowship. Attending more than one AAGP annual meeting (relative variance explained [RVE] = 34.2%), maintaining membership in the AAGP (RVE = 28.2%), and rating the Scholars Program as important for meeting potential collaborators (RVE = 26.6%) explained the vast majority of variance in the decision to pursue geriatric psychiatry fellowship.

CONCLUSION

Nearly two-thirds of Scholars Program participants decided to pursue geriatric psychiatry fellowship, suggesting the existing program is an effective fellowship recruitment pipeline. Moreover, greater involvement in the AAGP longitudinally may positively influence Scholars to pursue fellowship. Creative approaches that encourage Scholars to develop collaborations, maintain AAGP membership, and regularly attend AAGP annual meetings may help attract more trainees into geriatric psychiatry.

ERASE-ing Patient Mistreatment of Trainees: Faculty Workshop

INTRODUCTION

Mistreatment of physicians by patients is a long-standing phenomenon that has garnered increased attention recently. Medical students and residents also experience mistreatment, and many supervising physicians do not know how to recognize it or respond appropriately. Little guidance exists as to how faculty should best address these situations. We developed, taught, and evaluated a stepwise approach to help faculty physicians manage patient mistreatment of trainees (residents and students).

METHODS

Our approach is summarized by the acronym ERASE: (1) Expect that mistreatment will occur. (2) Recognize episodes of mistreatment. (3) Address the situation in real time. (4) Support the learner after the event. (5) Establish/encourage a positive culture. We designed an interactive, case-based educator development session to teach ERASE and surveyed participants before and after to evaluate the session. Sixty-nine participants attended one of four workshops between November 2017 and January 2018.

RESULTS

Nearly 80% of attendees reported having received no prior training in managing mistreatment of trainees by patients. Participants noted significant changes in their confidence in recognizing and responding to episodes of mistreatment after the session compared with just prior to it.

DISCUSSION

ERASE fills an important void in medical education by introducing a novel, easy-to-understand approach that faculty can employ to manage mistreatment of trainees. We have continued to disseminate this model to faculty and residents in various departments around our medical center and at national conferences. This resource will allow educators to disseminate the ERASE model at their home institutions.

Medical student depression and its correlates across three international medical schools

BACKGROUND

Medical students have high rates of depression, anxiety, and burnout that have been found to affect their empathy, professional behaviors, and performance as a physician. While studies have examined predictors for burnout and depression in the United States (US), no study, to our knowledge, has compared depression in medical students cross-culturally, or has attempted to examine the effect of factors influencing rates including burnout, exercise, stress, unmet mental health needs, and region.

AIM

To examine rates of depression in three international cohorts of medical students, and determine variables that may explain these differences.

METHODS

Convenience samples of medical students from three countries (US, China, and a Middle Eastern country whose name remains anonymous per request from the school) were surveyed in this observational study. Using the Patient Health Questionnaire-2 (PHQ-2) and a modified Maslach Burnout Inventory, depression and burnout were examined among medical students from the three cohorts (n = 473). Chi-square test and analysis of variance were used to examine differences in demographics, behavioral, and psychological variables across these three schools to identify potentially confounding descriptive characteristics. Analysis of covariance compared depression and the emotional exhaustion component of burnout identified through Principal Component Analysis across countries. Multiple linear regression was used to analyze the impact of demographic, behavioral, and psychological variables on screening positive for depression.

RESULTS

Medical students from the Middle Eastern country had the highest rates of positive depression screens (41.1%), defined as a PHQ-2 score of ≥ 3, followed by China (14.1 %), and then the US (3.8%). More students in the Middle Eastern school had unmet mental health needs (50.8%) than at the medical school in China (34.8%) or the school in the US (32.8%) (Pearson chi-square significance < 0.05). Thus, PHQ-2 scores were adjusted for unmet mental health needs; however, the Middle Eastern country continued to have the highest depression. Adjusting for PHQ-2 score, medical students from the US scored the highest on emotional exhaustion (a measure of burnout). Demographic variables did not significantly predict medical student depression; however, lack of exercise, unmet mental health needs, stress, and emotional exhaustion predicted nearly half of depression in these cohorts. In comparison to the US, coming from the Middle Eastern country and China predicted higher levels of depression.

CONCLUSION

Depression rates differ in three international cohorts of medical students. Measured factors contributed to some observed differences. Identifying site-specific prevention and intervention strategies in medical student mental health is warranted.

When patients hurt us

In this thoughtful article, medical educators in various stages of their careers (resident, mid-career clinician-educators, medical school deans) reflect upon increasing reports of harassment and mistreatment of trainees by patients. In addition to providing a general overview of the limited literature on this topic, the authors describe their own experience collecting information on trainee mistreatment by patients at their institution. They explore the universal difficulty that educators face regarding how to best address this mistreatment and support both faculty and trainees. Given the current sociopolitical climate, there has never been a more urgent need to critically examine this issue. The authors call on the greater medical education community to join them in these important conversations.

Integration of Primary Care and Psychiatry: A New Paradigm for Medical Student Clerkships

BACKGROUND

Public health crises in primary care and psychiatry have prompted development of innovative, integrated care models, yet undergraduate medical education is not currently designed to prepare future physicians to work within such systems.

AIM

To implement an integrated primary care-psychiatry clerkship for third-year medical students.

SETTING

Undergraduate medical education, amid institutional curriculum reform.

PARTICIPANTS

Two hundred thirty-seven medical students participated in the clerkship in academic years 2015-2017.

PROGRAM DESCRIPTION

Educators in psychiatry, internal medicine, and pediatrics developed a 12-week integrated Biopsychosocial Approach to Health (BAH)/Primary Care-Psychiatry Clerkship. The clerkship provides students clinical experience in primary care, psychiatry, and integrated care settings, and a longitudinal, integrated didactic series covering key areas of interface between the two disciplines.

PROGRAM EVALUATION

Students reported satisfaction with the clerkship overall, rating it 3.9-4.3 on a 1-5 Likert scale, but many found its clinical curriculum and administrative organization disorienting. Students appreciated the conceptual rationale integrating primary care and psychiatry more in the classroom setting than in the clinical setting.

CONCLUSIONS

While preliminary clerkship outcomes are promising, further optimization and evaluation of clinical and classroom curricula are ongoing. This novel educational paradigm is one model for preparing students for the integrated healthcare system of the twenty-first century.

Alcohol Withdrawal and Lithium Toxicity: A Novel Psychiatric Mannequin-Based Simulation Case for Medical Students

INTRODUCTION

High-fidelity mannequin-based simulation is frequently used to compliment medical student education during clinical clerkships. However, psychiatric educators have not broadly adopted this modality, focusing rather on standardized patient actors. We developed and delivered a simulation case involving a patient with alcohol withdrawal and lithium toxicity followed by a debriefing session to medical students at the end of their psychiatric clerkship.

METHODS

The case involves a 40-year-old male truck driver with a history of bipolar disorder who presents to the emergency room after a truck accident. The patient is in alcohol withdrawal, which responds to benzodiazepines. A workup reveals that the patient also has lithium toxicity related to the co-ingestion of lithium and naproxen for pain. Participants learn to evaluate and treat alcohol withdrawal, consider medical comorbidities and legal consequences, and complete a brief intervention for substance use. This case requires a simulation mannequin.

RESULTS

To date, 150 second-, third-, and fourth-year medical students have participated in this case and 76 have been surveyed. Participants have provided a postsession rating of 4.49 on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree) on a question about enjoyment, and 3.93 on a question about confidence with evaluation and treatment of patients in alcohol withdrawal.

DISCUSSION

Psychiatric education currently underutilizes mannequin-based simulation compared to other medical disciplines. Mannequin simulation is feasible and effective in psychiatric education, especially in cases involving medical complexity, as shown in this novel case involving a patient with alcohol withdrawal and lithium toxicity.

Development of Geriatric Mental Health Learning Objectives for Medical Students: A Response to the Institute of Medicine 2012 Report

America is aging as the population of older adults increases. The shortage of geriatric mental health specialists means that most geriatric mental healthcare will be provided by physicians who do not have specialty training in geriatrics. The Institute of Medicine Report of 2012 highlighted the urgent need for development of national competencies and curricula in geriatric mental health for all clinicians. Virtually all physicians can expect to treat older patients with mental health symptoms, yet currently there are no widely accepted learning objectives in geriatric mental health specific for medical students. The authors describe the development of a set of such learning objectives that all medical students should achieve by graduation. The iterative process included initial drafting by content experts from five medical schools with input and feedback from a wider group of geriatric psychiatrists, geriatricians, internists, and medical educators. The final document builds upon previously published work and includes specific knowledge, attitudes and skills in six key domains: Normal Aging, Mental Health Assessment of the Geriatric Patient, Psychopharmacology, Delirium, Depression, and Dementia. These objectives address a pressing need, providing a framework for national standards and curriculum development.

Integration of Basic and Clinical Science in the Psychiatry Clerkship

OBJECTIVE

Integration of basic and clinical science is a key component of medical education reform, yet best practices have not been identified. The authors compared two methods of basic and clinical science integration in the psychiatry clerkship.

METHODS

Two interventions aimed at integrating basic and clinical science were implemented and compared in a dementia conference: flipped curriculum and coteaching by clinician and physician-scientist. The authors surveyed students following each intervention. Likert-scale responses were compared.

RESULTS

Participants in both groups responded favorably to the integration format and would recommend integration be implemented elsewhere in the curriculum. Survey response rates differed significantly between the groups and student engagement with the flipped curriculum video was limited.

CONCLUSIONS

Flipped curriculum and co-teaching by clinician and physician-scientist are two methods of integrating basic and clinical science in the psychiatry clerkship. Student learning preferences may influence engagement with a particular teaching format.

Mental health self-care in medical students: a comprehensive look at help-seeking

OBJECTIVE

The authors characterize medical student help-seeking behaviors and examine the relationship with stress, burnout, stigma, depression, and personal health behaviors.

METHODS

In 2013, the authors administered an electronic survey of all enrolled students at Yale School of Medicine (183 responders, response rate=35 %), inquiring about students' primary medical and mental health care, personal health behaviors, support systems, and help-seeking behaviors. Students completed the Attitudes to Mental Health Questionnaire, the Patient Health Questionnaire-2, and a modified Maslach Burnout Inventory. The authors analyzed the results with logistic regression, the Wilcoxon rank-sum test, the Kruskal-Wallis test, or a test for significance of Kendall rank correlation.

RESULTS

Most students reported having a primary care provider (PCP), yet few reported seeking care when sick (33 %). Nineteen percent of students reported having a mental health provider, fewer than reported having a PCP (p<0.0001). Twenty-five percent of students reported increased mental health needs since beginning medical school, and these students were more likely to agree that their needs were untreated. The majority of students endorsed stress, which correlated with increased and unmet mental health needs (p<0.001). Burnout peaked in second- and third-year students and correlated with stress and increased and untreated needs. Most students reported comfort with asking for academic help; those uncomfortable were more likely to have mental health needs for which they did not seek treatment (p=0.004). Mental health stigma was low.

CONCLUSIONS

Medical students had a significant unmet need for health care, influenced by barriers to accessing care, stress, burnout, and depression. Academic help seeking and supportive faculty relationships appear related to mental health treatment seeking. Targeted interventions for stress and burnout reduction, as well as incorporation of reflective practice, may have an impact on overall care seeking among medical students. Future studies should expand to other medical and professional schools.

Depressive symptoms related to infertility and infertility treatments

This article reviews depressive symptoms in women as they relate to infertility and infertility treatments. Common causes of infertility in women are discussed and the literature on depressive symptoms before and during various infertility treatments is presented. Recommendations are made from a psychiatric perspective regarding how to manage depressive symptoms in women in the context of infertility.

Clinical utility of the Hopkins Competency Assessment Test on an inpatient geropsychiatry unit

This study examined the clinical use of routine administration of the Hopkins Competency Assessment Test on an inpatient geropsychiatry unit. The purpose was to determine whether the Hopkins Competency Assessment Test results influenced the psychiatrist's capacity assessment or confidence in that determination. The test was administered to all patients admitted voluntarily during an 18-week period. The attending psychiatrist determined treatment consent capacity and rated confidence in that determination, before and after review of the test results. Fifty seven patients were assessed. After review of the test results, the psychiatrist's capacity rating changed in only 2 (3.5%) cases. However, the test increased the psychiatrist's confidence ratings, particularly among the patients with cognitive impairment. The Hopkins Competency Assessment Test is not suited for routine administration among geropsychiatry inpatients. However, the test may serve a role as a supplementary tool for assessing treatment consent capacity among patients with evidence of cognitive impairment.

Use of gabapentin in the treatment of behavioural and psychological symptoms of dementia: a review of the evidence

Behavioural and psychological symptoms of dementia (BPSD) have been defined as a heterogeneous range of psychological reactions, psychiatric symptoms and behaviours that may be unsafe, disruptive and impair the care of a patient in a given environment. To date, there are no US FDA-approved drugs or clear standards of pharmacological care for the treatment of BPSD. The novel antiepileptic agent gabapentin is being increasingly considered for use in the geriatric population because of its relatively favourable safety profile compared with other classes of psychiatric medications. Gabapentin has been administered to several geriatric patients with bipolar disorder and patients with dementia. It has also been reported to be successful in the treatment of a 13-year-old boy with behavioural dyscontrol, a finding that suggested a possible role for gabapentin in the treatment of other behavioural disorders. The purpose of this review was to find evidence for the use of gabapentin in the treatment of BPSD. To this end, a search was performed for case reports, case series, controlled trials and reviews of gabapentin in the treatment of this condition. The key words 'dementia', 'Alzheimer's disease' and 'gabapentin' were used. Searches were performed in PubMed, PsycINFO, Ovid MEDLINE, Cochrane Library and ClinicalTrials.gov. The search revealed that there are limited data on the efficacy of gabapentin for BPSD in the form of 11 case reports, 3 case series and 1 retrospective chart review; no controlled studies appear to have been published to date on this topic. In most of the reviewed cases, gabapentin was reported to be a well tolerated and effective treatment for BPSD. However, two case reports in which gabapentin was used in the context of agitation in dementia with Lewy bodies questioned the appropriateness of gabapentin for all types of dementia-related agitation. The dearth of available data limits support for the off-label use of gabapentin for the treatment of BPSD. Furthermore, controlled studies should be conducted before gabapentin can be clinically indicated for the successful treatment of BPSD.

Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: a review of the literature

Electroconvulsive therapy (ECT) is well established as a safe and effective treatment for several psychiatric disorders. Responsiveness to ECT does not abate with age, and data indicate that the use of ECT in the treatment of psychiatric disorders in the elderly persons has increased in recent decades. Special consideration must be given to the baseline cognitive abilities of an elderly patient prior to treatment with ECT. Much of the literature on the use of ECT in the elderly persons has focused on the treatment of mood disorders, whereas less research has been devoted to its use in the treatment of other psychiatric conditions. Although depressive syndromes remain the most common indication for ECT in the elderly persons, clinicians treating elderly patients should remain aware of the safety and efficacy of this treatment modality with other psychiatric disorders. This review examines the literature on the use of ECT in elderly patients with some common neuropsychiatric disorders including catatonia, bipolar mania, schizophrenia, dementia with behavioral disturbance, and Parkinson's disease.

Evaluating the quality of websites offering information on female hypoactive sexual desire disorder

This study evaluates websites relevant to female hypoactive sexual desire disorder (HSDD). Its primary aim is to evaluate the quality of Internet HSDD information. One hundred and one websites, identified through simple Google searches, were scored using a tool incorporating expert consensus-derived quality criteria for HSDD. The tool included structural criteria such as currency, authorship, and disclosure of competing interests. It also included performance criteria, evaluating accuracy, and comprehensiveness, and was adapted from a published website evaluation tool for diabetes. For each website, a quality index score with a potential range from 1 to 5 (1 = poor, 5 = excellent) was calculated, and the websites were rank ordered using this score. Quality index scores ranged from 1.68 to 4.64, with 75% of websites scoring at or below 3.27. Test-retest reliability was moderate (n = 24, r = 0.6601, P = .0004). Rank ordering of the websites by quality index allowed identification of the top five highest quality websites. The majority of HSDD websites' quality scores fell in the score range from 1 to 3, indicating room for improvement in the quality of websites that address HSDD. Website evaluation tools utilizing both structural and performance quality criteria may help clinicians to assist their patients in assessing the quality of Internet health information.

Filtration of shed mediastinal blood

Re-infusion of shed blood carries the risk of re-infusing cellular debris. All re-infusion devices have some sort of integral filtration which is variably supplemented with a second intravenous filter. Using electron microscopy we have observed what debris is collected by secondary filtration. In 12 patients studied, nine out of 12 filters had significant amounts of cellular debris present, but not clearly related to increased rates of postoperative bleeding. Noncellular debris, silicon and strands of cellulose were also observed. Although we have not detected any clinically significant embolic phenomena from re-infusion of shed mediastinal blood, it seems prudent to include a second filter prior to re-infusion.

Hazards of parenteral treatment: do particles count?

After prolonged parenteral nutrition a 12 month old infant died with pulmonary hypertension and granulomatous pulmonary arteritis. A review of necropsy findings in 41 infants who had been fed parenterally showed that two of these also had pulmonary artery granulomata, while none of 32 control patients who died from sudden infant death syndrome had similar findings. Particulate contaminants have been implicated in the pathogenesis of such lesions and these were quantified in amino acid/dextrose solutions and fat emulsions using automated particle counting and optical microscope counting respectively. Parenteral feed infusions compounded for a 3000 g infant according to standard nutritional regimens were found to include approximately 37,000 particles between 2 and 100 microns in size in one day's feed, of which 80% were derived from the fat emulsion. In-line end filtration of intravenous infusions may reduce the risk of particle associated complications. A suitable particle filter is required for use with lipid.

Use of cytotoxic drugs with an end-line filter--a study of four drugs commonly administered to paediatric patients

The absorption of Novantrone (Mitozantrone), Adriamycin (Doxorubicin Hydrochloride), Cerubidin (Daunorubicin) and methotrexate to 0.2-microM endotoxin-retentive end-line filters was studied under simulated infusion conditions. The drugs were injected into a burette containing saline and then infused using an infusion pump set at 100 ml/h or 80 ml/h. Filtrate samples were collected over a total period of 2.5 h and assayed spectrophotometrically. Recovery of all four drugs following filtration was 96% or greater; indicating absence of absorption by the end-line filters used.

The migration of bacteria through gels in the presence of IUCD monofilament tails

An in vitro model was developed to investigate the migration of a variety of bacteria of different characteristics through a gel system in the presence or absence of a wide range of polymer monofilament threads. The bacteria were unable to migrate through the gel from the point of inoculation in the absence of a solid substrate. Migration occurred along all thread types tested, including those used as IUCD marker tails and the extent of bacterial migration appeared to be determined primarily by the motility of the microorganisms. The implications of these findings in relation to the development of pelvic infections in IUCD wearers is discussed.