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An electronic health record-based intervention to increase follow-up office visits and decrease rehospitalization in older adults

Wed, 09/24/2014 - 9:05am

OBJECTIVES: To assess the effect of an electronic health record-based transitional care intervention involving automated alerts to primary care providers and staff when older adults were discharged from the hospital.

DESIGN: Randomized controlled trial.

SETTING: Large multispecialty group practice.

PARTICIPANTS: Individuals aged 65 and older discharged from hospital to home.

INTERVENTION: In addition to notifying primary care providers about the individual's recent discharge, the system provided information about new drugs added during the inpatient stay, warnings about drug-drug interactions, recommendations for dose changes and laboratory monitoring of high-risk medications, and alerts to the primary care provider's support staff to schedule a posthospitalization office visit.

MEASUREMENTS: An outpatient office visit with a primary care provider after discharge and rehospitalization within 30 days after discharge.

RESULTS: Of the 1,870 discharges in the intervention group, 27.7% had an office visit with a primary care provider within 7 days of discharge. Of the 1,791 discharges in the control group, 28.3% had an office visit with a primary care provider within 7 days of discharge. In the intervention group, 18.8% experienced a rehospitalization within the 30-day period after discharge, compared with 19.9% in the control group. The hazard ratio for an office visit with a primary care physician did not significantly differ between the intervention and control groups. The hazard ratio for rehospitalization in the 30-day period after hospital discharge in the intervention versus the control group was 0.94 (95% confidence interval = 0.81-1.1).

CONCLUSION: This electronic health record-based intervention did not have a significant effect on the timeliness of office visits to primary care providers after hospitalization or risk of rehospitalization. Geriatrics Society.

Rates of insurance for injured patients before and after health care reform in Massachusetts: a possible case of double jeopardy

Wed, 09/24/2014 - 9:05am

OBJECTIVES: We determined how preinjury insurance status and injury-related outcomes among able-bodied, community-dwelling adults treated at a Level I Trauma Center in central Massachusetts changed after health care reform.

METHODS: We compared insurance status at time of injury among non-Medicare-eligible adult Massachusetts residents before (2004-2005) and after (2009-2010) health care reform, adjusted for demographic and injury covariates, and modeled associations between insurance status and trauma outcomes.

RESULTS: Among 2148 patients before health care reform and 2477 patients after health care reform, insurance rates increased from 77% to 84% (P < .001). Younger patients, men, minorities, and penetrating trauma victims were less likely to be insured irrespective of time period. Uninsured patients were more likely to be discharged home without services (adjusted odds ratio = 3.46; 95% confidence interval = 2.65, 4.52) compared with insured patients.

CONCLUSIONS: Preinjury insurance rates increased for trauma patients after health care reform but remained lower than in the general population. Certain Americans may be in "double jeopardy" of both higher injury incidence and worse outcomes because socioeconomic factors placing them at risk for injury also present barriers to compliance with an individual insurance mandate.

Trends in stroke rates, risk, and outcomes in the United States, 1988 to 2008

Wed, 09/24/2014 - 9:05am

BACKGROUND: Stroke is a major cause of morbidity and mortality. We describe trends in the incidence, outcomes, and risk factors for stroke in the US Medicare population from 1988 to 2008.

METHODS: We analyzed data from a 20% sample of hospitalized Medicare beneficiaries with a principal discharge diagnosis of ischemic (n = 918,124) or hemorrhagic stroke (n = 133,218). Stroke risk factors were determined from the National Health and Nutrition Examination Survey (years 1988-1994, 2001-2008) and medication uptake from the Medicare Current Beneficiary Survey (years 1992-2008). Primary outcomes were stroke incidence and 30-day mortality after stroke hospitalization.

RESULTS: Ischemic stroke incidence decreased from 927 per 100,000 in 1988 to 545 per 100,000 in 2008, and hemorrhagic stroke decreased from 112 per 100,000 to 94 per 100,000. Risk-adjusted 30-day mortality decreased from 15.9% in 1988 to 12.7% in 2008 for ischemic stroke and from 44.7% to 39.3% for hemorrhagic stroke. Although observed stroke rates decreased, the Framingham stroke model actually predicted increased stroke risk (mean stroke score 8.3% in 1988-1994, 8.8% in 2005-2008). Statin use in the general population increased (4.0% in 1992, 41.4% in 2008), as did antihypertensive use (53.0% in 1992, 73.5% in 2008).

CONCLUSIONS: Incident strokes in the Medicare population aged >/=65 years decreased by approximately 40% over the last 2 decades, a decline greater than expected on the basis of the population's stroke risk factors. Case fatality from stroke also declined. Although causality cannot be proven, declining stroke rates paralleled increased use of statins and antihypertensive medications.

Long-term survival for patients with acute decompensated heart failure according to ejection fraction findings

Wed, 09/24/2014 - 9:05am

Limited data exist about the long-term prognosis of patients with acute decompensated heart failure (ADHF) further stratified according to ejection fraction (EF) findings. The primary objective of this population-based observational study was to characterize and compare trends in long-term prognosis after an episode of ADHF across 3 EF strata. Hospital medical records were reviewed for 3,604 residents of the Worcester, Massachusetts, metropolitan area who were discharged after ADHF from all 11 medical centers in central Massachusetts during 1995, 2000, 2002, and 2004 and had EF measurements during their index hospitalizations. The average age of this population was 75 years, most were white, and 44% were men. Approximately 49% of the population had heart failure (HF) with preserved EF (EF >/=50%), 37% had HF with reduced EF (EF

Congenital and acquired disorders presenting as psychosis in children and young adults

Tue, 09/16/2014 - 3:18pm

A review of the published literature found 60 congenital and acquired disorders with symptoms that include psychosis in youth. The prevalence, workup, genetics, and associated neuropsychiatric features of each disorder are described. Eighteen disorders (30%) have distinct phenotypes (doorway diagnoses); 18 disorders (30%) are associated with intellectual disability; and 43 disorders (72%) have prominent neurologic signs. Thirty-one disorders (52%) can present without such distinct characteristics, and are thus more easily overlooked. A systematic and cost-effective differential diagnostic approach based on estimated prevalence and most prominent associated signs is recommended.

Predictive accuracy in the neuroprediction of rearrest

Tue, 09/16/2014 - 3:18pm

A recently published study by the present authors reported evidence that functional changes in the anterior cingulate cortex within a sample of 96 criminal offenders who were engaged in a Go/No-Go impulse control task significantly predicted their rearrest following release from prison. In an extended analysis, we use discrimination and calibration techniques to test the accuracy of these predictions relative to more traditional models and their ability to generalize to new observations in both full and reduced models. Modest to strong discrimination and calibration accuracy were found, providing additional support for the utility of neurobiological measures in predicting rearrest.

Changes in pro-inflammatory cytokines and body weight during 6-month risperidone treatment in drug naive, first-episode schizophrenia

Tue, 09/16/2014 - 3:18pm

OBJECTIVE: The present study aimed to examine the changes in pro-inflammatory cytokines and body weight during 6-month risperidone treatment in drug naive, first-episode schizophrenia. METHODS: Sixty-two drug naive, first-episode schizophrenia (SZ group) and 60 healthy individuals (control group) were enrolled in the study. Serum interleukin-1beta (IL-1beta), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha) levels, and body weight were measured at baseline for both groups, and repeated for the SZ group at five different time points during 6-month risperidone treatment. RESULTS: At baseline, serum IL-1beta, IL-6, and TNF-alpha levels in the SZ group (53.28 +/- 12.62, 33.98 +/- 14.13, 50.08 +/- 12.86 pg/mL, respectively) were significantly higher than those in the control group (23.49 +/- 15.27, 15.53 +/- 7.16, 32.12 +/- 15.23 pg/mL, respectively) (p's < 0.001). Within the SZ group, serum IL-1beta levels decreased significantly at 2 weeks (48.02 +/- 16.00 pg/mL, p < 0.01) and 1 month (44.70 +/- 16.63 pg/mL, p < 0.001), but then gradually increased at 2 months (48.49 +/- 18.87 pg/mL), 3 months (50.59 +/- 18.48 pg/mL) and 6 months (53.64 +/- 16.22 pg/mL) to the levels comparable to baseline; serum IL-6 levels changed significantly over the course of treatment (p = 0.001), but reached the levels comparable to baseline at 6 months (37.13 +/- 13.23 pg/mL); serum levels of TNF-alpha increased significantly at 3 months (55.02 +/- 16.69 pg/mL, p < 0.01) and 6 months (58.69 +/- 13.57 pg/mL, p < 0.001); steady and significant weight gain was observed at each follow-up time point (p's < 0.001), from 56.71 +/- 9.25 kg at baseline to 62.72 +/- 9.53 kg at 6 months. CONCLUSIONS: Risperidone treatment is associated with changes in serum pro-inflammatory cytokines levels and weight. There is an initial anti-inflammatory effect that reduces with treatment, potentially due to its weight gain side effect.

The NIH Toolbox Cognition Battery: results from a large normative developmental sample (PING)

Tue, 09/16/2014 - 3:18pm

OBJECTIVE: The NIH Toolbox Cognition Battery (NTCB) was designed to provide a brief, efficient computerized test of key neuropsychological functions appropriate for use in children as young as 3 years of age. This report describes the performance of a large group of typically developing children and adolescents and examines the impact of age and sociocultural variables on test performance. METHOD: The NTCB was administered to a sample of 1,020 typically developing males and females ranging in age from 3 to 20 years, diverse in terms of socioeconomic status (SES) and race/ethnicity, as part of the new publicly accessible Pediatric Imaging, Neurocognition, and Genetics (PING) data resource, at 9 sites across the United States. RESULTS: General additive models of nonlinear age-functions were estimated from age-differences in test performance on the 8 NTCB subtests while controlling for family SES and genetic ancestry factors (GAFs). Age accounted for the majority of the variance across all NTCB scores, with additional significant contributions of gender on some measures, and of SES and race/ethnicity (GAFs) on all. After adjusting for age and gender, SES and GAFs explained a substantial proportion of the remaining unexplained variance in Picture Vocabulary scores. CONCLUSIONS: The results highlight the sensitivity to developmental effects and efficiency of this new computerized assessment battery for neurodevelopmental research. Limitations are observed in the form of some ceiling effects in older children, some floor effects, particularly on executive function tests in the youngest participants, and evidence for variable measurement sensitivity to cultural/socioeconomic factors.

Influence of sex and menopausal status on response, remission, and recurrence in patients with recurrent major depressive disorder treated with venlafaxine extended release or fluoxetine: analysis of data from the PREVENT study

Tue, 09/16/2014 - 3:18pm

OBJECTIVE: To evaluate the effects of sex and menopausal status on acute-, continuation-, and maintenance-phase treatment outcomes in patients with recurrent major depressive disorder (MDD). METHOD: This was a secondary analysis of data from the Prevention of Recurrent Episodes of Depression With Venlafaxine for Two Years (PREVENT) trial, a multiphase, multicenter, double-blind study in which adult outpatients with recurrent MDD (by DSM-IV criteria) were randomly assigned to 10 weeks of acute-phase venlafaxine extended release (ER) (75-300 mg/d) or fluoxetine (20-60 mg/d). Patients achieving response or remission had 6 months of continuation-phase treatment. Responding or remitting patients in the venlafaxine ER group were randomly assigned to venlafaxine ER or placebo for 2 consecutive 12-month maintenance phases; fluoxetine-treated patients continued receiving fluoxetine. The outcome measures for this analysis were acute- and continuation-phase response and remission rates (as measured by the 17-item Hamilton Depression Rating Scale) and time to depression recurrence in the maintenance phases according to sex and menopausal status at baseline. RESULTS: The intent-to-treat population comprised 781 patients in the venlafaxine ER group (65% women) and 266 patients in the fluoxetine group (61% women); 64% of all women were premenopausal, and 25% were postmenopausal (5% perimenopausal; not analyzed). At acute-phase end, remission rates in the venlafaxine ER vs fluoxetine groups were 44% vs 47% in men, 51% vs 52% in women, 50% vs 52% in premenopausal women, and 52% vs 55% in postmenopausal women. At continuation-phase end, remission rates in the venlafaxine ER vs fluoxetine groups were 71% vs 74% in men, 72% vs 67% in women, 72% vs 69% in premenopausal women and 71% vs 63% in postmenopausal women. Response rates were consistent with these findings. Based on a Cox proportional hazards model, sex was not a significant predictor of recurrence during the first or second maintenance phase (hazard ratio [HR] = 1.233; P = .3712 and HR = 1.103; P = .8075, respectively), and neither was menopausal status at acute-phase baseline (HR = 0.941; P = .8234 and HR = 0.531; P = .2065, respectively). CONCLUSIONS: In this study of patients with recurrent MDD, treatment outcomes with venlafaxine ER and fluoxetine did not differ on the basis of sex or menopausal status. Our confidence in these findings is limited by the lack of a placebo arm during the acute and continuation phases and by the small sample sizes for subgroup analyses in the maintenance phases. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00046020.

Structure-centered portal for child psychiatry research

Tue, 09/16/2014 - 3:18pm

The real world needs of the clinical community require a domain-specific solution to integrate disparate information available from various web-based resources for data, materials, and tools into routine clinical and clinical research setting. We present a child-psychiatry oriented portal as an effort to deliver a knowledge environment wrapper that provides organization and integration of multiple information and data sources. Organized semantically by resource context, the portal groups information sources by context type, and permits the user to interactively "narrow" or "broaden" the scope of the information resources that are available and relevant to the specific context. The overall objective of the portal is to bring information from multiple complex resources into a simple single uniform framework and present it to the user in a single window format.

Psychopathic traits modulate brain responses to drug cues in incarcerated offenders

Tue, 09/16/2014 - 3:18pm

Recent neuroscientific evidence indicates that psychopathy is associated with abnormal function and structure in limbic and paralimbic areas. Psychopathy and substance use disorders are highly comorbid, but clinical experience suggests that psychopaths abuse drugs for different reasons than non-psychopaths, and that psychopaths do not typically experience withdrawal and craving upon becoming incarcerated. These neurobiological abnormalities may be related to psychopaths' different motivations for-and symptoms of-drug use. This study examined the modulatory effect of psychopathic traits on the neurobiological craving response to pictorial drug stimuli. Drug-related pictures and neutral pictures were presented and rated by participants while hemodynamic activity was monitored using functional magnetic resonance imaging. These data were collected at two correctional facilities in New Mexico using the Mind Research Network mobile magnetic resonance imaging system. The sample comprised 137 incarcerated adult males and females (93 females) with histories of substance dependence. The outcome of interest was the relation between psychopathy scores (using the Hare Psychopathy Checklist-Revised) and hemodynamic activity associated with viewing drug-related pictures vs. neutral pictures. There was a negative association between psychopathy scores and hemodynamic activity for viewing drug-related cues in the anterior cingulate, posterior cingulate, hippocampus, amygdala, caudate, globus pallidus, and parts of the prefrontal cortex. Psychopathic traits modulate the neurobiological craving response and suggest that individual differences are important for understanding and treating substance abuse.

The relationship between change in apathy and changes in cognition and functional outcomes in currently non-depressed SSRI-treated patients with major depressive disorder

Tue, 09/16/2014 - 3:18pm

AIMS: Apathy in the context of treated major depressive disorder (MDD) is a frequently observed phenomenon in clinical practice. This study aimed to assess the validity of the Rothschild Scale for Antidepressant Tachyphylaxis(R) (RSAT) and the Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire (CPFQ) for measuring apathy, and to assess the relationship between apathy and possible contributing factors, in patients with MDD and residual apathy in the absence of depressed mood. METHODS: The underlying structure and validity of the RSAT and CPFQ were assessed via factor analysis and correlation with the Apathy Evaluation Scale-Clinician rated version (AES-C) in 483 patients who had previously responded to treatment with a selective serotonin reuptake inhibitor. The relationship between apathy and contributing variables was investigated via structural equation modeling. Correlation and regression analyses were conducted to examine the relationship between the Sheehan Disability Scale (SDS) and the RSAT, CPFQ, and AES-C. RESULTS: The RSAT and CPFQ were validated with the AES-C with respect to energy and motivation. The latent variable "Energy and Interest", based on the energy, motivation, and interest items (RSAT and CPFQ), was a major contributing factor to apathy. Improvements in function (SDS) were significantly correlated with, and predicted by, improvements in apathy and cognitive and physical functioning (assessed by the RSAT, CPFQ, and AES-C). CONCLUSIONS: These analyses provide further information on apathy and its assessment in the context of treated MDD. A better understanding of apathy will aid further investigation of this phenomenon and, ultimately, determination of the most appropriate approach for its clinical management.

The Development of Comorbid Conduct Problems in Children With ADHD: An Example of an Integrative Developmental Psychopathology Perspective

Tue, 09/16/2014 - 3:18pm

Objective: We describe interactions among factors that contribute to the development of conduct problems among children with ADHD. Method: An integrative developmental psychopathology analysis combines various approaches and posits one model of how diverse risk factors operate together to contribute to the development of conduct problems among children with ADHD. Results: Substantial genetic risk increases covariation between ADHD and conduct problems. Candidate genes are associated with CNS monoaminergic neurotransmission. Subsequent neurodevelopmental impairment interferes with executive function, with impaired verbal working memory playing an important role. Parent/child bi-directional influences exacerbate the risk for conduct problems when ADHD symptoms increase the likelihood of a coercive parenting style. Parent stress in reaction to child comorbid ADHD and conduct problems, and parent attribution for the child's conduct problem behavior, add to the potential for coercion and reduce constructive parent-child interaction that might otherwise enhance the development of verbal working memory. Conclusion: In an integrated manner, these variables increase the risk that a child with ADHD will subsequently develop conduct problems. (J. of Att. Dis. 2013; XX(X) 1-XX).

Exploring Knowledge Exchange at the Research-Policy-Practice Interface in Children's Behavioral Health Services

Tue, 09/16/2014 - 3:18pm

This case study explored core components of knowledge exchange among researchers, policymakers, and practitioners within the context of the Rosie D. versus Romney class action lawsuit in Massachusetts and the development and implementation of its remedial plan. We identified three distinct, sequential knowledge exchange episodes with different purposes, stakeholders, and knowledge exchanged, as decision-making moved from Federal Medicaid policy to state Medicaid program standards and to community-level practice. The knowledge exchanged included research regarding Wraparound, a key component of the remedial plan, as well as contextual information critical for implementation (e.g., Federal Medicaid policy, managed care requirements, community organizations' characteristics).

Enhancement in cognitive function recovery by granulocyte-colony stimulating factor in a rodent model of traumatic brain injury

Tue, 09/16/2014 - 3:18pm

Traumatic brain injury (TBI) is characterized by neuronal damage and commonly, secondary cell death, leading to functional and neurological dysfunction. Despite the recent focus of TBI research on developing therapies, affective therapeutic strategies targeting neuronal death associated with TBI remain underexplored. This study explored the efficacy of granulocyte-colony stimulating factor (G-CSF) as an intervention for improving cognitive deficits commonly associated with TBI. Although G-CSF has been studied with histological techniques, to date, its effects on functional outcome remain unknown. To this end, we used a closed head injury (CHI) model in Wistar rats that were randomly assigned to one of four groups (untreated TBI, G-CSF treated TBI, G-CSF treated Control, Control). The treatment groups were administered subcutaneous injections of G-CSF 30 min (120 mug/kg) and 12 h (60 mug/kg) post-trauma. The Morris Water Maze test was used to measure any treatment-associated changes in cognitive deficits observed in TBI animals at days 2-6 post-injury. Our findings demonstrate a significant improvement in cognitive performance in the G-CSF treated TBI animals within a week of injury, compared to untreated TBI, indicative of immediate and beneficial effect of G-CSF on cognitive performance post CHI. Our model suggests that early G-CSF exposure may be a promising therapeutic approach in recovery of cognitive deficits due to TBI.

A DSM-5 to-do list for adult psychiatry residency directors

Tue, 09/16/2014 - 3:18pm

A small study within the author's department, comparing resident and faculty attitudes toward the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), revealed that the DSM-5 transition process is starting from a point in which neither faculty nor residents are optimistic that the new DSM will result in improved diagnosis or treatment. However, the publication of DSM-5 presents training directors with opportunities to engage trainees in the study of the evolution of psychiatric nosology and the evidence for core psychiatric diagnoses. Residents should be encouraged to become familiar with both DSM-5 and National Institute of Mental Health Research Domain Criteria (NIMH RDoC) categories in their study of the neurobiology of psychiatric disorders. Department chairs are encouraged to establish timelines for the DSM-5 transition for faculty, residents, medical student teaching, medical record keeping, and billing for services. Training directors should be aware that national examinations for trainees will transition gradually between 2014 and 2017, so comparisons should be made whenever possible between DSM-IV-TR and DSM-5. To minimize trainee confusion, departments should attend to the coherence of transition timelines among faculty, resident, and medical student training.

Implementing an intervention for parents with mental illness: Building workforce capacity

Tue, 09/16/2014 - 3:18pm

OBJECTIVE: This article describes the challenges in building workforce capacity when implementing an intervention for families living with parental mental illnesses. METHOD: Data were obtained in the context of a larger, developmental, mixed-methods study. Participants included all agency employees working with families in the Family Options intervention on a daily basis. In-depth interviews were representative of the implementation time frame and activities, and the range of staff members' roles and involvement in the implementation process. Themes emerged as interview transcripts were coded qualitatively using a constant comparative approach. RESULTS: Identifying complex family needs, anticipating the needs of children, and addressing staff needs for training and support were crucial considerations in implementing a family intervention. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: As the psychiatric rehabilitation field acknowledges the impact of family life on adults as well as children, and moves toward family informed services, knowledge of how to shape and support this specialized workforce is essential. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

The role of coping in depression treatment utilization for VA primary care patients

Tue, 09/16/2014 - 3:18pm

OBJECTIVE: To examine the impact of Veterans' coping strategies on mental health treatment engagement following a positive screen for depression. METHODS: A mixed-methods observational study using a mailed survey and semi-structured interviews. Sample included 271 Veterans who screened positive for depression during a primary care visit at one of three VA medical centers and had not received a diagnosis of depression or prescribed antidepressants 12 months prior to screening. A subsample of 23 Veterans was interviewed. RESULTS: Logistic regression models showed that Veterans who reported more instrumental support and active coping were more likely to receive depression or other mental health treatment within three months of their positive depression screen. Those who reported emotional support or self-distraction as coping strategies were less likely to receive any treatment in the same time frame. Qualitative analyses revealed that how Veterans use these and other coping strategies can impact treatment engagement in a variety of ways. CONCLUSIONS: The relationship between Veterans' use of coping strategies and treatment engagement for depression may not be readily apparent without in-depth exploration. PRACTICE IMPLICATIONS: In VA primary care clinics, nurse care managers and behavioral health providers should explore how Veterans' methods of coping may impact treatment engagement.