Medication Adherence in a Transdiagnostic First-Episode Psychosis Sample.

Objective: Medication adherence is an important component of treatment and has the potential to influence illness trajectory in individuals with first-episode psychosis (FEP). We sought to examine time to medication non-adherence as well as factors related to non-adherence in a real-world FEP clinic.Methods: We conducted a survival analysis to examine time to medication non-adherence using data extracted from medical records of patients admitted to a FEP clinic at an academic psychiatric hospital between May 2012 and October 2017 (n = 219). The risk pool included patients who were adherent during the first 6 months in the clinic (n = 122). Data were extracted for the entire length of participants' time in the clinic, up to 66 months. Pre-selected clinical and demographic variables of interest were extracted and entered into a Cox proportional hazards model.Results: Of the risk pool of 122 patients, 37 (30%) had documented non-adherence events. The risk of non-adherence was 0.35 (95% CI, 0.25-0.46) and 0.49 (95% CI, 0.37-0.63) at the 24- and 36-month time points, respectively, and plateaued after 36 months. Non-White race (adjusted HR = 3.69; P = .003; 95% CI, 1.57-8.70), lack of insight in the prior 6 months (adjusted HR = 3.24; P = .005; 95% CI, 1.43-7.35), and substance use in the prior 6 months (adjusted HR = 2.58; P = .022; 95% CI, 1.15-5.81) were significant predictors of non-adherence.Conclusions: Clinicians should consider efforts to strengthen therapeutic alliance with non-White patients, improve insight, and help patients reduce or cease substance use when supporting medication adherence in the FEP population.

Catatonia in a 6-year-old Patient Following Disseminated Group A Streptococcus Infection.

Pediatric catatonia is a complex entity that is easily missed in the hospital setting and seldom reported in the literature. Here, we present the case of a 6-year-old previously healthy female patient who was initially thought to have intractable delirium secondary to disseminated Group A streptococcus (GAS) infection. Careful examination, utilization of the Pediatric Catatonia Rating Scale, and lorazepam challenge were key to elucidating the diagnosis. While GAS is most often associated with pediatric acute-onset neuropsychiatric syndrome (PANS) in the child and adolescent population, we reviewed the limited literature to suggest a mechanism by which it can lead to catatonia. Further systematic study of catatonia in the pediatric population is warranted to better understand pathogenesis and long-term neuropsychiatric outcomes.

Neurodevelopmental Effects of Cannabis Use in Adolescents and Emerging Adults with ADHD: A Systematic Review.

OBJECTIVE: Systematically review the scientific literature to characterize the effects of cannabis use on brain structure, function, and neurodevelopmental outcomes in adolescents and young adults with ADHD. METHOD: Systematic review following PRISMA guidelines utilizing PubMed, Embase, PsycINFO, and Cochrane CENTRAL trials register from inception until 1 January 2020. Articles that examined the impact of cannabis use on youth with ADHD were included. RESULTS: Eleven studies were identified that compared outcomes for individuals with ADHD who used cannabis or synthetic cannabinoids against those with ADHD who did not. Seven of these studies used neuroimaging techniques, including fMRI, structural MRI, and SPECT. Differential regions of activation were identified, including the right hippocampus and cerebellar vermis, and bilateral temporal lobes. Morphological differences were identified in the right precentral and postcentral gyri, left nucleus accumbens, right superior frontal and postcentral gyri. No study identified any additive or ADHD × cannabis use interaction on neuropsychological tasks of executive function. Two studies found adverse differential impacts of early-onset cannabis use in this population. CONCLUSION: A dearth of evidence is available on the impact of cannabis use on the developing brain and functioning for individuals with ADHD, despite the elevated risk for substance use in this population. The limited, potentially underpowered evidence does not support the hypothesis that cannabis use has a deleterious impact on neuropsychological tasks in transitional age youth with ADHD. Larger and longer-term studies are needed, however, to better inform clinicians and patients as to the impacts of cannabis use in youth with ADHD.

Return to College After a First Episode of Psychosis.

A first episode of psychosis (FEP) can derail a patient's educational goals, including attainment of a college education, and this can have lasting ramifications for socioeconomic and health outcomes. Despite this, few studies have examined return to college, which is an important index of real-world educational success after a FEP. In this study, we conducted a longitudinal medical record review of patients in a transdiagnostic outpatient FEP program and performed survival analysis, setting return to college as the endpoint, among the subset of patients whose college education was interrupted. We found that 82% (93/114) of college-enrolled FEP individuals experienced disruptions to their education after FEP, but that return to college also occurred in a substantial proportion (49/88, 56%) among those on leave who had follow-up data. In this sample, the median time to college return was 18 months. When separated by baseline diagnostic category, FEP patients with affective psychotic disorders (FEAP, n = 45) showed faster time to college return than those with primary psychotic disorders (FEPP, n = 43) (median 12 vs 24 mo; P = .024, unadjusted). When adjusted for having no more than 1 psychiatric hospitalization at intake and absence of cannabis use in the 6 months prior to intake (which were also significant predictors), differences by diagnostic category were more significant (hazard ratio 2.66, 95% CI 1.43-4.94, P = .002). Participation in education is an important outcome for stakeholders, and students with FEP can be successful in accomplishing this goal.

Psychiatry Resident Attitudes Toward Practice Habit Data.

OBJECTIVE: This descriptive study queries the attitudes of psychiatry residents regarding provision of practice habit data to trainees by residency programs, as required by the Accreditation Council for Graduate Medical Education (ACGME). Identifying trainee perspectives may assist program directors in tailoring practice habit data reporting to better engage residents and to increase resident-reported adherence to the ACGME requirement. METHODS: Residents at a large, hospital-based adult psychiatry training program completed an anonymous survey of attitudes regarding practice habit data, including perceptions of the residency program's current reporting, preferences toward mechanisms of delivering this data, and perceived relative utility of five hypothetical domains of practice habit data. RESULTS: Of 61 eligible residents, 52 (85%) completed surveys. Only 29 (56%) recalled receiving prior-year individual practice habit data, and only 10 (19%) recalled receiving team-based data. Seventy-five percent desired more practice habit data. Out of five hypothetical thematic domains for practice habit reporting, residents preferred patient-oriented domains as opposed to process-oriented domains. Resident concerns about dissemination of these data included confidentiality, effect on evaluations, and difficulty translating data to changes in clinical practice. CONCLUSIONS: Residents generally desire increased dissemination of practice habit data that focuses on patient-oriented measures such as adherence to disease-specific guidelines and is both individual and team-based. Residency programs may benefit their trainees and improve resident-reported adherence to the ACGME requirement both by taking resident preferences into account and by addressing concerns about confidentiality when providing practice habit data.

Two-year diagnostic stability in a real-world sample of individuals with early psychosis.

OBJECTIVES: Diagnostic shifts in first episode psychosis (FEP) are not uncommon. Many studies examining diagnostic stability use structured diagnostic interviews. Less is known about the stability of FEP diagnoses made clinically. METHODS: We conducted a retrospective chart review of patients enrolled in a transdiagnostic FEP clinic. For the 96 patients followed clinically at least 2 years, we compared diagnoses at intake and 24 months. RESULTS: Diagnostic stability was high for bipolar disorder (89%), schizoaffective disorder (89%), and schizophrenia (82%). Psychosis not otherwise specified (13%) was more unstable, with limited baseline differences that would enable clinicians to predict who would convert to a primary psychotic vs affective psychotic disorder. CONCLUSIONS: Our real-world clinical sample shows that FEP diagnoses, with the exception of unspecified psychosis, are diagnostically stable, even without structured diagnostic interviews.

Improving Communication Between Nursing Staff and On-Call Residents via a Standardized Paging Protocol.

OBJECTIVES: Clear and efficient communication between nursing staff and medical providers is an essential component of healthcare delivery. At McLean Hospital, there is an inconsistency in utilization of alphanumeric paging, with many individuals communicating primarily via numeric-only pages that can cause difficulty in triaging importance of pages and lead to disruptions in care. This quality improvement project sought to improve communication between nursing staff and residents by decreasing the number of difficult to triage pages sent to the psychiatrist-on-call at a stand-alone academic psychiatric hospital. METHODS: Pages were analyzed during two discrete month-long periods before and after the implementation of a standardized paging protocol, which included an updated online template asking the individual sending the page to include specific information (urgency of page, identifying information of patient, contact information, and name of sender) and dissemination of information on its use. RESULTS: The implementation of this protocol resulted in a statistically significant decrease in the percentage of pages that were difficult to triage (22.1 to 15.0%; p < 0.05). Examining specific units in the hospital revealed significant variation of change, with as much as 40% reduction to as large as an 11% increase in difficult to triage pages. CONCLUSIONS: The decrease in the percentage of difficult to triage pages suggests that a standard paging protocol can improve delivery of patient care by minimizing interruptions with low-priority pages and may improve quality of communication between nursing staff and physicians on-call, ultimately improving quality of care provided and bettering the resident learning environment.

Verbalizing, visualizing, and navigating: The effect of strategies on encoding a large-scale virtual environment.

Using novel virtual cities, we investigated the influence of verbal and visual strategies on the encoding of navigation-relevant information in a large-scale virtual environment. In 2 experiments, participants watched videos of routes through 4 virtual cities and were subsequently tested on their memory for observed landmarks and their ability to make judgments regarding the relative directions of the different landmarks along the route. In the first experiment, self-report questionnaires measuring visual and verbal cognitive styles were administered to examine correlations between cognitive styles, landmark recognition, and judgments of relative direction. Results demonstrate a tradeoff in which the verbal cognitive style is more beneficial for recognizing individual landmarks than for judging relative directions between them, whereas the visual cognitive style is more beneficial for judging relative directions than for landmark recognition. In a second experiment, we manipulated the use of verbal and visual strategies by varying task instructions given to separate groups of participants. Results confirm that a verbal strategy benefits landmark memory, whereas a visual strategy benefits judgments of relative direction. The manipulation of strategy by altering task instructions appears to trump individual differences in cognitive style. Taken together, we find that processing different details during route encoding, whether due to individual proclivities (Experiment 1) or task instructions (Experiment 2), results in benefits for different components of navigation-relevant information. These findings also highlight the value of considering multiple sources of individual differences as part of spatial cognition investigations. (PsycINFO Database Record

The Difference a Decade Makes: Smoking Cessation Counseling and Screening at Pediatric Visits.

INTRODUCTION: There has been a sharp decline in adolescents who smoke cigarettes but no national-level study evaluating the impact of smoking cessation counseling by pediatricians or other clinicians who care for children. METHODS: Combined data from ambulatory portions of the National Hospital Ambulatory Care Survey and National Ambulatory Medical Care Survey from 1997-1999 and 2009-2011 were analyzed to determine changes in the frequency of pediatric visits that included clinician-reported tobacco counseling and how such counseling varied by child, family, and clinician characteristics. RESULTS: In 1997-1999, 1.5% of all medical visits for children aged below 19 years included tobacco counseling; this increased to 3.8% in 2009-2011 (P < .001). A marked increase from 4.1% to 11.1% was noted at well-child visits (P < .001). There were significant increases in counseling by pediatricians but not mid-level providers or general/family physicians. Provision of counseling did not result in greater visit length during either time point. During 2009-2011, visits with a diagnosis of asthma were four times as likely (OR 4.2, 95% CI 2.8-6.2) and visits for otitis media two times as likely (OR 2.1, 95% CI 1.2-3.7) to include smoking cessation counseling than sick visits for all other diagnoses. CONCLUSION: These results demonstrate a significant increase in tobacco counseling by pediatric providers within the last decade, especially at well-child visits. However, the American Academy of Pediatrics' recommendation that pediatricians counsel about the harms of tobacco use and secondhand smoke exposure has not yet been exhaustively implemented. IMPLICATIONS: A significant increase in smoking cessation counseling at pediatric medical appointments, especially at well-child visits, occurred from 2009-2011 compared with 1997-1999, paralleling a large decrease in smoking prevalence. These improvements in counseling rates have been predominantly noted for pediatricians but not mid-level providers or general practitioners. Counseling was not associated with increased visit lengths. Although improved counseling practices by pediatricians have been demonstrated, there is still room for improvement.

Storytelling in the context of vaccine refusal: a strategy to improve communication and immunisation.

The December 2014 outbreak of measles in California impacted over 100 children and served as a reminder that this disease still plagues the USA, even 50 years following the first licensed vaccine. Refusal of vaccination is a complicated and multifaceted issue, one that clearly demands a closer look by paediatricians and public health officials alike. While medical doctors and scientists are trained to practice 'evidence-based medicine', and studies of vaccine safety and efficacy speak the language of statistics, there is reason to believe that this is not the most effective strategy for communicating with all groups of parents. Herein, we consider other methods such as narrative practices that employ stories and appeal more directly to parents. We also examine how doctors are trained to disseminate information and whether there are reasonable supplementary methods that could be used to improve vaccine communication and ultimately immunisation rates.

Childhood vaccination requirements: Lessons from history, Mississippi, and a path forward.

Mississippi consistently leads the United States in childhood vaccination with a greater than 99% measles-mumps-rubella vaccination rate for children entering kindergarten. The story of how this came to pass in a state that lags behind on nearly every other public health measure is pertinent given the recent outbreaks of measles in the United States, especially in pockets of the country where there is strong resistance to vaccination. The fight against compulsory vaccination law is centuries old and the enduring success of Mississippi at repelling challenges to their vaccination requirements is a testament to the public health infrastructure and legal framework established in the state. Herein we trace the anti-vaccination movement from its origins in England up until the present time in the United States and explore how Mississippi has established a model vaccination system. Seminal court cases and legislation are evaluated for their impact. Finally, contemporary battles over vaccination legislation are examined and the feasibility of national-level change is considered.

An Exploration of Online Behaviors and Social Media Use Among Hookah and Electronic-Cigarette Users.

INTRODUCTION: The purpose of this study was to explore the relationship between social norms and attitudes towards ENDS and hookah and use of these products. METHODS: We conducted surveys with hookah and ENDS users who regularly used the Internet and social media and analyzed the primary social media account (e.g. Facebook) of each participant, coding all references to nicotine or tobacco products. The survey included domains on perceived favorability, perceived vulnerability and subjective norms. RESULTS: We surveyed 21 ENDS users and 20 hookah users. Both groups used the Internet to look up information about their respective tobacco product (95% for hookah vs. 90% for ENDS). Seventy percent of hookah users had references to hookah on their social media profiles while 43% of ENDS users had references to ENDS on their page. The majority of both groups were exposed to content posted by friends in their social media network about their respective products online. Those who posted on social media about hookah and those who read about ENDS online had lower perceived vulnerability to the health risks associated with tobacco products. CONCLUSIONS: Hookah and ENDS users actively use the Internet and social media to obtain and share information about nicotine/tobacco products. Study participants who use hookah were more likely to share photos and discuss hookah related activities via social media than those who use ENDS. Social networks also represent valuable and untapped potential resources for communicating with this group about risks and harm reduction related to emerging nicotine/tobacco products.

Pharmacological Smoking Cessation Therapies in Older Adults: A Review of the Evidence.

Nearly 12% of adults 65 years and over in Europe and 9% in the USA are current cigarette smokers. Numerous studies have demonstrated tangible benefits of smoking cessation, regardless of advanced age. However, it is unclear which pharmacotherapy strategies are most effective in the elderly population. To that end, the literature on smoking cessation in older adults was reviewed with the aim of identifying the safest and most effective cessation pharmacotherapies. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for all articles pertaining to elderly smoking cessation strategies. Randomized controlled trials and cohort studies were included. Studies were included without regard to population or intervention, as long as results were analyzed with a group of smokers aged 60 years and above and at least one arm of the study involved a pharmacotherapy. Only 12 studies were identified that met our inclusion criteria. The limited existing literature does not allow for a definitive answer to the most effective pharmacotherapy for smoking cessation in older adult smokers. Nicotine replacement therapy (NRT) is the pharmacotherapy most studied in older adults, and the limited evidence that exists suggests that NRT is effective for smoking cessation among this population. Higher-quality studies that directly compare cessation strategies, including bupropion and varenicline, are needed in the older population in order to guide treatment decision making.

Persistent racial and ethnic differences in location of death for children with cancer.

BACKGROUND: Approximately one in 285 children will be diagnosed with cancer before reaching their 20th birthday. While both oncologists and parents report a preference that these children die at home rather than in a hospital, there are limited data exploring this issue in depth. PROCEDURE: We performed a retrospective analysis of national-level data from 1999 to 2011 from the National Center for Health Statistics "Underlying Cause of Death" database. Characteristics investigated included sex, race, age, ethnicity, cancer type, geographic location, and population density where the child lived. RESULTS: Of the 2,130 children with a death attributable to neoplasm in 2011, 37.6% (95% CI, 35.5-39.6%) died at home compared to 36.9% (95% CI, 35.0-38.8%) in 1999. In 2011, there were statistically significant racial differences between white, black, and Hispanic children across nearly every age group, with white children consistently most likely to die at home. Children of non-Hispanic origin were significantly more likely to die at home than Hispanic children (40.3% vs. 29.3%, P < 0.001). Children with CNS tumors are more likely to die at home than children with neoplasms as a whole, while children with leukemia are less likely. Statistically significant differences by race and ethnicity persist regardless of cancer type. CONCLUSIONS: There has been no significant change in the rate of children with cancer who die at home over the past decade. Racial and ethnic differences have persisted in end of life care for children with cancer with white non-Hispanic children being most likely to die at home.

Tracking Hookah Bars in New York: Utilizing Yelp as a Powerful Public Health Tool.

BACKGROUND: While cigarette use has seen a steady decline in recent years, hookah (water pipe) use has rapidly increased in popularity. While anecdotal reports have noted a rise in hookah bars, methodological difficulties have prevented researchers from drawing definitive conclusions about the number of hookah bars in any given location. There is no publicly available database that has been shown to reliably provide this information. It is now possible to analyze Internet trends as a measure of population behavior and health-related phenomena. OBJECTIVE: The objective of the study was to investigate whether Yelp can be used to accurately identify the number of hookah bars in New York State, assess the distribution and characteristics of hookah bars, and monitor temporal trends in their presence. METHODS: Data were obtained from Yelp that captures a variety of parameters for every business listed in their database as of October 28, 2014, that was tagged as a "hookah bar" and operating in New York State. Two algebraic models were created: one estimated the date of opening of a hookah bar based on the first Yelp review received and the other estimated whether the bar was open or closed based on the date of the most recent Yelp review. These findings were then compared with empirical data obtained by Internet searches. RESULTS: From 2014 onward, the date of the first Yelp review predicts the opening date of new hookah bars to within 1 month. Yelp data allow the estimate of such venues and demonstrate that new bars are not randomly distributed, but instead are clustered near colleges and in specific racial/ethnic neighborhoods. New York has seen substantially more new hookah bars in 2012-2014 compared with the number that existed prior to 2009. CONCLUSIONS: Yelp is a powerful public health tool that allows for the investigation of various trends and characteristics of hookah bars. New York is experiencing tremendous growth in hookah bars, a worrying phenomenon that necessitates further investigation.