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Case-Finding for Complex Chronic Conditions in Seniors 75+ (C5-75) is a systematic approach to identify frailty using gait speed and hand-grip strength and to screen for co-morbid conditions. We identified the C5-75 features offering the highest yield for identifying frailty and to streamline the screening program. Analyses included 1,948 C5-75 assessments completed from 2013 to 2018. Age 85 or older, less than regular physical activity, and more than two falls in the previous six months had the strongest associations with frailty. Exempting patients under 85 who reported regular physical activity and less than two falls excluded 39.1 per cent of the cohort while maintaining a sensitivity of 95.2 per cent and a negative predictive value of 99.4 per cent for frailty. These findings provide insight into optimizing screening for frailty, making it more feasible to implement and to identify co-existing conditions that may contribute to or be affected by frailty.
Impairments in social cognition contribute significantly to disability in schizophrenia patients (SzP). Perception of facial expressions is critical for social cognition. Intact perception requires an individual to visually scan a complex dynamic social scene for transiently moving facial expressions that may be relevant for understanding the scene. The relationship of visual scanning for these facial expressions and social cognition remains unknown.
In 39 SzP and 27 healthy controls (HC), we used eye-tracking to examine the relationship between performance on The Awareness of Social Inference Test (TASIT), which tests social cognition using naturalistic video clips of social situations, and visual scanning, measuring each individual's relative to the mean of HC. We then examined the relationship of visual scanning to the specific visual features (motion, contrast, luminance, faces) within the video clips.
TASIT performance was significantly impaired in SzP for trials involving sarcasm (p < 10−5). Visual scanning was significantly more variable in SzP than HC (p < 10−6), and predicted TASIT performance in HC (p = 0.02) but not SzP (p = 0.91), differing significantly between groups (p = 0.04). During the visual scanning, SzP were less likely to be viewing faces (p = 0.0001) and less likely to saccade to facial motion in peripheral vision (p = 0.008).
SzP show highly significant deficits in the use of visual scanning of naturalistic social scenes to inform social cognition. Alterations in visual scanning patterns may originate from impaired processing of facial motion within peripheral vision. Overall, these results highlight the utility of naturalistic stimuli in the study of social cognition deficits in schizophrenia.
Antisocial behaviour is common among patients with severe mental illness (SMI) requiring hospitalisation.
To determine whether differential treatments and services are provided to patients with SMI who engage in antisocial behaviour.
A random sample of 161 inpatients with SMI were recruited from general adult wards and assessed at baseline and two years later. Information on symptoms, aggressive behaviour, substance misuse, and service use was obtained from patients and clinical files.
Past antisocial behaviours were not associated with type or intensity of treatments and services. Severity of positive symptoms, aggressive behaviour, and illicit drug use were positively associated with the frequency of CMHT contact, but not with the type of CMHT, type of medication, or other treatments and benefits.
While the frequency of meetings with CMHTs increased with the severity of antisocial behaviours, no specific treatments were provided to patients with SMI engaging in antisocial behaviours.
Epidemiologic surveys conducted across Europe indicate that the lifetime prevalence of social anxiety disorder in the general population is close to 7%. The disorder in adulthood rarely presents in its ‘pure’ form and 70–80% of patients have at least one other psychiatric disorder, most commonly depression. Social anxiety disorder is a risk factor for the development of depression and alcohol/substance use or dependence, especially in cases with an early onset (< 15 years). Individuals with social anxiety disorder have significant functional impairment, notably in the areas of initiation and maintenance of social/romantic relationships and educational and work achievement. The economic consequences of social anxiety disorder are considerable, with a high level of diminished work productivity, unemployment and an increased utilisation of medical services amongst sufferers. Effective treatment of social anxiety disorder would improve its course and its health and economic consequences.
Inner-city youth suffer a high burden of mental illness and seek health care on an episodic basis (McCreary, 2001).
These youth tend to receive limited support services due to a lack of continuity of care as they move from child to adult services. Other barriers include homelessness and substance use.
The Vancouver Inner City Youth Mental Health Program (ICYMHP) is a psychiatry led initiative to provide psychiatric services and further collaboration between inner-city youth agencies providing care to at risk youth.
To introduce and review a collaborative model of care between psychiatric services and community based organizations.
To review the demographics, presentations and outcomes of youth assessed through the ICYMHP.
A chart review of all clients assessed through the program from its inception (November 2007) to May 2009 (18 months).
Results from clients seen between November 2007 and June 2008 indicate an incidence of psychosis of 40% in men and 21% in women. Mood disorders were the primary diagnosis in 18% of men and 29% of women. Active substance misuse is high (71% of men, cannabis as drug of choice; 54% of women, methamphetamine as drug of choice). Length of stay at Covenant House nearly tripled for those under the care of the ICYMH versus the general shelter population, a positive outcome (21 days versus 9).
Inner-city homeless youth suffer from a high burden of mental illness. A collaborative model of care exists to improve health care quality and delivery to this population.
Some clinicians consider depot antipsychotics to be stigmatizing and coercive. Former coercion studies have predominantly considered hospital admission rather than medication. This cross-sectional study investigated patients' perspectives of coercion for depot and oral antipsychotics.
72 participants, with schizophrenia or schizoaffective disorder on voluntary maintenance medication were randomly selected for further in-depth interviews as a sub-sample from an antipsychotic attitudinal study. The MacArthur Admission Experience (short form) was adapted to explore coercion regarding medication. Scores were compared for formulation groups (depot versus oral).
Only 9 (12.5%) had no concerns about coercion. Coercion scores were higher for depot than oral in terms of total score (mean 4.39 vs 2.80, p=0.027), perceived coercion (2.52 vs 1.73, p=0.041) and negative pressures subscales (1.17 vs 0.33, p=0.009). No significant differences were found for the “voice” subscale (0.70 vs 0.73) and affective reactions. Specifically, more participants on depot felt that people try to force them to take medication (30% vs 2%, p<0.001).
To our knowledge, this is study is unique in that it reports specifically on coercion regarding both depot and oral antipsychotics, using systematic quantitative methodology. Participants felt that treatment with depots was more coercive than with oral antipsychotics and was associated with a relative lack of true autonomy. One reason for this might be that depots are “given” rather than “taken”; thus the “power of others” may be seen as more potent. Greater perceived coercion may explain why some consider depots to be a more stigmatizing form of treatment.
Cannabis use has demonstrated an association with earlier onset of psychosis. Investigation of sociodemographic and clinical characteristics in association with cannabis use in adults with first-episode psychosis (FEP) has resulted in inconsistent findings. The clinical profile of cannabis users amongst adolescents with FEP remain widely understudied.
To investigate the frequency of cannabis use, and its association with sociodemographic and clinical characteristics in adolescent-versus adult-onset FEP.
Naturalistic cross-sectional study of 1363 FEP cases aged 14-35 (136 with adolescent-onset psychosis) referred to Early Intervention Services for psychosis in London (UK) (2003-2009). Sociodemographic and clinical data (age of psychosis onset, symptom domains, substance misuse, insight, violence, global functioning, and duration of untreated psychosis [DUP]) were collected at entry to EIS.
Cannabis users were more likely to be male (78.2%), White (43.0%) and unemployed (72.0%). No significant difference was found in cannabis abuse/dependence frequencies between adolescents (28.4%) and adults (24.7%). Cannabis abuse/dependence was associated with an earlier onset of psychosis by 2 years (p<0.001), greater manic and positive symptoms (p<0.001), increased violence (p=0.011), and poorer functioning (p=0.013) and insight (p=0.003). For adolescents, cannabis abuse/dependence was associated with greater positive symptoms, poorer functioning and longer DUP.
Cannabis use shapes the clinical presentation of FEP individuals. Similar frequencies of cannabis use between age groups suggest that substance misuse services should be provided to all, aiming to reducing consumption. Greater vigilance amongst clinicians would enable earlier detection of psychosis in substance misusing adolescents, to reduce DUP and minimise associated poor outcomes.
Internally displaced persons (IDPs) reach almost 6% of Georgia's total population. They were uprooted by the military conflicts in Abkhazia and South Ossetia in the 1990s and the brief but intensive war with Russia in 2008.
To examine the patterns of mental disorders and functional disability among conflict-affected populations in Georgia.
The study used a cross-sectional household survey design with multi-stage random sampling IDPs and “returnees” (IDPs who have returned to their original villages). Disorders of PTSD, depression, anxiety, and their co-morbidity, were measured, along with functional disability. A range of questions on exposure to violent and traumatic events and demographic and socio-economic characteristics were included. Descriptive and multivariate regression analyses were used.
Of 3600 respondents, 24% were recorded with PTSD, 14% with depression, 11% with anxiety. 30% of all respondents had ≥1 condition and 6% had all 3. Factors significantly associated with the mental disorders and their comorbidity included greater frequency of exposure to traumatic events, female gender, older age, displacement status, low levels of neighbourhood support, poor community conditions, and a bad economic situation. PTSD mediated the influence of traumatic events on outcomes of depression and anxiety. All 3 disorders significant influenced functional disability.
The study provides the most comprehensive data on mental health problems among conflict-affected populations in Georgia. It highlights the persisting burden of poor mental health and the associated characteristics, and the significant impact of mental disorders on functional disability. It calls for greater access to needs-driven mental health services.
To enhance the performance evaluation of Clinical and Translational Science Award (CTSA) hubs, we examined the utility of advanced bibliometric measures that go beyond simple publication counts to demonstrate the impact of translational research output.
The sampled data included North Carolina Translational and Clinical Science Institute (NC TraCS)-supported publications produced between September 2008 and March 2017. We adopted advanced bibliometric measures and a state-of-the-art bibliometric network analysis tool to assess research productivity, citation impact, the scope of research collaboration, and the clusters of research topics.
Totally, 754 NC TraCS-supported publications generated over 24,000 citation counts by April 2017 with an average of 33 cites per article. NC TraCS-supported research papers received more than twice as many cites per year as the average National Institute of Health-funded research publications from the same field and time. We identified the top productive researchers and their networks within the CTSA hub. Findings demonstrated the impact of NC TraCS in facilitating interdisciplinary collaborations within the CTSA hub and across the CTSA consortium and connecting researchers with right peers and organizations.
Both improved bibliometrics measures and bibliometric network analysis can bring new perspectives to CTSA evaluation via citation influence and the scope of research collaborations.
The symptoms of bipolar disorder are sometimes misrecognised for unipolar depression and inappropriately treated with antidepressants. This may be associated with increased risk of developing mania. However, the extent to which this depends on what type of antidepressant is prescribed remains unclear.
To investigate the association between different classes of antidepressants and subsequent onset of mania/bipolar disorder in a real-world clinical setting.
Data on prior antidepressant therapy were extracted from 21,012 adults with unipolar depression receiving care from the South London and Maudsley NHS Foundation Trust (SLaM). multivariable Cox regression analysis (with age and gender as covariates) was used to investigate the association of antidepressant therapy with risk of developing mania/bipolar disorder.
In total, 91,110 person-years of follow-up data were analysed (mean follow-up: 4.3 years). The overall incidence rate of mania/bipolar disorder was 10.9 per 1000 person-years. The peak incidence of mania/bipolar disorder was seen in patients aged between 26 and 35 years (12.3 per 1000 person-years). The most frequently prescribed antidepressants were SSRIs (35.5%), mirtazapine (9.4%), venlafaxine (5.6%) and TCAs (4.7%). Prior antidepressant treatment was associated with an increased incidence of mania/bipolar disorder ranging from 13.1 to 19.1 per 1000 person-years. Multivariable analysis indicated a significant association with SSRIs (hazard ratio 1.34, 95% CI 1.18–1.52) and venlafaxine (1.35, 1.07–1.70).
In people with unipolar depression, antidepressant treatment is associated with an increased risk of subsequent mania/bipolar disorder. These findings highlight the importance of considering risk factors for mania when treating people with depression.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Mood instability is an important problem but has received relatively little research attention. Natural language processing (NLP) is a novel method, which can used to automatically extract clinical data from electronic health records (EHRs).
To extract mood instability data from EHRs and investigate its impact on people with mental health disorders.
Data on mood instability were extracted using NLP from 27,704 adults receiving care from the South London and Maudsley NHS Foundation Trust (SLaM) for affective, personality or psychotic disorders. These data were used to investigate the association of mood instability with different mental disorders and with hospitalisation and treatment outcomes.
Mood instability was documented in 12.1% of people included in the study. It was most frequently documented in people with bipolar disorder (22.6%), but was also common in personality disorder (17.8%) and schizophrenia (15.5%). It was associated with a greater number of days spent in hospital (B coefficient 18.5, 95% CI 12.1–24.8), greater frequency of hospitalisation (incidence rate ratio 1.95, 1.75–2.17), and an increased likelihood of prescription of antipsychotics (2.03, 1.75–2.35).
Using NLP, it was possible to identify mood instability in a large number of people, which would otherwise not have been possible by manually reading clinical records. Mood instability occurs in a wide range of mental disorders. It is generally associated with poor clinical outcomes. These findings suggest that clinicians should screen for mood instability across all common mental health disorders. The data also highlight the utility of NLP for clinical research.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
There are often substantial delays before diagnosis and initiation of treatment in people bipolar disorder. Increased delays are a source of considerable morbidity among affected individuals.
To investigate the factors associated with delays to diagnosis and treatment in people with bipolar disorder.
Retrospective cohort study using electronic health record data from the South London and Maudsley NHS Foundation Trust (SLaM) from 1364 adults diagnosed with bipolar disorder. The following predictor variables were analysed in a multivariable Cox regression analysis on diagnostic delay and treatment delay from first presentation to SLaM: age, gender, ethnicity, compulsory admission to hospital under the UK Mental Health Act, marital status and other diagnoses prior to bipolar disorder.
The median diagnostic delay was 62 days (interquartile range: 17–243) and median treatment delay was 31 days (4–122). Compulsory hospital admission was associated with a significant reduction in both diagnostic delay (hazard ratio 2.58, 95% CI 2.18–3.06) and treatment delay (4.40, 3.63–5.62). Prior diagnoses of other psychiatric disorders were associated with increased diagnostic delay, particularly alcohol (0.48, 0.33–0.41) and substance misuse disorders (0.44, 0.31–0.61). Prior diagnosis of schizophrenia and psychotic depression were associated with reduced treatment delay.
Some individuals experience a significant delay in diagnosis and treatment of bipolar disorder, particularly those with alcohol/substance misuse disorders. These findings highlight a need to better identify the symptoms of bipolar disorder and offer appropriate treatment sooner in order to facilitate improved clinical outcomes. This may include the development of specialist early intervention services.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The Nilgiri tahr Nilgiritragus hylocrius is an Endangered species of mountain ungulate endemic to the Western Ghats of India, a biodiversity hotspot. Habitat fragmentation, hunting and a restricted range are the major threats to this species. Although several surveys have assessed the species’ status, a population estimate based on a scientifically robust method is needed. We used the double-observer method to estimate the population of the Nilgiri tahr in the Anamalai Tiger Reserve, a protected area in the Western Ghats. We walked 257 km of transects across the Reserve, covering 36 grassland blocks (i.e. clusters of montane grasslands that were relatively separate from each other). We counted a minimum of 422 individuals in 28 groups, and estimated the tahr population in the study area to be 510 individuals (95% CI 300–858) in 35 groups. The male:female ratio was 0.71 and the young:female ratio was 0.56. Comparing our estimate with previous surveys suggests that the Nilgiri tahr population in Anamalai Tiger Reserve is stable. We found the double-observer survey method to be appropriate for population estimation and long-term monitoring of this species, and make recommendations for improved field protocols to facilitate the implementation of the method in the tropical mountains of the Western Ghats. Our findings suggest that the Reserve harbours 20–25% of the global population of the Nilgiri tahr, highlighting the area's importance for the conservation of this species.
Flucytosine, CAS #2022-85-7, crystallizes in the tetragonal space group P41212 (#94) with a = 6.643768(27), c = 23.89009(10) Å, V = 1054.500(7) Å3, and Z = 8. In this work, the sample was obtained from the United States Pharmacopeial Convention (USP) Lot #R03100 and analyzed as-received. The room temperature (295 K) crystal structure was refined using synchrotron (λ = 0.412826 Å) powder diffraction data and optimized using the density functional theory (DFT). When looking down the a-axis, the crystal structure consists of multiple ribbon-like structures stacked into columns. The powder X-ray diffraction pattern of the compound has been submitted to ICDD® for inclusion in the Powder Diffraction File™ (PDF®). The agreement of the Rietveld-refined and DFT-optimized structures is good, with the largest difference in the external amine group with an overall root mean displacement of 0.056 Å. There is also evidence of unit cell expansion at higher temperatures, as the volume of the unit cell at 298 K was 1.6–1.9% greater than the two unit cells obtained at 150 K. A N–H⋯O hydrogen bond exists in the inter-ribbon region between the flucytosine molecules, resulting in a 3D hydrogen bond network.
The Ross procedure involves using the native pulmonary valve for aortic valve replacement then replacing the pulmonary valve with an allograft or xenograft. We aimed to compare our age-matched experience with the bovine jugular vein conduit and the pulmonary homograft for pulmonary valve replacement during the Ross procedure in children.
Between 1998 and 2016, 15 patients <18 years of age underwent a Ross procedure using the bovine jugular vein conduit (Ross-Bovine Jugular Vein Conduit) at our institution. These patients were age-matched with 15 patients who had the Ross operation with a standard pulmonary homograft for right ventricular outflow tract reconstruction (Ross-Pulmonary Homograft). Paper and electronic medical records were retrospectively reviewed.
The median age of the Ross-Bovine Jugular Vein Conduit and Ross-Pulmonary Homograft patients were 4.8 years (interquartile range 1.1–6.6) and 3.3 years (interquartile 1.2–7.6), respectively (p = 0.6). The median follow-up time for the Ross-Bovine Jugular Vein Conduit and Ross-Pulmonary Homograft groups were 1.7 years (interquartile range 0.5–4.9) and 6.8 years (interquartile range 1.9–13.4), respectively (p = 0.03). Overall, 5-year survival, freedom from redo aortic valve replacement, and freedom from pulmonary valve replacement were similar between groups.
The bovine jugular vein conduit and pulmonary homograft have favourable mid-term durability when used for right ventricular outflow tract reconstruction for the Ross operation. The bovine jugular vein conduit may be a suitable replacement for appropriately sized patients undergoing a Ross aortic valve replacement, though longer follow-up is needed.
Stenting of ostial pulmonary artery stenosis presents several unique challenges. These include difficulty in defining anatomy and need for precise stent placement in order to avoid missing the ostial stenosis or jailing either the contralateral branch pulmonary artery or the ipsilateral upper lobe branch.
A retrospective review of outcomes was conducted in 1.5 or 2-ventricle patients who underwent stent placement for ostial branch pulmonary artery stenosis. Specific catheterisation lab techniques were reviewed.
Forty-seven branch pulmonary arteries underwent stent placement for ostial stenosis in 43 patients. The median age and weight were 3.7 (0.3–18.1) years and 14.2 (5.6–70.0) kg, respectively. Three (2–8) angiographic projections were needed to profile the ostial stenosis. Open-cell stents were used in 23 and stents were modified in 5 cases. Following stent implantation, the minimum diameter improved from 3.6 (0.8–10.5) to 8.1 (4.2–16.5) mm (p < 0.001). The gradient improved from 21 (0–66) to 4 (0–27) mmHg (p < 0.001). Stent malposition occurred in eight (17%) of the stents placed. Five migrated distally causing suboptimal ostial coverage necessitating placement of a second stent in four. Three migrated proximally and partially jailed the contralateral pulmonary artery. Intentional jailing of the upper lobe branch occurred in four additional cases. At a follow-up of 2.4 (0.3–4.9) years, 15 stents underwent further dilation and 1 had a second stent placed within the exiting stent.
Ostial branch pulmonary artery stenosis may require additional angiography to accurately define the ostial stenosis. Treatment with stents is effective but carries high rates of stent malposition.
Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship.
Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression.
Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies.
Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non–ID-trained pharmacists and clinicians in antibiotic stewardship.