Predictors of inpatient suicide in an Irish psychiatric service, a longitudinal case-control study.

OBJECTIVE: Inpatient suicide remains difficult to predict. This study aimed to identify individual patient predictors to help identify those at greater risk. METHODS: This case-control study was undertaken in an independent mental health service in Ireland. Cases were drawn from all admissions to the service between March 2004 and February 2019. Controls were matched for date of admission. Univariate and multivariate analyses were conducted. RESULTS: Thirty-three cases of inpatient suicide were compared to 132 controls. The inpatient suicide rate was 76.2 per 100,000 admissions. The rate of inpatient suicide fell in line with national rates despite less restrictive practices being implemented in the service. Males accounted for 66% of cases. Hanging was the most common method of suicide overall and among male patients, and drowning was the most common among females. Male gender, tertiary referral, an adverse psychosocial event during admission, a period of absence without leave and expressing hopelessness were identified as independent risk factors for inpatient suicide. Substance use, involuntary detention, family history of suicide, and number of previous admissions were not significant. CONCLUSIONS: While not highly sensitive, a period of absence without leave, tertiary referral and hopelessness are important predictors of inpatient suicide risk that treating teams should consider in care planning.

Machine-learning based prediction of Cushing's syndrome in dogs attending UK primary-care veterinary practice.

Cushing's syndrome is an endocrine disease in dogs that negatively impacts upon the quality-of-life of affected animals. Cushing's syndrome can be a challenging diagnosis to confirm, therefore new methods to aid diagnosis are warranted. Four machine-learning algorithms were applied to predict a future diagnosis of Cushing's syndrome, using structured clinical data from the VetCompass programme in the UK. Dogs suspected of having Cushing's syndrome were included in the analysis and classified based on their final reported diagnosis within their clinical records. Demographic and clinical features available at the point of first suspicion by the attending veterinarian were included within the models. The machine-learning methods were able to classify the recorded Cushing's syndrome diagnoses, with good predictive performance. The LASSO penalised regression model indicated the best overall performance when applied to the test set with an AUROC = 0.85 (95% CI 0.80-0.89), sensitivity = 0.71, specificity = 0.82, PPV = 0.75 and NPV = 0.78. The findings of our study indicate that machine-learning methods could predict the future diagnosis of a practicing veterinarian. New approaches using these methods could support clinical decision-making and contribute to improved diagnosis of Cushing's syndrome in dogs.

Outcome of First-admission Depression Treated in a Specialized Mood Disorders Service.

OBJECTIVE: Few studies have described the treatment or outcome of depression in specialized mood disorders units (MDUs). Previous studies have focused on cohorts of patients with highly treatment-resistant illness who are likely to have a poor prognosis even with intensive treatment. This study describes the treatment and medium-term outcomes of a cohort of first-admission depressed patients with less treatment-resistant illness treated in a specialized MDU. METHODS: A cohort of 137 consecutive first-admission depressed patients, referred to an MDU over 2 years, were interviewed using standardized schedules and followed up prospectively from admission for ∼18 months to describe baseline characteristics, treatment, outcome, and predictors of outcome. Times to recovery and recurrence were evaluated using survival analyses and predictors of outcome were examined using bivariate and multivariate regression analyses. RESULTS: On admission, 75% of the 137 patients had depression that had been found to be resistant to pharmacological treatment, and 34% had been chronically depressed (>2 y). Over half of the patients had likely maladaptive personality traits and one third had at least 1 comorbid psychiatric disorder. By discharge, a significantly higher proportion of the patients were being prescribed very high (P<0.01) or high doses (P<0.05) of antidepressants, augmentation therapy (P<0.001), or a combination of antidepressants (P<0.001) or were engaged in individual psychotherapy (P<0.001), compared with baseline. With intensive treatment, 62% of the patients recovered by 6 months and 76% by 12 months, with 83% overall recovering and patients found to be asymptomatic during almost 60% of the follow-up period. However, 48% suffered a recurrence over the course of the follow-up. Chronicity of mood episodes (P<0.01) and the presence of psychiatric comorbidity (P<0.05) predicted recurrence. CONCLUSIONS: This prospective, naturalistic, medium-term study describes better outcomes, in terms of recovery and symptomatology over time, in a cohort of first-admission depressed patients than previous first-admission studies after continuous, intensive treatment, although the proportion of patients who experienced recurrences remained high.

Development and internal validation of a prediction tool to aid the diagnosis of Cushing's syndrome in dogs attending primary-care practice.

BACKGROUND: Novel methods to aid identification of dogs with spontaneous Cushing's syndrome are warranted to optimize case selection for diagnostics, avoid unnecessary testing, and ultimately aid decision-making for veterinarians. HYPOTHESIS/OBJECTIVES: To develop and internally validate a prediction tool for dogs receiving a diagnosis of Cushing's syndrome using primary-care electronic health records. ANIMALS: Three hundred and ninety-eight dogs diagnosed with Cushing's syndrome and 541 noncase dogs, tested for but not diagnosed with Cushing's syndrome, from a cohort of 905 544 dogs attending VetCompass participating practices. METHODS: A cross-sectional study design was performed. A prediction model was developed using multivariable binary logistic regression taking the demography, presenting clinical signs and some routine laboratory results into consideration. Predictive performance of each model was assessed and internally validated through bootstrap resampling. A novel clinical prediction tool was developed from the final model. RESULTS: The final model included predictor variables sex, age, breed, polydipsia, vomiting, potbelly/hepatomegaly, alopecia, pruritus, alkaline phosphatase, and urine specific gravity. The model demonstrated good discrimination (area under the receiver operating curve [AUROC] = 0.78 [95% CI = 0.75-0.81]; optimism-adjusted AUROC = 0.76) and calibration (C-slope = 0.86). A tool was developed from the model which calculates the predicted likelihood of a dog having Cushing's syndrome from 0% (score = -13) to 96% (score = 10). CONCLUSIONS AND CLINICAL IMPORTANCE: A tool to predict a diagnosis of Cushing's syndrome at the point of first suspicion in dogs was developed, with good predictive performance. This tool can be used in practice to support decision-making and increase confidence in diagnosis.

Monolayer Doping of Germanium with Arsenic: A New Chemical Route to Achieve Optimal Dopant Activation.

Reported here is a new chemical route for the wet chemical functionalization of germanium (Ge), whereby arsanilic acid is covalently bound to a chlorine (Cl)-terminated surface. This new route is used to deliver high concentrations of arsenic (As) dopants to Ge, via monolayer doping (MLD). Doping, or the introduction of Group III or Group V impurity atoms into the crystal lattice of Group IV semiconductors, is essential to allow control over the electronic properties of the material to enable transistor devices to be switched on and off. MLD is a diffusion-based method for the introduction of these impurity atoms via surface-bound molecules, which offers a nondestructive alternative to ion implantation, the current industry doping standard, making it suitable for sub-10 nm structures. Ge, given its higher carrier mobilities, is a leading candidate to replace Si as the channel material in future devices. Combining the new chemical route with the existing MLD process yields active carrier concentrations of dopants (>1 × 1019 atoms/cm3) that rival those of ion implantation. It is shown that the dose of dopant delivered to Ge is also controllable by changing the size of the precursor molecule. X-ray photoelectron spectroscopy (XPS) data and density functional theory (DFT) calculations support the formation of a covalent bond between the arsanilic acid and the Cl-terminated Ge surface. Atomic force microscopy (AFM) indicates that the integrity of the surface is maintained throughout the chemical procedure, and electrochemical capacitance voltage (ECV) data shows a carrier concentration of 1.9 × 1019 atoms/cm3 corroborated by sheet resistance measurements.

Physician, heal thyself: a cross-sectional survey of doctors' personal prescribing habits.

BACKGROUND: Self-prescribing and prescribing to personal contacts is explicitly discouraged by General Medical Council guidelines. AIMS: This study examines how widespread the practice of self-prescribing and prescribing to personal contacts is. METHODS: A 16-item questionnaire was distributed via an online forum comprising 4445 young medical doctors (representing 20% of all Irish registered doctors), which asked respondents about previous prescribing to themselves, their families, friends and colleagues, including the class of medication prescribed. Demographic details were collected including medical grade and specialty. RESULTS: A total of 729 responses were obtained, the majority of which were from young non-consultant hospital doctors from a range of specialties. Two-thirds of respondents had self-prescribed, over 70% had prescribed to family, and nearly 60% had prescribed to a friend or colleague. Older doctors were more likely to self-prescribe (χ2=17.51, p<0.001). Interns being less likely to self-prescribe was not unexpected (χ2=69.55, p<0.001), while general practitioners (GPs) and paediatricians were more likely to self-prescribe (χ2=13.33, p<0.001; χ2=11.35, p<0.001). GPs, paediatricians and hospital medicine specialties were more likely to prescribe to family (χ2=5.19, p<0.05; χ2=8.38, p<0.05; χ2=6.17, p<0.05) and surgeons were more likely to prescribe to friends (χ2=15.87, p<0.001). Some 3% to 7% who had self-prescribed had prescribed an opiate, benzodiazepine or psychotropic medication. Male doctors, anaesthetists and surgeons were more likely to self-prescribe opioids (χ2=7.82, p<0.01; χ2=7.31, p<0.01; χ2=4.91, p<0.05), while those in hospital medicine were more likely to self-prescribe psychotropic medications (χ2=5.47, p<0.05). CONCLUSION: Prescribing outside the traditional doctor-patient relationship is widespread despite clear professional guidance advising against it.

Detecting false-positive disease references in veterinary clinical notes without manual annotations.

Clinicians often include references to diseases in clinical notes, which have not been diagnosed in their patients. For some diseases terms, the majority of disease references written in the patient notes may not refer to true disease diagnosis. These references occur because clinicians often use their clinical notes to speculate about disease existence (differential diagnosis) or to state that the disease has been ruled out. To train classifiers for disambiguating disease references, previous researchers built training sets by manually annotating sentences. We show how to create very large training sets without the need for manual annotation. We obtain state-of- the-art classification performance with a bidirectional long short-term memory model trained to distinguish disease references between patients with or without the disease diagnosis in veterinary clinical notes.

Phosphorus monolayer doping (MLD) of silicon on insulator (SOI) substrates.

This paper details the application of phosphorus monolayer doping of silicon on insulator substrates. There have been no previous publications dedicated to the topic of MLD on SOI, which allows for the impact of reduced substrate dimensions to be probed. The doping was done through functionalization of the substrates with chemically bound allyldiphenylphosphine dopant molecules. Following functionalization, the samples were capped and annealed to enable the diffusion of dopant atoms into the substrate and their activation. Electrical and material characterisation was carried out to determine the impact of MLD on surface quality and activation results produced by the process. MLD has proven to be highly applicable to SOI substrates producing doping levels in excess of 1 × 1019 cm-3 with minimal impact on surface quality. Hall effect data proved that reducing SOI dimensions from 66 to 13 nm lead to an increase in carrier concentration values due to the reduced volume available to the dopant for diffusion. Dopant trapping was found at both Si-SiO2 interfaces and will be problematic when attempting to reach doping levels achieved by rival techniques.

OA41†How can we support people living with death, dying, loss and care using animation? social workers reflect on the compassionate communities 'let's talk' films.

BACKGROUND: Milford Care Centre's Compassionate Communities Project has developed a series of animated films - The 'Let's Talk' Series. These films are used by the project to encourage people to have think about having difficult conversations about illness and death. The films are available on the project website, via You Tube and are shown during Café Conversations as part of the Compassionate Communities Project. More recently, members of the Specialist Palliative Care Social Work department have been using the films during their direct work with patients and their families. AIM: This presentation aims to introduce participants to the Let's Talk film series and describe the learning from social workers who have used the films at home, and in the inpatient unit, with patients, their partners and their children. METHOD: Social workers were interviewed, sharing their experience and reflection on using the animated films as a practice tool. RESULTS: A number of case studies will be presented to describe the use and impact of the films in practice. CONCLUSION: The films are a very useful addition to the social work toolbox. Guidelines for their use in practice will be presented.

Mauling of the "Celtic Tiger": clinical characteristics and outcome of first-episode depression secondary to the economic recession in Ireland.

BACKGROUND: There is a dearth of studies describing clinical characteristics and outcome of patients who present with mood disorders related to economic recession. AIMS: To describe a cohort of patients admitted with first-episode depression related to the Irish economic recession and compare this cohort with all other first-episode depressives admitted during the same time period (2009-2010). METHODS: A cohort of 137 patients admitted with first-episode depression to an independent university teaching hospital was prospectively identified and followed up from admission over 2 years (mean follow-up 430 days, s.d. 176 days). The cohort was divided into "Celtic Tiger" (patients with first-episode depression secondary to the economic recession) and non-Celtic Tiger control patients (other first-episode depressed patients). Both groups were compared in terms of clinical characteristics at baseline and outcome over follow-up. RESULTS: The number of admissions due to first depressive episodes were higher in recession years 2009/10 than in pre-recession years 2008/9. Celtic Tiger patients were predominantly male and more severely depressed with more marked suicidal ideation (χ(2), p<0.001) than control patients. They were more likely to recover (χ(2), p=0.013), less likely to recur (χ(2), p<0.001) and had faster time to recovery (log rank, p<0.001) and slower time to full recurrence (log rank, p=0.001). The Celtic Tiger patients spent more time asymptomatic and less time at full and subthreshold depression levels over follow-up. LIMITATIONS: Study setting of centre specializing in affective disorders treatment, retrospective nature of follow-up after initial prospective interview and lack of patient follow-up interview. CONCLUSION: The study describes a subgroup of patients with severe depression associated with economic recession with likely high suicide risk but very favourable outcome.

Cannabis and hyperemesis.

The adverse effects of marijuana are well documented, as well as its positive therapeutic uses. Cannabis has traditionally been associated with an antiemetic action following acute ingestion and synthetic cannabinoids have an established use as antiemetics for chemotherapy induced nausea. However, there has been limited recognition of chronic cannabis use as a cause of cyclic vomiting syndrome. Cannabinoid hyperemesis was first identified by Allen er al in 2004. Compulsive bathing was also described as part of the clinical picture. This same syndrome has been confirmed a number of times in the medical literature in the interim. The condition has, to our knowledge, never been reported, in a psychiatric patient.

Suicide and other causes of mortality in bipolar disorder: a longitudinal study.

BACKGROUND: The high risk of suicide in bipolar disorder is well recognized, but may have been overestimated. There is conflicting evidence about deaths from other causes and little known about risk factors for suicide. We aimed to estimate suicide and mortality rates in a cohort of bipolar patients and to identify risk factors for suicide. METHOD: All patients who presented for the first time with a DSM-IV diagnosis of bipolar I disorder in a defined area of southeast London over a 35-year period (1965-1999) were identified. Mortality rates were compared with those of the 1991 England and Wales population, indirectly standardized for age and gender. Univariate and multivariate analyses were used to test potential risk factors for suicide. RESULTS: Of the 239 patients in the cohort, 235 (98.3%) were traced. Forty-two died during the 4422 person-years of follow-up, eight from suicide. The standardized mortality ratio (SMR) for suicide was 9.77 [95% confidence interval (CI) 4.22-19.24], which, although significantly elevated compared to the general population, represented a lower case fatality than expected from previous literature. Deaths from all other causes were not excessive for the age groups studied in this cohort. Alcohol abuse [hazard ratio (HR) 6.81, 95% CI 1.69-27.36, p=0.007] and deterioration from pre-morbid level of functioning up to a year after onset (HR 5.20, 95% CI 1.24-21.89, p=0.024) were associated with increased risk of suicide. CONCLUSIONS: Suicide is significantly increased in unselected bipolar patients but actual case fatality is not as high as previously claimed. A history of alcohol abuse and deterioration in function predict suicide in bipolar disorder.

Long-term social functioning after depression treated by psychiatrists: a review.

OBJECTIVES: Numerous long-term studies of depression in psychiatric settings have shown a poor clinical outcome but little emphasis has been placed on psychosocial or functional outcome in studies to date. This article reviews published data on long-term social functioning after depression and considers why psychosocial recovery appears delayed compared with clinical recovery. METHODS: Searches were carried out of the databases MEDLINE, PSYCHLIT and EMBASE for articles published from 1980 using keywords relating to social and functional outcomes of unipolar and bipolar depression. Review articles and relevant textbooks were also searched. RESULTS: The few outcome studies published have described long-term functional impairment in the majority of patients but have been limited by methodological shortcomings. Psychosocial impairment tends to persist even after clinical remission from depression. Residual symptomatology after remission from depression may lead to enduring psychosocial impairment, as may subtle neurocognitive deficits. Axis I and II comorbidities predict a poor psychosocial outcome, but episodes of depression do not appear to lead to personality 'scarring'. CONCLUSIONS: Future outcome studies need to focus on longitudinal social functioning. Full functional recovery after an episode of depression should be the goal of treatment as enduring residual symptoms lead to long-term psychosocial impairment.

Influence of ethnicity on presentation and outcome of first episode psychosis.

We describe a young African male presenting to an Irish psychiatric service with first episode psychosis with an acute onset, no prodromal features and early and complete remission. Migrant and ethnic minority groups may differ in their clinical presentation, course and outcome of psychosis compared with the Caucasian population. This has implications for assessment and treatment of ethnic minority patients in an Irish context given the recent migration into a previously homogeneous population.

What's new? The clinical epidemiology of bipolar I disorder.

The last few decades have seen a rapid change in our understanding of the epidemiology of bipolar disorder, which has only recently started to achieve major research attention. This article reviews recent developments. In addition to electronic searches using MEDLINE and PsycLIT, references from articles were identified, major journals hand searched, and major textbooks of psychiatry and epidemiology reviewed. Studies may have overestimated the prevalence of mania, and underestimated incidence. The incidence of mania may be increasing in recent generations, but the data remain inconclusive. Age at onset of mania is earlier than previously believed, and there are gender differences in epidemiology and clinical course. Ethnic differences in epidemiology and clinical course of bipolar disorder are highlighted. Comorbid alcohol and substance abuse are common in patients suffering from bipolar disorder and are associated with a more severe clinical course and a worse outcome. Urban living and lower socioeconomic and single marital status may be risk factors for developing bipolar disorder.

The impact of residual symptoms on outcome of major depression.

Unipolar depression should be viewed as a chronic illness with multiple phases rather than as a relapsing-remitting disorder. Incomplete remission from depression is common, with approximately one third of patients continuing to have residual depression at remission. Patients who have had a depressive episode spend more time with residual depressive symptoms than with major depression long term. The presence of residual symptomatology after an episode of depression is associated with an increased risk of short-term relapse, a long-term chronic course, higher risk of suicide attempts, poor social functioning, and poor outcome of comorbid medical illnesses.

Incidence of bipolar affective disorder in three UK cities: results from the AESOP study.

BACKGROUND: There has been a relative dearth of epidemiological research into bipolar affective disorder. Furthermore, incidence studies of bipolar disorder have been predominantly retrospective and most only included hospital admission cases. AIMS: To determine the incidence of operationally defined bipolar disorder in three areas of the UK and to investigate any differences in gender and ethnicity. METHOD: All patients who contacted mental health services with first-episode psychosis or non-psychotic mania between September 1997 and August 1999 were identified and diagnosed according to ICD-10 criteria. Incidence rates of bipolar affective disorder were standardised for age and stratified by gender and ethnic group across the three areas. RESULTS: The incidence rate per 100,000 per year in south-east London was over twice that in Nottingham and Bristol. There was no significant difference in the rates of disorder in men and women. Incidence rates of bipolar disorder in the combined Black and minority ethnic groups in all three areas were significantly higher than those of the comparison White groups. CONCLUSIONS: The incidence of bipolar disorder was higher in south-east London than in the other two areas, and was higher among Black and minority ethnic groups than in the White population.

Gender differences in incidence and age at onset of mania and bipolar disorder over a 35-year period in Camberwell, England.

OBJECTIVE: Despite clear gender differences in the symptoms and course of bipolar affective disorder, studies investigating age at onset by gender have yielded inconsistent results. The authors investigated gender differences in age at onset and incidence of first-episode mania and bipolar disorder in an epidemiological catchment area in southeast London over a 35-year period. METHOD: All adult cases of first-episode psychosis, mania, or hypomania presenting to services in Camberwell, southeast London (1965-1999), were identified. Computerized diagnoses for these cases were generated by using the Operational Checklist for Psychotic Disorders program. Incidence rates and rate ratios of DSM-IV bipolar I disorder, first manic episode, by gender and age (10-year age-at-onset categories) were calculated. Differences in age at onset of first-episode mania and bipolar disorder by gender were examined by using univariate and multivariate analyses. RESULTS: Men had a significantly earlier onset of first-episode mania and bipolar disorder, with childhood antisocial behavior also being significantly associated, after multivariate analysis. Women had higher incidence rates of bipolar I disorder throughout adult life, except for early life (ages 16-25 years), although gender differences in individual age bands did not reach statistical significance. CONCLUSIONS: Men appear to have an earlier onset of mania and bipolar disorder than women. The association of male gender and childhood antisocial behavior with early-onset bipolar disorder raised the possibility of the existence of an early-onset subgroup.

Meta-analysis of magnetic resonance imaging brain morphometry studies in bipolar disorder.

BACKGROUND: Several studies assessing volumetric measurements of regional brain structure in bipolar disorder have been published in recent years, but their results have been inconsistent. Our aim was to complete a meta-analysis of regional morphometry in bipolar disorder as assessed using magnetic resonance imaging (MRI). METHODS: We conducted a systematic literature search of MRI studies of bipolar disorder and identified studies which reported volume measurements in a selected number of regions. Twenty-six studies comprising volumetric measurements on up to 404 independent patients with bipolar disorder were included. A meta-analysis was carried out comparing the volumes of regions in bipolar disorder to comparison subjects using a random effects model. RESULTS: Patients with bipolar disorder had enlargement of the right lateral ventricle, but no other regional volumetric deviations which reached significance. Strong heterogeneity existed for several regions, including the third ventricle, left subgenual prefrontal cortex, bilateral amygdala and thalamus. CONCLUSIONS: Regional volume of most structures we studied is preserved in bipolar disorder as a whole, which was significantly associated only with right-sided ventricular enlargement. However the extensive heterogeneity detected indicates the need for further studies to establish if consistent regional brain volume deviation exists in bipolar disorder or in specific clinical subsets of the illness.