A 10-Year Observational Study of the Use, Acceptability and Effectiveness of Long-Acting Paliperidone Palmitate: Implications for Clinical Decision Making.

BACKGROUND: Long-acting injectable antipsychotics (LAIs) have been shown to improve adherence and prevent relapse in the treatment of schizophrenia and psychotic disorders, though longitudinal data on treatment outcomes are limited. OBJECTIVES: To establish the long-term acceptability and effectiveness of paliperidone palmitate once monthly (PP1M). METHODS: This independent 10-year mirror image study was carried out in a large urban mental health provider. The study evaluated the retention and hospitalization rates 5 years following initiation of PP1M in a naturalistic patient cohort of all adult patients who were newly initiated on PP1M between 2011 and 2015. Electronic records were used to compare the frequency and length of hospital admissions in the 5 years before and after introduction of PP1M. Switching and discontinuation rates and reasons were also recorded with a separate analysis of patients who continued and discontinued PP1M during the study period. RESULTS: A total of 167 patients were included in the study (70% with schizophrenia, 30% with other diagnoses). Discontinuation rates were 24%, 15%, 17%, 5% and 8% in years 1-5, respectively; poor tolerability was the most common cause for stopping PP1M. Demographic and clinical factors such as age, sex, diagnosis and care setting did not discriminate between continuers and discontinuers. The group that completed 5 years on PP1M (46%) showed an overall reduction of 72% in the mean number and 68% in the mean length of admissions compared to the 5-year period before initiation, with more than half of the patients requiring no admission at all during this period of time (median = 0). On the contrary, discontinuers demonstrated worse outcomes in overall bed occupancy than continuers. Findings were overall similar across the total cohort and schizophrenia-only group. CONCLUSIONS: Our study has one of the longest durations of follow up of a naturalistic cohort treated with LAIs confirming sustained improvements for patients who continued treatment for up to 5 years with implicit implications for cost effectiveness. Study findings may facilitate shared decision making in this area, overcoming some of the common barriers for use.

Acceptability and feasibility of using avatar-based virtual world software as an adjunct to clinical interventions, training, and reflective practice in a medium secure setting: A qualitative interview study.

BACKGROUND: Relationships are at the core of recovery, particularly in secure services where patients have usually had difficulties with authority figures and can have mentalisation deficits. Early indications are that avatar-based virtual world software may help facilitate communication and emotional expression. AIMS: To establish the feasibility of using avatar-based virtual world software in a medium secure hospital, adjunctive to standard staff-patient interactions during clinical interventions and staff activities including reflective practice and training; to explore patient, staff participant and facilitator experiences using it. METHODS: Use of the software was offered across an 89-bedded unit as an optional adjunct to clinical interventions, reflective practice and training sessions. Qualitative data were collected using semi-structured interviews and analysed using thematic analysis. Volunteer sampling was used. Five patients volunteered and were matched with an equal number of staff facilitators and participants. RESULTS: Eighty four sessions were completed using the avatar software with between 1 and 11 participant(s) per session, totalling 347 participant sessions. No adverse events occurred relatable to the sessions. An overarching theme of 'adding value' emerged, encompassing subthemes such as 'concrete visual presence and imagery', 'mentalisation processes' and 'enhanced focus, depth and problem solving'. Experiences of added value were affected by moderators which were 'power and relationship dynamics', the 'ability to use software', 'practical processes' and 'literacy'. CONCLUSIONS: Avatar software is feasible to implement, acceptable to patients and staff and may offer an opportunity to aid mentalisation and reflection. By definition, everyone engaging in this study was a volunteer, even an enthusiast, so it would now be useful to extend evaluation to those who need some encouragement to use avatar software. Research to quantify benefits and establish the cost impact is now indicated, as our findings show it may offer a novel way of connecting with hard-to-reach patient groups.

Race, mental health, and evictions filings in Memphis, TN, USA.

Although evictions are a major disruptor of residential stability, their contribution to health disparities is understudied. Both experiencing eviction and the threat of being evicted are associated with adverse physical and mental health outcomes. Communities with higher proportions of Black people have higher rates of eviction filings. Market characteristics alone are insufficient for explaining the clustering of eviction in neighborhoods of color. Memphis is the fastest-growing rental market in the United States, facing an eviction crisis and is rife with persistent racial health disparities. This study explored the relationship between eviction filings, mental health, and neighborhood racial composition in Memphis to inform local policy approaches. We combined health from the City Health Dashboard, 2019 American Community Survey 5-year estimates, and eviction filings from the Shelby County, TN General Sessions Civil Court. Multivariate regression models were used to examine the relationship between health outcomes and eviction filing rates while controlling other relevant neighborhood characteristics. Separate models were run based on neighborhood racial composition. Poor mental health was significantly associated with higher eviction filling rates in majority Black neighborhoods but not in majority white and racially mixed neighborhoods. These findings point to evictions as an important contributor to racial health inequities in Memphis and the importance of race-conscious policy interventions that address the dual crisis of evictions and racial health disparities.

Medial/central PF arthritis and functionally stable ACL deficiency do not compromise outcomes of fixed-bearing medial UKA.

BACKGROUND: There is limited published data assessing functional scores and patient satisfaction following unicompartmental knee arthroplasty (UKA) in patients with patellofemoral (PF) arthritis or anterior cruciate ligament (ACL) deficiency. The purpose of this study was to determine whether medial/central PF arthritis or functionally stable ACL deficiency compromise outcomes of fixed-bearing medial UKA at a minimum follow-up of 2 years. The hypothesis was that equivalent outcomes can be achieved in patients with substantial medial/central PF arthritis or with functionally stable ACL deficiency. METHODS: The authors studied a consecutive series of 229 patients (240 knees) at 36.9 ± 6.3 months after receiving fixed-bearing medial UKA. Patients completed pre- and post-operative (2 years) clinical outcome questionnaires for Oxford Knee Score (OKS), EQ-5D, Knee injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), University of California, Los Angeles (UCLA) activity score, and Forgotten Joint Score (FJS). Multivariable analyses were performed to determine associations between clinical scores, patient demographics, PF arthritis and functionally stable ACL deficiency. RESULTS: Of the 240 knees, 125 (54%) had substantial medial/central PF arthritis and 21 (9%) functionally stable ACL deficiency. Multivariable analyses revealed no association between outcomes and medial/central PF arthritis, but knees with functionally stable ACL deficiency were associated with better KOOS-PS (ß = 8.99, p = 0.012). CONCLUSION: Fixed-bearing medial UKA grants satisfactory outcomes at 2 years even in knees with substantial medial/central PF arthritis or functionally stable ACL deficiency. Longer-term prospective studies with larger cohorts are needed to confirm these promising findings regarding outcomes in patients traditionally contraindicated for medial UKA.

Effectiveness of 2-year treatment with aripiprazole long-acting injectable and comparison with paliperidone palmitate.

BACKGROUND: The pragmatic management of psychotic disorders is more complex than that delivered in a controlled trial environment. Therefore, this study aims to evaluate the real-world effectiveness of aripiprazole long-acting injectable (ALAI) and compare it with another commonly used long-acting anti-psychotic, once-monthly paliperidone palmitate (PP1M). METHODS: This naturalistic, independent 4-year mirror image study compared the mean number and length of hospital admissions 2 years before and 2 years after treatment initiation with ALAI. Retention rates, discontinuation reasons and level of adherence were also recorded. Furthermore, indirect comparisons were made between treatment outcomes on ALAI and PP1M. RESULTS: A total of 109 eligible patients with a severe mental illness (65% with schizophrenia and 35% with other diagnosis) commenced on ALAI and 173 patients (69% with schizophrenia and 31% with other diagnoses) initiated on PP1M were included. Of these, 37% on ALAI and 34% on PP1M stopped treatment at 2 years; retention rates were most favourable for the schizophrenia group on PP1M. Patients were more likely to discontinue due to lack of effectiveness on ALAI and due to tolerability issues on PP1M. Those who continued for 2 years on ALAI (n = 69), demonstrated an overall decrease of 84% in the mean number and 88% in the mean length of hospital admissions compared with the 2 years before initiation. Although patients on ALAI appeared to have a significantly higher bed occupancy the 2-year period before initiation than patients on PP1M, the reductions in hospitalizations were comparable across both cohorts after 2 years of treatment. CONCLUSIONS: The introduction of ALAI had a substantial impact on long-term clinical outcomes in this naturalistic cohort; more than half of patients continued treatment and had no admission during 2 years of follow up. There were no significant differences in hospitalisation rates between patients on ALAI and PP1M at 2 years.

Partial compliance with long-acting paliperidone palmitate and impact on hospitalization: a 6-year mirror-image study.

BACKGROUND: Previous studies showed a linear correlation between partial compliance with an oral antipsychotic medication and hospitalisation risk among patients with schizophrenia. Long-acting injections (LAIs) may significantly improve adherence and reduce relapse in patients with psychosis. The aim of this study was to evaluate the relationship between the level of compliance with 1-monthly paliperidone palmitate (PP1M) and hospitalisation rates. METHODS: This was a naturalistic, mirror-image study examining retention, compliance and hospitalisation rates 3 years pre- and 3 years post-PP1M initiation. Compliance was divided in three groups: full (no missed dose/year), good (6-11injections/year), poor (<6 injections/year). RESULTS: A total of 173 patients suffering from a severe mental illness (70% with a diagnosis of schizophrenia and 30% with other diagnoses) were included; 77% of patients continued PP1M for 1 year, 66% for 2 years and 55% for 3 years. Of the 95 patients who remained on PP1 throughout the 3 years of follow up, 81% showed full, 13% good, and only 6% poor compliance. In the patients who were fully compliant, the mean number of hospital admissions decreased from 1.34 to 0.43, and the mean number of bed days from 82 to 19 days per patient 3 years before and 3 years after PP1M initiation (p < 0.001). It is noteworthy that the reductions in hospital stay were statistically significant for the group of patients with full compliance but not for the other two groups. In fact, patients with poor compliance demonstrated higher hospitalisation rates both before and after PPM1 initiation. These findings were similar in the subgroup of patients with schizophrenia who continued treatment for 3 years (n = 68). CONCLUSION: There was a direct association between partial compliance and re-hospitalisation; fully compliant patients maintained the best outcomes in terms of reduced bed use following PPM1 initiation.

Excellent survival and outcomes with fixed-bearing medial UKA in young patients (≤ 60 years) at minimum 10-year follow-up.

PURPOSE: To evaluate whether long-term (10-year minimum) patient outcomes and survival of fixed-bearing medial unicompartmental knee arthroplasty (UKA) in patients aged ≤ 60 years were favorable despite non-conventional age criteria. METHODS: The authors reviewed the records of 91 consecutive medial UKAs performed in patients aged ≤ 60 by a single surgeon. All patients received the same fixed-bearing M/G Unicompartmental Knee System. Patients records were updated, noting complications or revisions, and Oxford Knee Scores and overall satisfaction collected. If deceased, the general practitioner or next of kin provided data. RESULTS: Of the initial 91 knees, 10 were revised, 6 were deceased, and 1 was lost to follow-up. The final cohort of 74 knees was aged 54.3 ± 4.3 years (range 41.8-60.6) at index surgery. Using revision of any component as endpoint, the present series had a KM survival of 92.9% (CI 84.8-96.7%) at 10 years, and 87.8% (CI 78.4-93.2%) at 15 years, and a single non-fatal DVT was reported. At final follow-up of 15 ± 1.3 years (range 11-18), OKS (available for all 74 knees) was 38.4 ± 8.4 (range 18-48). Overall patients were pleased or very pleased with 72 of the knees (97%). CONCLUSION: Fixed-bearing medial UKA yields favorable results in the treatment of single compartment osteoarthritis of the knee in patients ≤ 60 years. The present study demonstrates low complication rates, good-to-excellent long-term patient outcomes, and satisfactory implant survival for this age group considering the advantages of UKA. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Long-term effects of paliperidone palmitate on hospital stay and treatment continuation.

There is a growing need for real world data on long-term clinical and health resource utilization outcomes. The main purpose of this study was to establish the effects of 1-monthly Paliperidone Palmitate (PP1M) on treatment continuation and hospital stay in routine clinical practice. This is a naturalistic, 6-year mirror-image study examining retention and hospitalization rates 3 years pre-PP1M and 3 years post-PP1M initiation. One hundred seventy-three patients were included; 120 (70%) had a primary diagnosis of schizophrenia and 53 (30%) other diagnosis. In total, 77% of patients continued PP1M for one year, 66% for two years and 55% for three years. For the patients who continued with PP1M for 3 years (n = 95), the mean number of hospital admissions decreased significantly from 1.44 to 0.53 and the mean number of bed days from 93 to 29 bed days 3 years before and 3 years after PP1M initiation (P < 0.001). The group of patients with schizophrenia who continued for 3 years (n = 79) demonstrated similar outcomes. The introduction of PP1M had a significant impact on long-term clinical outcomes. More than half of patients were still continuing on PP1M at 3 years after initiation and had no admission during 3 years follow-up.

Impact of a referral management "gateway" on the quality of referral letters; a retrospective time series cross sectional review.

BACKGROUND: Referral management centres (RMC) for elective referrals are designed to facilitate the primary to secondary care referral path, by improving quality of referrals and easing pressures on finite secondary care services, without inadvertently compromising patient care.This study aimed to evaluate whether the introduction of a RMC which includes triage and feedback improved the quality of elective outpatient referral letters. METHODS: Retrospective, time-series, cross-sectional review involving 47 general practices in one primary care trust (PCT) in South-East England. Comparison of a random sample of referral letters at baseline (n = 301) and after seven months of referral management (n = 280). Letters were assessed for inclusion of four core pieces of information which are used locally to monitor referral quality (blood pressure, body mass index, past medical history, medication history) and against research-based quality criteria for referral letters (provision of clinical information and clarity of reason for referral). RESULTS: Following introduction of the RMC, the proportion of letters containing each of the core items increased compared to baseline. Statistically significant increases in the recording of 'past medical history' (from 71% to 84%, p < 0.001) and 'medication history' (78% to 87%, p = 0.006) were observed. Forty four percent of letters met the research-based quality criteria at baseline but there was no significant change in quality of referral letters judged on these criteria across the two time periods. CONCLUSION: Introduction of RMC has improved the inclusion of past medical history and medication history in referral letters, but not other measures of quality. In approximately half of letters there remains room for further improvement.