Nitrous oxide-induced myeloneuropathy: a case series.

BACKGROUND: Nitrous oxide (N2O) is the second most common recreational drug used by 16- to 24-year-olds in the UK. Neurological symptoms can occur in some people that use N2O recreationally, but most information comes from small case series. METHODS: We describe 119 patients with N2O-myeloneuropathy seen at NHS teaching hospitals in three of the UK's largest cities: London, Birmingham and Manchester. This work summarises the clinical and investigative findings in the largest case series to date. RESULTS: Paraesthesia was the presenting complaint in 85% of cases, with the lower limbs more commonly affected than the upper limbs. Gait ataxia was common, and bladder and bowel disturbance were frequent additional symptoms. The mid-cervical region of the spinal cord (C3-C5) was most often affected on MRI T2-weighted imaging. The number of N2O canisters consumed per week correlated with methylmalonic acid levels in the blood as a measure of functional B12 deficiency (rho (ρ)=0.44, p=0.04). CONCLUSIONS: Preventable neurological harm from N2O abuse is increasingly seen worldwide. Ease of access to canisters and larger cylinders of N2O has led to an apparent rise in cases of N2O-myeloneuropathy in several areas of the UK. Our results highlight the range of clinical manifestations in a large group of patients to improve awareness of risk, aid early recognition, and promote timely treatment.

Vertebral artery dissection managed by interventional radiology.

A 21-year-old patient presented with sudden-onset headache, visual disturbance and left hand incoordination. She was diagnosed with a left vertebral artery dissection of the V3 segment resulting in multiple cerebellar and cerebral infarcts. There were no risk factors for dissection other than recent COVID-19 infection. She was treated initially with antiplatelets, followed by anticoagulation, but experienced recurrent ischaemia. Although guidance suggests endovascular repair may be beneficial for patients with cerebral artery dissection (CAD) who experience recurrent strokes on medical therapy, evidence is limited. After multidisciplinary team consideration of the individual patient anatomy and risks and benefits of different endovascular techniques, the patient was treated with endovascular coiling. At 10 months follow-up, she had no further strokes and improving neurological symptoms. The case highlighted COVID-19 as a potential trigger for CAD and the use of endovascular coiling in preventing catastrophic cerebral ischaemia in CAD refractive to medical therapy.

Spectrum, risk factors and outcomes of neurological and psychiatric complications of COVID-19: a UK-wide cross-sectional surveillance study.

SARS-CoV-2 is associated with new-onset neurological and psychiatric conditions. Detailed clinical data, including factors associated with recovery, are lacking, hampering prediction modelling and targeted therapeutic interventions. In a UK-wide cross-sectional surveillance study of adult hospitalized patients during the first COVID-19 wave, with multi-professional input from general and sub-specialty neurologists, psychiatrists, stroke physicians, and intensivists, we captured detailed data on demographics, risk factors, pre-COVID-19 Rockwood frailty score, comorbidities, neurological presentation and outcome. A priori clinical case definitions were used, with cross-specialty independent adjudication for discrepant cases. Multivariable logistic regression was performed using demographic and clinical variables, to determine the factors associated with outcome. A total of 267 cases were included. Cerebrovascular events were most frequently reported (131, 49%), followed by other central disorders (95, 36%) including delirium (28, 11%), central inflammatory (25, 9%), psychiatric (25, 9%), and other encephalopathies (17, 7%), including a severe encephalopathy (n = 13) not meeting delirium criteria; and peripheral nerve disorders (41, 15%). Those with the severe encephalopathy, in comparison to delirium, were younger, had higher rates of admission to intensive care and a longer duration of ventilation. Compared to normative data during the equivalent time period prior to the pandemic, cases of stroke in association with COVID-19 were younger and had a greater number of conventional, modifiable cerebrovascular risk factors. Twenty-seven per cent of strokes occurred in patients <60 years. Relative to those >60 years old, the younger stroke patients presented with delayed onset from respiratory symptoms, higher rates of multi-vessel occlusion (31%) and systemic thrombotic events. Clinical outcomes varied between disease groups, with cerebrovascular disease conferring the worst prognosis, but this effect was less marked than the pre-morbid factors of older age and a higher pre-COVID-19 frailty score, and a high admission white cell count, which were independently associated with a poor outcome. In summary, this study describes the spectrum of neurological and psychiatric conditions associated with COVID-19. In addition, we identify a severe COVID-19 encephalopathy atypical for delirium, and a phenotype of COVID-19 associated stroke in younger adults with a tendency for multiple infarcts and systemic thromboses. These clinical data will be useful to inform mechanistic studies and stratification of patients in clinical trials.

Behavioral Health Service Utilization Among Detained Adolescents: A Meta-Analysis of Prevalence and Potential Moderators.

PURPOSE: Utilization of behavioral health treatment services among adolescents who have been detained or incarcerated within the juvenile justice system is poorly understood, with estimated utilization rates varying widely across studies. This meta-analysis was conducted to review and synthesize the literature on the prevalence of service utilization among this population. METHODS: Data from 27 studies of 28 distinct samples were abstracted and coded. A meta-analysis was conducted to calculate individual prevalence estimates of behavioral health service utilization, which were combined using random effects models. A moderator analysis was also conducted. RESULTS: Prevalence effect sizes (pr) for service utilization were low, with effect sizes pr = 33.1% for mental health services, pr = 27.95% for substance use-related services, and pr = 45.32% for unspecified services. The moderator analysis showed significant heterogeneity in prevalence of behavioral health service utilization. CONCLUSIONS: The findings suggest limited service utilization by adolescents who had been detained or incarcerated, whether assessed before, during, or after confinement. Future research should focus on assessing the quality of, and youth access to, behavioral health services within and outside of juvenile justice facilities. Improved programs to ensure consistent treatment for previously detained or incarcerated adolescents are warranted.

Health Care Use and Spending for Medicaid Enrollees in Federally Qualified Health Centers Versus Other Primary Care Settings.

OBJECTIVES: To compare health care use and spending of Medicaid enrollees seen at federally qualified health centers versus non-health center settings in a context of significant growth. METHODS: Using fee-for-service Medicaid claims from 13 states in 2009, we compared patients receiving the majority of their primary care in federally qualified health centers with propensity score-matched comparison groups receiving primary care in other settings. RESULTS: We found that health center patients had lower use and spending than did non-health center patients across all services, with 22% fewer visits and 33% lower spending on specialty care and 25% fewer admissions and 27% lower spending on inpatient care. Total spending was 24% lower for health center patients. CONCLUSIONS: Our analysis of 2009 Medicaid claims, which includes the largest sample of states and more recent data than do previous multistate claims studies, demonstrates that the health center program has provided a cost-efficient setting for primary care for Medicaid enrollees.

Detained Adolescents: Mental Health Needs, Treatment Use, and Recidivism.

Although approximately 60 to 70 percent of detained adolescents meet criteria for a mental disorder, few receive treatment upon community re-entry. Given that mental health treatment can reduce recidivism, we examined detained adolescents' mental health needs and their postdetention mental health treatment and recidivism. Altogether, 1,574 adolescents (≤18 years) completed a mental health screening at a detention center. Scores on the screening, mental health treatment utilization (60 days after detention), and recidivism (6 months after detention) were measured. About 82.2 percent of adolescents had elevated scores on the mental health screening, but only 16.4 percent obtained treatment and 37.2 percent reoffended. Logistic regression models revealed adolescents with insurance and higher angry-irritable scores were significantly more likely to obtain treatment, whereas males, black and older adolescents, and those endorsing a trauma history were less likely. Black adolescents, insured adolescents, and those with higher alcohol and drug use scores were significantly more likely to reoffend. Mental health treatment increased the likelihood of recidivism. The prevalence of mental health needs among detained adolescents was high, but treatment utilization was low, with notable treatment disparities across race, gender, and age. The use of mental health treatment predicted recidivism, suggesting that treatment acts as a proxy measure of mental health problems. Future research should assess the impact of timely and continuous mental health services on recidivism among detained adolescents.

The "Critical" Elements of Illness Management and Recovery: Comparing Methodological Approaches.

This study examined three methodological approaches to defining the critical elements of Illness Management and Recovery (IMR), a curriculum-based approach to recovery. Sixty-seven IMR experts rated the criticality of 16 IMR elements on three dimensions: defining, essential, and impactful. Three elements (Recovery Orientation, Goal Setting and Follow-up, and IMR Curriculum) met all criteria for essential and defining and all but the most stringent criteria for impactful. Practitioners should consider competence in these areas as preeminent. The remaining 13 elements met varying criteria for essential and impactful. Findings suggest that criticality is a multifaceted construct, necessitating judgments about model elements across different criticality dimensions.

Comparing the Cost of Caring for Medicare Beneficiaries in Federally Funded Health Centers to Other Care Settings.

OBJECTIVE: To compare total annual costs for Medicare beneficiaries receiving primary care in federally funded health centers (HCs) to Medicare beneficiaries in physician offices and outpatient clinics. DATA SOURCES/STUDY SETTINGS: Part A and B fee-for-service Medicare claims from 14 geographically diverse states. The sample was restricted to beneficiaries residing within primary care service areas (PCSAs) with at least one HC. STUDY DESIGN: We modeled separately total annual costs, annual primary care costs, and annual nonprimary care costs as a function of patient characteristics and PCSA fixed effects. DATA COLLECTION: Data were obtained from the Centers for Medicare & Medicaid Services. PRINCIPAL FINDINGS: Total median annual costs (at $2,370) for HC Medicare patients were lower by 10 percent compared to patients in physician offices ($2,667) and by 30 percent compared to patients in outpatient clinics ($3,580). This was due to lower nonprimary care costs in HCs, despite higher primary care costs. CONCLUSIONS: HCs may offer lower total cost practice style to the Centers for Medicare & Medicaid Services, which administers Medicare. Future research should examine whether these lower costs reflect better management by HC practitioners or more limited access to specialty care by HC patients.

Behavioral Health Care Needs, Detention-Based Care, and Criminal Recidivism at Community Reentry From Juvenile Detention: A Multisite Survival Curve Analysis.

OBJECTIVES: We examined the provision of behavioral health services to youths detained in Indiana between 2008 and 2012 and the impact of services on recidivism. METHOD: We obtained information about behavioral health needs, behavioral health treatment received, and recidivism within 12 months after release for 8363 adolescents (aged 12-18 years; 79.4% male). We conducted survival analyses to determine whether behavioral health services significantly affected time to recidivating. RESULTS: Approximately 19.1% of youths had positive mental health screens, and 25.3% of all youths recidivated within 12 months after release. Of youths with positive screens, 29.2% saw a mental health clinician, 16.1% received behavioral health services during detention, and 30.0% received referrals for postdetention services. Survival analyses showed that being male, Black, and younger, and having higher scores on the substance use or irritability subscales of the screen predicted shorter time to recidivism. Receiving a behavior precaution, behavioral health services in detention, or an assessment in the community also predicted shorter time to recidivating. CONCLUSIONS: Findings support previous research showing that behavioral health problems are related to recidivism and that Black males are disproportionately rearrested after detention.

Job-related burnout among juvenile probation officers: Implications for mental health stigma and competency.

The high demands and responsibilities of probation work, particularly with juvenile clients, may lead to burnout, which can negatively impact how probation officers work with clients, particularly individuals with behavioral health concerns. Yet, research examining burnout and related outcomes among juvenile probation officers (JPOs) is limited. We surveyed 246 JPOs in a Midwestern state to identify the prevalence, predictors, and potential outcomes of burnout. JPOs reported moderate levels of burnout; about 30% of the sample scored in the high range for emotional exhaustion and cynicism. Contrary to study hypotheses, there were no group-level differences in burnout scores across gender, race/ethnicity, age, or education. In regression models, burnout was predicted by being White (vs. minority), serving in an urban (vs. rural) county, dissatisfaction with department guidelines, job dissatisfaction, viewing job role as more treatment-oriented along the enforcement-treatment continuum, and turnover intention. JPOs with burnout were more likely to endorse mental health stigma and lack of mental health competency to address juvenile clients with behavioral health concerns. Findings suggest burnout prevention and intervention programs should be considered for JPOs to increase job satisfaction, limit job turnover, reduce burnout, and possibly increase effective practices for managing juvenile clients with behavioral health needs.

Factors affecting implementation of an evidence-based practice in the Veterans Health Administration: Illness management and recovery.

OBJECTIVE: Illness management and recovery (IMR) is an evidence-based practice that assists consumers in managing their illnesses and pursuing personal recovery goals. Although research has examined factors affecting IMR implementation facilitated by multifaceted, active roll-outs, the current study attempted to elucidate factors affecting IMR implementation outside the context of a research-driven implementation. METHODS: Semi-structured interviews with 20 local recovery coordinators and 18 local IMR experts were conducted at 23 VA medical centers. Interviews examined perceived and experienced barriers and facilitators to IMR implementation. Data were analyzed via thematic inductive/deductive analysis in the form of crystallization/immersion. RESULTS: Six factors differed between sites implementing IMR from those not providing IMR: awareness of IMR, importer-champions, autonomy-supporting leadership, veteran-centered care, presence of a sensitive period, and presence of a psychosocial rehabilitation and recovery center. Four factors were common in both groups: recovery orientation, evidence-based practices orientation, perceived IMR fit within program structure, and availability of staff time. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: IMR can be adopted in lieu of active implementation support; however, knowledge dissemination appears to be key. Future research should examine factors affecting the quality of implementation.

The policy implications of the cost structure of home health agencies.

PURPOSE: To examine the cost structure of home health agencies by estimating an empirical cost function for those that are Medicare-certified, ten years following the implementation of prospective payment. DESIGN AND METHODS: 2010 national Medicare cost report data for certified home health agencies were merged with case-mix information from the Outcome and Assessment Information Set (OASIS). We estimated a fully interacted (by tax status) hybrid cost function for 7,064 agencies and calculated marginal costs as percent of total costs for all variables. RESULTS: The home health industry is dominated by for-profit agencies, which tend to be newer than the non-profit agencies and to have higher average costs per patient but lower costs per visit. For-profit agencies tend to have smaller scale operations and different cost structures, and are less likely to be affiliated with chains. Our estimates suggest diseconomies of scale, zero marginal cost for contracting with therapy workers, and a positive marginal cost for contracting with nurses, when controlling for quality. IMPLICATIONS: Our findings suggest that efficiencies may be achieved by promoting non-profit, smaller agencies, with fewer contract nursing staff. This conclusion should be tested further in future studies that address some of the limitations of our study.

Parenthood and severe mental illness: relationships with recovery.

OBJECTIVE: Parenting is an important life domain for many people, but little research examines the parenting experience and its role in recovery for those with a severe mental illness. The current study provides preliminary evidence of how these concepts are related in a sample of individuals living with severe mental illness attending a community mental health center. We also explored potential differences between mothers and fathers, which could help better tailor services to meet the needs of parents with severe mental illness. METHOD: Data were obtained during baseline interviews for a study testing an intervention designed to increase shared decision making in psychiatric treatment. Participants (N = 167) were administered measures of patient activation, recovery, autonomy preference, hope, and trust in providers. We compared parents and nonparents and compared mothers and fathers using chi-square tests, t tests, and, when appropriate, analysis of covariance. RESULTS: Parents had a significantly higher level of trust in their psychiatric care provider than nonparents. Contrary to hypotheses, parents were less active in their treatment and preferred less information-seeking autonomy than did nonparents, but did not differ on other recovery-related indices. No differences on recovery-related indices were detected between mothers and fathers. Secondary analyses revealed parents with minor children had more hope than parents of older children. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Although parents may have higher levels of trust in their physicians, our preliminary findings suggest that parents with severe mental illness may benefit from increased efforts to help them be more active and interested in information about their illnesses.

Assertive community treatment for parents with serious mental illnesses: a comparison of "parent-sensitive" assertive community treatment teams versus other teams.

OBJECTIVE: Assertive Community Treatment (ACT) is an evidence-based practice for individuals living with serious mental illnesses. Although studies estimate that at least half of people with serious mental illnesses are parents, little is known about ACT policies and services for parent consumers. METHOD: Seventy-three ACT providers from 67 teams completed a survey about treatment services for parent consumers. Teams were divided into "parent-sensitive" and "nonsensitive" teams based on 3 indicators of parent-related services: identifying parental status, discussing parenting issues, and assisting with parenting needs. For each treatment indicator, teams were compared to determine factors that may contribute to parent-supportive services. RESULTS: Providers from parent-sensitive teams that consistently identified consumers' parental status were more likely to talk with consumers about committed relationships and to assist consumers with parent-child communication. Parent-sensitive teams that frequently discussed parenting issues with consumers were less likely to be unsure of consumers' family plans, more likely to find out about parenting during goal setting, and more likely to assist with parent-related needs. Parent-sensitive teams that frequently provided assistance with parenting needs were more likely to serve minority consumers and consumers who want children, spend more time discussing parenting issues, and offer special programs for parent consumers. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Findings suggest that simply identifying consumers as parents is not sufficient for ensuring consistent provision of parent-supportive services, whereas discussing parenting issues is associated with increased service provision. More intensive, evidence-based parent-supportive services are needed, as well as continued research on parents with serious mental illnesses and available treatment services. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Implementation of illness management and recovery in the Veterans Administration: an on-line survey.

OBJECTIVE: This study explores the implementation of illness management and recovery (IMR) across Veterans Affairs Medical Centers (VAMCs). The implementation of illness management programming has been mandated in certain programs within VAMCs. IMR is consistent with the Department of Veteran Affairs (VA) emphasis on recovery-oriented, evidence-based treatments. This study examines both the penetration of IMR within the VA system and the barriers and facilitators to implementation. METHODS: An online survey was sent to local recovery coordinators, who, in turn, identified other local IMR experts. RESULTS: Respondents from 107 clinics (representing 101 VAMCs) answered the survey. Less than half of VAMCs provide IMR services. Psychosocial Rehabilitation and Recovery Centers (PRRC), which specialize in services for Veterans with psychiatric disabilities, are more likely to provide IMR; however, more than one third do not. Few respondents had access to IMR implementation tools such as training, consultation, or fidelity monitoring. Only about one fifth of IMR providers have been trained in IMR. Respondents reported several facilitators to implementation, such as knowledgeable staff members and peer support. Common barriers to implementation included limited staff availability and "intimidating" workbook materials. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The VA is well underway in its implementation of IMR; however, there is room for expansion. Implementation tools such as training and consultation are needed to ensure dissemination and quality within VA. Given the comparative resources and infrastructure of VA, it is likely that equal or greater implementation tools are necessary in other systems of care.

Parents served by assertive community treatment: parenting needs, services, and attitudes.

OBJECTIVE: Assertive Community Treatment (ACT) is an evidence-based practice for individuals with severe mental illness. Although at least half of all people with severe mental illness are parents, little is known about their experiences as parents and as recipients of mental health interventions like ACT. The purpose of the current study was to examine the experiences of parent consumers served by ACT. METHOD: Seventeen parents being served by ACT teams were interviewed about parenting, parenting needs, severe mental illness, satisfaction with ACT services, and suggestions for improved parent-focused treatment services. RESULTS: All parents identified at least one positive aspect of parenting and most parents (77%) also identified negative aspects of parenting. Loss of custody emerged as a significant parenting problem, with most parents (88%) experiencing custody loss at least once. Parents expressed interest in numerous parent-focused services, including family therapy, parenting skills, communication skills training, resources for children, and peer support groups. Most participants with adult children (88%) reported having no unmet parent-related needs and high satisfaction (4.63 of 5) with ACT services, whereas parents with young children (78%) reported having several unmet parenting needs and relatively lower satisfaction (3.78 out of 5) with ACT services. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The ACT treatment model may not be adequately serving parents of young, dependent children. Findings suggest the need for more attention and focus on parent consumers, including identification of parental status and improved parent-related treatment services and support.

Parents served by assertive community treatment: prevalence, treatment services, and provider attitudes.

Assertive Community Treatment (ACT) is an evidence-based practice for individuals with severe mental illness. Although studies estimate at least half of all people with severe mental illness are parents, little is known about ACT policies and services for consumers who are parents. ACT providers from 67 teams completed a survey assessing policies for identifying parent consumers of ACT, estimated prevalence of parent consumers, available treatment services, and attitudes about parent consumers. Participants estimated that 18% of ACT consumers are parents. However, less than half of participants (47.8%) reported formally asking about parental status during intake and only 22.4% reported providing programs or services designed for parent consumers. Most participants (about 80%) reported negative or mixed attitudes about parenting with severe mental illness. Findings suggest the need for more attention and focus on parent consumers, including the formal identification of consumers' parental status and availability of parent-related treatment services.

A comparison of self-reported and phone-administered methods of ACT fidelity assessment: a pilot study in Indiana.

OBJECTIVE: Monitoring fidelity of assertive community treatment (ACT) teams is costly. This study investigated the reliability and validity of a less burdensome approach: self-reported assessment. METHODS: Phone-administered and self-reported assessments were compared for 16 ACT teams. Team leaders completed a self-report protocol providing information sufficient to score the Dartmouth Assertive Community Treatment Scale (DACTS). Two raters scored the DACTS using only self-reported information. Two additional raters conducted phone interviews with team leaders, verifying the self-reported data, and independently scored the DACTS. RESULTS: DACTS total scores obtained via self-reported assessments were reliable and valid compared with phone-administered assessment on the basis of interrater consistency (intraclass correlation) and consensus (mean rating differences). Phone-administered assessments agreed with self-reported assessments within .25 scale points (out of 5 points) for 15 of 16 teams. CONCLUSIONS: A self-report approach could address concerns regarding costs of monitoring as part of a stepped approach to quality assurance.

Development and reliability of a measure of clinician competence in providing illness management and recovery.

OBJECTIVE: Illness management and recovery (IMR) is an evidence-based, manualized illness self-management program for people with severe mental illness. This study sought to develop a measure of IMR clinician competence and test its reliability and validity. METHODS: Two groups of subject matter experts each independently created a clinician-level IMR competence scale based on the IMR Fidelity Scale and on two unpublished instruments used to evaluate provider competence. The two versions were merged, and investigators used the initial version to independently rate recordings of IMR sessions. Ratings were compared and discussed, discrepancies were resolved, and the scale was revised through 14 iterations. The resulting IMR Treatment Integrity Scale (IT-IS) includes 13 required items and three optional items rated only when the particular skill is attempted. Four independent raters then used the IT-IS to score tapes of 60 IMR sessions and 20 control group sessions. RESULTS: The IT-IS showed excellent interrater reliability (.92). A factor analysis supported a one-factor model that showed good internal consistency. The scale successfully differentiated between IMR and control groups. Reliability and validity of individual items varied widely. CONCLUSIONS: The IT-IS is a promising measure of clinician competence in providing IMR. The scale could be used for research and quality assurance and as a supervisory feedback tool. Future research is needed to examine item-level changes, predictive validity of the IT-IS, discriminant validity compared with other more structured interventions, and the reliability and validity of the scale for nongroup IMR.