Despite decades of research, racial and ethnic disparities in behavioral health care persist. The Affordable Care Act expanded access to behavioral health care, but many reform initiatives fail to consider research about racial/ethnic minorities. Mistaken assumptions that underlie the expansion of behavioral health care risk replicating existing service disparities. Based on a review of relevant literature and numerous observational and field studies with minority populations, we identified the following three mistaken assumptions: improvement in health care access alone will reduce disparities, current service planning addresses minority patients’ preferences, and evidence-based interventions are readily available for diverse populations. We propose tailoring the provision of care to remove obstacles that minority patients face in accessing treatment, promoting innovative services that respond to patient needs and preferences, and allowing flexibility in evidence-based practice and the expansion of the behavioral health workforce. These proposals should help meet the health care needs of a growing racial/ethnic minority population.

Context Latino immigrants constitute a large portion of the Spanish and U.S. immigrant populations, yet a dearth of research exists regarding barriers to retention in behavioral health care. Objectives To identify and compare perceived barriers related to behavioral health care among first and second generation Latinos in Boston, Madrid, and Barcelona, and evaluate whether the frequency of behavioral health care use in the last year was related to these barriers. Design, Setting and Participants Data come from the International Latino Research Partnership project. First or second generation self-identified Latino immigrants ages 18+ who resided more than one year in the host country were recruited from community agencies and primary care, mental health, substance abuse, and HIV clinics. Main Outcome Measures Eleven barriers were assessed and compared across sites. The relationship between barriers and behavioral services visits within the last year was evaluated, adjusting for socio-demographics, clinical measures, degree of health literacy, cultural and social factors. Results Wanting to handle the problem on one's own, thinking that treatment would not work, and being unsure of where to go or who to see were the most frequently reported barriers for Latino immigrants. Previous treatment failure, difficulties in transportation or scheduling, and linguistic barriers were more likely to be reported in Boston; trying to deal with mental health problems on one's own was more commonly reported in Barcelona and Madrid. Two barriers associated with number of visits were concerns about the cost of services and uncertainty about where to go or who to see. Conclusions After adjusting for socio-demographics, clinical measures, degree of health literacy, cultural and social factors, barriers still differed significantly across sites. Efforts to improve behavioral health services must be tailored to immigrants' context, with attention to changing attitudes of self-reliance and outreach to improve access to and retention in care.

Purpose: As the COVID-19 pandemic continues to evolve, the healthcare system has been forced to adapt in myriad ways. Residents have faced significant changes in work schedules, deployment to COVID-19 units, and alterations to didactics. This study aims to identify the effects of the COVID-19 pandemic on resident perception of their own education within the Nuvance Health Network. Methods: We conducted an observational study assessing resident perception of changes in education and lifestyle during the COVID-19 pandemic. A survey was developed to assess the quality and quantity of resident education during this time and administered anonymously to all residents within the healthcare network. Results: Eighty-four (68%) residents responded to the survey from 5 different specialties, including general surgery, internal medicine, obstetrics and gynecology, pathology, and radiology. The average change in hours per week performing clinical work was −6 hours (SD = 17; P = .003), in time studying was +0 hours (SD = 5; P = .96), in weekly didactics was −2 hours (SD = 3; P < .001), and in attending involvement was −1 hours (SD = 2; P < .001). Additionally, 32% of residents expressed concern that the pandemic has diminished their preparedness to become an attending, 13% expressed concern about completing graduation requirements, and 3% felt they would need an additional year of training. Conclusion: During the COVID-19 pandemic thus far, residents perceived that time spent on organized didactics/conferences decreased and that attending physicians are less involved in education. Furthermore, the majority of residents felt that the quality of didactic education diminished as a result of the pandemic. Surprisingly, while many residents expressed concerns about being prepared to become an attending, few were concerned about completing graduation requirements or needing an extra year of education. In light of these findings, it is critical to devote attention to the effects of the pandemic on residents’ professional trajectories and create innovative opportunities for improving education during this challenging time.

Purpose We identify the prevalence and correlates of posttraumatic stress (PTSD) symptoms and their relationship to alcohol and substance use disorders (AUD/SUD) among Latino immigrants in two countries. Methods A screening battery assessing PTSD symptoms (PCL-C), alcohol use (AUDIT), drug abuse (DAST), and psychological measures was administered to 567 Latino immigrants recruited in clinics. We used logistical regression analyses to evaluate the relationship between PTSD symptoms and AUD/SUD. Results Prevalence of elevated PTSD symptoms was high (53.7% in Boston, 48.0% in Madrid and, 43.8% in Barcelona). Screening positive for psychological measures was significantly correlated to screening positive on the PCL-C (p<0.001). Significant gender differences in risk of AUD/SUD were moderated by PTSD symptoms. Presence of any PTSD symptoms predicted problems with benzodiazepine misuse. Conclusions Given the high rates of co-morbidity between PTSD symptoms and AUD/SUD, we recommend early interventions for dual pathology for Latino immigrants with trauma history.

Purpose: As the COVID-19 pandemic continues to evolve, the healthcare system has been forced to adapt in myriad ways. Residents have faced significant changes in work schedules, deployment to COVID-19 units, and alterations to didactics. This study aims to identify the effects of the COVID-19 pandemic on resident perception of their own education within the Nuvance Health Network. Methods: We conducted an observational study assessing resident perception of changes in education and lifestyle during the COVID-19 pandemic. A survey was developed to assess the quality and quantity of resident education during this time and administered anonymously to all residents within the healthcare network. Results: Eighty-four (68%) residents responded to the survey from five different specialties, including general surgery, internal medicine, obstetrics and gynecology, pathology, and radiology. The average change in hours per week performing clinical work was -5.6 hours (SD=16.8), in time studying was +0.02 hours (SD=4.6), in weekly didactics was -1.7 hours (SD=3.1), and in attending involvement was -1.2 hours (SD=2.3). Additionally, 32% of residents expressed concern that the pandemic has diminished their preparedness to become an attending, 13% expressed concern about completing graduation requirements, and 3% felt they would need an additional year of training. Conclusions: During the COVID-19 pandemic thus far, residents perceived that time spent on organized didactics/conferences decreased and that attending physicians are less involved in education. Furthermore, the majority of residents felt that the quality of didactic education diminished as a result of the pandemic. Surprisingly, while many residents expressed concerns about being prepared to become an attending, few were concerned about completing graduation requirements or needing an extra year of education. In light of these findings, it is critical to devote attention to the effects of the pandemic on residents' professional trajectories and create innovative opportunities for improving education during this challenging time.

We examine whether patient variables (geographic origin, gender, Spanish language proficiency) and subjective clinician aspects in emergency department psychiatric encounters (diagnostic certainty, clinician’s comfort level with patient) are associated with diagnosis and the use of coercive measures. Using a descriptive cross-sectional design, we recorded 467 visits (400 foreign-born and 67 native-born patients) in hospital psychiatry emergency rooms (ERs) in Barcelona between 2007 and 2015. We first assessed the association of patient variables and subjective clinician aspects of psychiatric encounters with service use outcomes and with mental illness diagnosis. Fitted logistic models predicted the likelihood of service use outcomes and estimated the propensity of receiving each diagnosis. The null model evaluated the role of patient’s geographical origin, while the full model evaluated the additional roles of patient’s gender and language, the clinician’s assessment of the influence of culture in diagnosis, and clinician comfort with two outcomes: patient’s diagnosis and use of coercive measures in the ER. Women were less likely to receive coercive measures or intramuscular medications compared to men. Significant ethnic/racial and gender differences were found in receiving certain diagnoses. Additionally, a patient’s lower Spanish proficiency was correlated with a higher probability of receiving a psychosis diagnosis. The clinician’s level of diagnostic certainty was also positively correlated with increasing clinician-reported comfort with patient. Overall, ethnic factors and the subjective aspects of psychiatric encounters were found to influence diagnosis and the use of coercive measures. Cultural competency programs and interpreter services within psychiatric ER settings should thus be required.

Background: This study aims to identify the effects of the COVID-19 pandemic on surgical resident training and education at Danbury Hospital. Methods: We conducted an observational study at a Western Connecticut hospital heavily affected by the first wave of the COVID-19 pandemic to assess its effects on surgical residents, focusing on surgical education, clinical experience, and operative skills development. Objective data was available through recorded work hours, case logs, and formal didactics. In addition, we created an anonymous survey to assess resident perception of their residency experience during the pandemic. Results: There are 22 surgical residents at our institution; all were included in the study. Resident weekly duty hours decreased by 23.9 hours with the majority of clinical time redirected to caring for COVID-19 patients. Independent studying increased by 1.6 hours (26.2%) while weekly didactics decreased by 2.1 hours (35.6%). The operative volume per resident decreased by 65.7% from 35.0 to 12.0 cases for the period of interest, with a disproportionately high effect on junior residents, who experienced a 76.2% decrease. Unsurprisingly, 70% of residents reported a negative effect of the pandemic on their surgical skills. Conclusions: During the first wave of the COVID-19 pandemic, surgical residents' usual workflows changed dramatically, as much of their time was dedicated to the critical care of patients with COVID-19. However, the consequent opportunity cost was to surgery-specific training; there was a significant decrease in operative cases and time spent in surgical didactics, along with elevated concern about overall preparedness for their intended career.

INTRODUCTION:Magnesium toxicity can occur due to decreased excretion or overconsumption and is rare in the general population. Early-onset symptoms of toxicity are nausea, flushing, weakness, and urinary retention. However, severe toxicity and its management is not well-described. We present a case of magnesium overdose with intractable hypotension. CASE PRESENTATION:A 34-year-old male presented to the emergency department after he was found unresponsive in a restaurant in the presence of empty bottles of magnesium supplements and ibuprofen. He was hypotensive, hypothermic, and emergently intubated for airway protection. His serum magnesium level was 11.7mg/dl. He was treated with gastric decontamination, intravenous calcium and admitted to the intensive care unit. Continuous Renal Replacement Therapy (CRRT) was initiated and led to a reduction in the measured serum magnesium concentration. Despite aggressive volume administration and multiple vasopressors, he had refractory shock and severe acidosis. An echocardiogram revealed adequate cardiac function; hence, he was not a candidate for Extracorporeal Membranous Oxygenation (ECMO). A trial of hydrocortisone and methylene blue also yielded no benefit to his distributive shock. His hospital course was further complicated by abdominal compartment syndrome requiring a bedside exploratory laparotomy, aspiration pneumonia, acute respiratory distress syndrome, and disseminated intravascular coagulation. Ultimately, his family elected to transition to comfort care, and the patient passed away on hospital day 4.DISCUSSION: Magnesium competitively blocks the entry of calcium into presynaptic terminals of smooth muscle cells, inhibiting the release of acetylcholinesterase, causing smooth muscle relaxation. In the setting of an overdose, this translates to refractory vasoplegia. Magnesium also alters the polarization of the cytoplasmic membrane in cardiac myocytes, causing lengthening of the action potential, thus predisposing to arrhythmias. While iatrogenic magnesium toxicity has been reported at levels of 3-5mg/dL, a level of >10mg/dL is uncommon. There may be a dose-dependent refractoriness that has not been identified in the literature so far. Treatment of severe magnesium toxicity requires urgent dialysis in conjunction with IV calcium which acts as an antagonist. If there is catecholamine resistance, methylene blue may be used to restore systemic vascular resistance. CONCLUSIONS:Severe magnesium toxicity can present with shock & acidosis. Despite dialysis and aggressive resuscitation, the vasoplegia can be refractory and lead to fatal complications, including respiratory collapse and cardiac arrest. Even with early recognition and treatment, the mortality can be high, and further studies are needed to improve outcomes.