Is MDD the right target for early-stage psychedelic-assisted therapy trials?

The recently published Imperial College study of a Phase II, double-blind, randomized, controlled trial comparing psilocybin-assisted therapy to a six-week titration of escitalopram for Major Depressive Disorder (MDD) should raise concerns for this illness category as a target of early psychedelic research given a goal of FDA approval. There are three reasons why MDD is the wrong target at this stage of research development. Firstly, the psychiatric category of MDD is heterogeneous, vaguely-defined, and overdiagnosed in a way that will problematize finding a reliable signal with psychedelic interventions (or any intervention), particularly within non-severe cases. Secondly, current rating scales for MDD (QIDS used in the Imperial College trial, but also HAM-D) are limited in approximating the kinds of things we ultimately care most about with depressive states, namely functional status, quality of life, and well-being: measures that seem more salient for psychedelic interventions and which are not adequately captured by these rating scales used in a majority of clinical trials. And thirdly, there are inherent conflicts between psychiatric conceptualizations of MDD (and its symptom amelioration) and the kinds of perspectives on one’s suffering often occasioned by psychedelic experiences themselves: while these kinds of psychedelic-catalyzed openings may lead to a form of acceptance or equanimity with regards to one’s life circumstances this could be in many ways orthogonal to reductions in HAM-D scores. We argue that for these reasons MDD is a non-ideal target at this stage of the science and propose alternative directions.

Effect of Amplitude Spectral Area on Termination of Fibrillation and Outcomes in Pediatric Cardiac Arrest

Background Amplitude spectral area (AMSA) predicts termination of fibrillation (TOF) with return of spontaneous circulation (ROSC) and survival in adults but has not been studied in pediatric cardiac arrest. We characterized AMSA during pediatric cardiac arrest from a Pediatric Resuscitation Quality Collaborative and hypothesized that AMSA would be associated with TOF and ROSC. Methods and Results Children aged <18 years with cardiac arrest and ventricular fibrillation were studied. AMSA was calculated for 2 seconds before shock and averaged for each subject (AMSA‐avg). TOF was defined as termination of ventricular fibrillation 10 seconds after defibrillation to any non‐ventricular fibrillation rhythm. ROSC was defined as >20 minutes without chest compressions. Univariate and multivariable logistic regression analyses controlling for weight, current, and illness category were performed. Primary end points were TOF and ROSC. Secondary end points were 24‐hour survival and survival to discharge. Between 2015 and 2019, 50 children from 14 hospitals with 111 shocks were identified. In univariate analyses AMSA was not associated with TOF and AMS‐Aavg was not associated with ROSC. Multivariable logistic regression showed no association between AMSA and TOF but controlling for defibrillation average current and illness category, there was a trend to significant association between AMSA‐avg and ROSC (odds ratio, 1.10 [1.00‒1.22] P =0.058). There was no significant association between AMSA‐avg and 24‐hour survival or survival to hospital discharge. Conclusions In pediatric patients, AMSA was not associated with TOF, whereas AMSA‐avg had a trend to significance for association in ROSC, but not 24‐hour survival or survival to hospital discharge. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02708134.

350 Opioid Use and Abuse are Associated with Use of Sedative Hypnotic Medications

Introduction The Department of Health and Human Services recently reported that 10.3 million people misused opioid drugs in 2018. Recent research attributed 21% of the deaths from opioid overdose to benzodiazepines. The overdose data and clinical experience show that opioid misusers commonly complain of insomnia and use hypnotic medications to self-medicate their sleep disturbance. At the same time, it remains unclear from a scientific perspective whether those who use/abuse opioids are more likely to use drugs in the sedative-hypnotic medication category. Consequently, the present study explores the relationship between comorbid use of opioids and sedative-hypnotic medications. Methods We extracted data from the 2015–2018 waves of the National Survey on Drug Use and Health (N=171,766). The primary outcome was the use of sedative-hypnotic medications, either in the z-class (zaleplon, zolpidem, eszopiclone) or sedating benzodiazepines (temazepam, flurazepam, triazolam). The primary exposures were prescription use of an opioid or abuse of an opioid (i.e., use of an illegal opioid such as heroin or misuse of a prescription opioid). Covariates included age, sex, race, income, education, and predicted mental illness category (none, mild, moderate, severe). Exposures were balanced on covariates using inverse probability of treatment weighting. Sequential binomial logistic regression estimated the association between opioid use/abuse and sedative-hypnotic use after adjusting for covariates. Results Opioid use and abuse varied by age, sex, race, education, and income (all p &lt; 0.001). When adjusted for age, sex, and race (Model 1), sedative benzodiazepine use was more common among opioid users (OR 4.4 [4.04–4.79] and opioid abusers (OR 11.9 [9.72–14.5]). The use of z-class drugs was also more prevalent in opioid users (OR 3.69 [3.48–3.89]) and abusers (OR 7.74 [6.97–8.60]). Further adjusting for income and education (Model 2) and mental illness category (Model 3) attenuated but did not eliminate these associations. Conclusion Individuals who use or abuse opioids are significantly more likely to receive a sedative-hypnotic medication, a finding that is of concern and one that also suggests that sleep disturbance is common in this population. Further research is needed to determine the underlying nature and prevalence of sleep continuity disturbances in this population. Support (if any) VA grant IK2CX000855 and I01 CX001957 (S.C.).

Walking Corpse Syndrome: A trauma-related idiom of distress amongst Sri Lankan Tamils

This article introduces Walking Corpse Syndrome, a common idiom of distress in Tamil Sri Lanka that is characterized by a variety of cognitive difficulties, feelings that an individual is functioning reflexively or impulsively, and acute attacks of dissociation that are accompanied with the sensation of empty-headedness. Walking Corpse Syndrome demonstrates some overlap with Western nosology, although it appears to be its own unique illness category, most likely of Ayurvedic provenance. The article comprises two studies. One is a secondary interview analysis of community members that aimed to identify the key symptoms of Walking Corpse Syndrome, allowing us to determine the local ethnopsychology of the syndrome and to elicit illustrative vignettes. The other study is a survey of Sri Lankan Tamil psychiatrists that aimed to investigate their understanding and experience of the disorder. This article outlines how, in certain cultural contexts, such syndromes emphasise the loss of attentional capacity and forgetfulness; it highlights the importance of “thinking a lot” as an idiom across cultures; and it details the many ways that Walking Corpse Syndrome is a key idiom of distress, in order to assess to give adequate mental healthcare to Sri Lankan Tamil populations.

Abstract 150: Effect of Amplitude Spectral Area on Termination of Fibrillation and Outcomes in Pediatric Cardiac Arrest

Introduction: Amplitude spectral area (AMSA) predicts termination of fibrillation (TOF) with return of spontaneous circulation (ROSC) and hospital survival in adults, but has not been studied during pediatric cardiac arrest (pCA). Hypothesis: We characterized AMSA during pCA from a pediatric resuscitation quality (pediRES-Q) collaborative and hypothesized that AMSA would be associated with TOF and ROSC. Methods: Children <18 years of age with pCA and VF were studied. AMSA was measured for 2 seconds prior to each shock and also averaged for each subject (AMSA-avg). TOF was defined as termination of VF 10 secs after defibrillation (DF) to any rhythm other than VF. ROSC was defined as >20 mins without chest compressions. Univariate and multivariable logistic regression analyses controlling for weight, current, and illness category (cardiac vs non-cardiac) were performed. Primary endpoints were TOF and ROSC without ECMO. Secondary endpoints were 24-hr survival and survival to hospital discharge. Results: Between 2015-2019, 50 children from 14 hospitals (median age 3.7 years [IQR 0.6, 13.1]; median weight 16.3 kgs [IQR 6.9, 37.2]; 46% male; 73% cardiac illness category) were identified. IHCA occurred in 47 children and OHCA in 3 children. We analyzed 111 shocks with median number of DFs 1.0 [IQR 1.0, 3.0], median DF energy dose 3.27 J/kg [IQR 2.65,5.01], median DF current 0.64 A/kg [IQR 0.38,0.96], median AMSA 12.21 [IQR 7.17,17.03], and median AMSA-avg 14.6 [IQR 8.6,19.2]. TOF was achieved in 72 DFs (65%), ROSC without ECMO in 31 (62%), ROC with ECMO in 11 (22%), 24-hr survival in 40 (80%), and survival to hospital discharge in 26 (52%). Weight (OR 0.91 [0.84, 0.99] P=0.025) and DF current (OR 1.44 [0.97, 2.2] P=0.07), but not AMSA, were significantly associated with TOF for the first shock. Controlling for DF current and illness category, there was a significant association between AMSA-avg (OR 1.11 [1.0, 1.24] P=0.044) and ROSC without ECMO. There was no significant association between AMSA-avg and 24-hr survival or survival to hospital discharge. Conclusions: In pediatric patients, TOF was associated with weight and DF current, but not AMSA, whereas AMSA-avg was associated with ROSC without ECMO, but not 24-hr survival or survival to hospital discharge.

Abstract 345: Resuscitation Quality in the Intensive Care Unit- A Retrospective, Observational Study

Background: Adherence to quality metrics during in-hospital cardiac arrest (IHCA) have been associated with improved outcomes, however, quality metric adherence in the intensive care unit (ICU) has not been well described. In this study, we assessed trends in adherence to time to epinephrine ≤ 5 min, time to defibrillation ≤ 2 min, and confirmation of endotracheal airway device placement during IHCA in the ICU and identified potential predictors of adherence failure. Methods: This was an observational study using the Get With The Guidelines® - Resuscitation registry, a United-States based IHCA registry. Adult patients (>18 years) with an index cardiac arrest in adult ICUs between 2006 and 2018 in the US were included. Generalized estimation equations were used for the analyses. Results: We included 75668 patients. From 2006-2018, adherence to time to epinephrine ≤ 5 min increased from 93% (95%CI, 93%-94%) to 98% (95%CI, 97%-98%), time to defibrillation ≤ 2 min went from 71% (95%CI, 68%-75%) to 74% (95% CI, 71%-77%) and confirmation of airway device placement increased from 93% (95%CI, 91%-94%) to 97% (95% CI, 96%-98%). Significant predictors of defibrillation >2 min included a non-cardiac (RR, 1.35; 95%CI, 1.25-1.46) and traumatic (RR, 1.67; 95%CI, 1.34-2.09) illness category, a prior history of renal insufficiency (RR, 1.13; 95%CI, 1.06-1.22), no myocardial infarction (RR, 1.09; 95%CI, 1.00-1.19), no metabolic abnormality (RR, 1.10; 95%CI, 1.01-1.20), events occurring at nighttime (RR, 1.08; 95%CI, 1.01-1.14), an initial PVT as opposed to VF rhythm (RR, 1.10; 95%CI, 1.03-1.16), no arterial line in place at time of event (RR, 1.20; 95%CI, 1.09-1.32), and events occurring at a small hospital (RR, 1.17; 95%CI, 1.02-1.34). Conclusions: Overall, quality metric adherence was high in the ICU, with the exception of time to defibrillation ≤ 2 min. Predictors associated with defibrillation >2 min, included a non-cardiac and traumatic illness category and nighttime arrests.

Analisis Beban Kerja Mental Pada Mekanik Menggunakan Metode SWAT dan Metode QNBM

Mental workload is the difference between the demands of a task workload with the maximum capacity of a person's mental capability in a motivated state. The purpose of this study was to determine the level of the mental burden of mechanics using the SWAT and QNBM methods. The results of the Subjective Workload Assessment Technique method for heavy service workload showed that the mechanics were 56.6% burdened. Mental workload dimensions for mechanics 1 and 3 are effort load, for mechanic 2 is time load. The category for light service is 11.11%, unburdened in the time load dimension for all mechanics. Nordic Body Map Questionnaire Method was 67%, with illness category included.

Pediatric Long-Term Endotracheal Intubation and Role for Tracheostomy: Patient and Provider Factors

Tracheostomy provides an alternative to long-term intubation in patients with respiratory failure, but there is little guidance for its use in pediatric patients. Our study used provider surveys of pediatric intensive care physicians managing patients intubated longer than 14 days to evaluate accuracy of physician estimates for total intubation time and the impact of medical history and illness category on determining tracheostomy placement. Providers' ability to estimate length of intubation was found to be highly inaccurate. With delayed tracheostomy conferring increased risk and mortality, better recommendations regarding indication and timing of pediatric tracheostomy placement are needed.