Dermatologic conditions of adult refugees following resettlement in the United States, 2015 to 2018.

Background: There is a paucity of literature regarding dermatologic conditions in migrant and refugee populations. Methods: We conducted a cross-sectional study of all adult refugees resettling in a region of Connecticut, U.S. from 7 January 2015 to 20 November 2018. We conducted a manual chart review to determine dermatologic conditions diagnosed during and within one year of resettlement. We used multivariable logistic regression to determine demographic and clinical factors associated with having any dermatologic condition. Results: We included 545 refugees primarily from Afghanistan (40.6%), Syria (24.6%) and Iraq (10.5%), with a median (interquartile range) age of 33 (28-40) years. Of the 545 participants, 213 (39.1%) had dermatologic conditions. Fifty-four participants (25%) had more than one dermatologic condition and 114 (53.5%) were diagnosed within the first month of resettlement. The most common categories of conditions were cutaneous infections (24.9%), inflammatory conditions (11.1%), and scar or burn (10.7%). Tobacco use was associated with having a cutaneous infection (OR 2.37, 95%CI:1.09-4.95), and younger age was associated with having a scar or burn (for each year increase in age, OR 0.95, 95%CI:0.91-0.99). Conclusion: Dermatologic conditions are common among adult refugees. The majority of conditions were diagnosed in the first month following resettlement suggesting that a high number of dermatologic conditions arise or go undetected and untreated during the migration process.

Management of SIADH-related hyponatremia due to psychotropic medications - An expert consensus from the Association of Medicine and Psychiatry.

OBJECTIVE: Hyponatremia is the most common electrolyte imbalance encountered in clinical practice and is associated with negative healthcare outcomes and cost. SIADH is thought to account for one third of all hyponatremia cases and is typically an insidious process. Psychotropic medications are commonly implicated in the etiology of drug induced SIADH. There is limited guidance for clinicians on management of psychotropic-induced SIADH. METHODS: After an extensive review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus recommendations for management of psychotropic-induced SIADH. A risk score was proposed based on risk factors for SIADH to guide clinical decision-making. RESULTS: SSRIs, SNRIs, antipsychotics, carbamazepine, and oxcarbazepine have moderate to high level of evidence demonstrating their association with SIADH. Evaluation for an avoidance of medications that cause hyponatremia is particularly important. Substitution with medication that is less likely to cause SIADH should be considered when appropriate. We propose an algorithmic approach to monitoring hyponatremia with SIADH and corresponding treatment depending on symptom severity. CONCLUSIONS: The proposed algorithm can help clinicians in determining whether psychotropic medication should be stopped, reduced or substituted where SIADH is suspected with recommendations for sodium (Na+) monitoring. These recommendations preserve a role for clinical judgment in the management of hyponatremia with consideration of the risks and benefits, which may be particularly relevant for complex patients that present with medical and psychiatric comorbidities. Further studies are needed to determine whether baseline and serial Na+ monitoring reduces morbidity and mortality.

Vaccine completion and infectious diseases screening in a cohort of adult refugees following resettlement in the U.S.: 2013-2015.

BACKGROUND: Refugees are frequently not immune to vaccine-preventable infections. Adherence to consensus guidelines on vaccination and infectious diseases screening among refugees resettling in the U.S. is unknown. We sought to determine rates of vaccine completion and infectious diseases screening in refugees following resettlement. METHODS: We conducted a retrospective cohort study of refugees resettling in a region in the U.S. using medical data from June 2013-April 2015. We determined the proportion of vaccine-eligible refugees vaccinated with measles-mumps-rubella (MMR), hepatitis A/B, tetanus, diphtheria, and acellular pertussis (Tdap), and human papillomavirus (HPV) following resettlement. We also determined the proportion of refugees who completed HIV and hepatitis C (HCV) screening. RESULTS: One hundred and eleven subjects were included, primarily from Iraq (53%), Afghanistan (19%), and Eritrea (11%). Of the 84 subjects who were vaccine-eligible, 78 (93%) initiated and 42 (50%) completed vaccinations within one year of resettlement. Odds of completing vaccination were higher for men (OR: 2.38; 95%CI:1.02-5.71) and for subjects with English proficiency (OR: 3.70; 95%CI:1.04-17.49). Of the 78 subjects (70%) completing HIV screening, two (3%) were diagnosed with HIV. Nearly all subjects completed screening for HCV, and one had active infection. CONCLUSION: While most refugees initiate vaccinations, only 50% completed vaccinations and 70% completed HIV screening within 1 year of resettlement. There is a need to emphasize vaccine completion and HIV screening in refugee patients following resettlement.

QTc monitoring in adults with medical and psychiatric comorbidities: Expert consensus from the Association of Medicine and Psychiatry.

OBJECTIVE: Several psychiatric medications have the potential to prolong the QTc interval and subsequently increase the risk for ventricular arrhythmias such as torsades de pointes (TdP). There is limited guidance for clinicians to balance the risks and benefits of treatments. METHODS: After a review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus guidelines for ECG monitoring of the QTc interval for patients with medical and psychiatric comorbidities who are prescribed medications with the potential to prolong the QTc interval. A risk score was developed based on risk factors for QTc prolongation to guide clinical decision-making. RESULTS: A baseline ECG may not be necessary for individuals at low risk for arrythmia. Those individuals with a risk score of two or more should have an ECG prior to the start of a potentially QTc-prolonging medication or be started on a lower risk agent. Antipsychotics are not equivalent in causing QTc prolongation. A consensus-based algorithm is presented for the management of those identified at high (QTc >500 msec), intermediate (males with QTc 450-499 msec or females with QTc > 470-499 msec), or low risk. CONCLUSIONS: The proposed algorithm can help clinicians in determining whether ECG monitoring should be considered for a given patient. These guidelines preserve a role for clinical judgment in selection of treatments that balance the risks and benefits, which may be particularly relevant for complex patients with medical and psychiatric comorbidities. Additional studies are needed to determine whether baseline and serial ECG monitoring reduces mortality.

Establishing an Integrated Health Care Clinic in a Community Mental Health Center: Lessons Learned.

Integrating primary care with behavioral health services at community mental health centers is one response to the disparity in mortality and morbidity experienced by adults with serious mental illnesses and co-occurring substance use disorders. Many integration models have been developed in response to the Primary and Behavioral Health Care Integration (PBHCI) initiative of the Substance Abuse and Mental Health Services Administration (SAMHSA). One model is a primary care clinic co-located within the mental health center. The Connecticut Mental Health Center (CMHC) Wellness Center is one such co-located clinic developed as a partnership between CMHC and a Federally Qualified Health Center (FQHC). In this article, we describe the process of developing this on-site clinic along with lessons learned during implementation. We review different aspects of building and maintaining such a clinic and outline lessons learned from both successes and challenges. We briefly describe the demographics and health characteristics of the patient population served in this clinic. We make recommendations for providers and agencies that are considering or are already developing a model for integrating care. Finally, we briefly review status of our clinic after completion of grant funding.

Factors Associated with Refugee Acute Healthcare Utilization in Southern Connecticut.

Our objective was to examine refugees' acute care use early in resettlement. We conducted a retrospective cohort study of acute care use, emergency room and hospital visits, by adult refugees arriving in Southern Connecticut between 2/1/2013 and 2/1/2015. We examined associations between any acute care use and collected demographic as well as health characteristics. Of the 248 refugees in our sample, 57% had a medical evaluation within 30 days of arrival. 102 (41%) had at least one acute care visit within 8 months of arrival. Male sex (OR 1.90, 95% CI 1.09-3.30) and prior history of hypertension (OR 2.87, 95% CI 1.06-7.33) were associated with greater likelihood of an acute care visit within 8 months of arrival, while having a medical evaluation within 30 days of arrival was associated with lower likelihood (OR 0.56, 95% CI 0.32-0.98). Designing systems to ensure timely evaluations of newly arrived refugees may reduce frequent acute care utilization.

Prevalence of obesity and diabetes in patients with schizophrenia.

AIM: To compare the prevalence of diabetes in patients with schizophrenia treated at a community mental health center with controls in the same metropolitan area and to examine the effect of antipsychotic exposure on diabetes prevalence in schizophrenia patients. METHODS: The study was a comprehensive chart review of psychiatric notes of patients with schizophrenia and schizoaffective disorder treated at a psychosis program in a community mental health center. Data collected included psychiatric diagnoses, diabetes mellitus diagnosis, medications, allergies, primary care status, height, weight, body mass index (BMI), substance use and mental status exam. Local population data was downloaded from the Centers for Disease Control Behavioral Risk Factor Surveillance System. Statistical methods used were χ2 test, Student's t test, general linear model procedure and binary logistic regression analysis. RESULTS: The study sample included 326 patients with schizophrenia and 1899 subjects in the population control group. Demographic data showed control group was on average 7.6 years older (P = 0.000), more Caucasians (78.7% vs 38.3%, P = 0.000), and lower percentage of males (40.7% vs 58.3%, P = 0.000). Patients with schizophrenia had a higher average BMI than the subjects in the population control (32.11, SD = 7.72 vs 27.62, SD = 5.93, P = 0.000). Patients with schizophrenia had a significantly higher percentage of obesity (58.5% vs 27%, P = 0.000) than the population group. The patients with schizophrenia also had a much higher rate of diabetes compared to population control (23.9% vs 12.2%, P = 0.000). After controlling for age sex, and race, having schizophrenia was still associated with increased risk for both obesity (OR = 3.25, P = 0.000) and diabetes (OR = 2.42, P = 0.000). The increased risk for diabetes remained even after controlling for obesity (OR = 1.82, P = 0.001). There was no difference in the distribution of antipsychotic dosage, second generation antipsychotic use or multiple antipsychotic use within different BMI categories or with diabetes status in the schizophrenia group. CONCLUSION: This study demonstrates the high prevalence of obesity and diabetes in schizophrenia patients and indicates that antipsychotics may not be the only contributor to this risk.

Screening and Treatment Rates for Latent Tuberculosis Among Newly-Arrived Refugees in an Urban Facility in Connecticut.

There is a high prevalence of latent tuberculosis infection (LTBI) and risk of reactivation among refugees. This study describes LTBI prevalence, treatment initiation, and completion rates in refugee patients seen at one urban Connecticut hospital. This retrospective chart review includes 248 adult refugee patients screened between January 2009 and April 2012. Demographics, tuberculin skin test (TST) results, treatment initiation and completion rates, and treatment-related variables were collected. Ninety-eight percent of adult refugees received TST screening and 44.0% were diagnosed with LTBI. Of these, 95.5% initiated treatment, and of those, 48.2% completed treatment. Early treatment discontinuation was high, with 29.5% of patients diagnosed with LTBI defaulting after the first clinic visit. Despite near-universal screening within this refugee population, LTBI treatment initiation and completion rates remain low. Greater efforts should be made to ensure LTBI treatment initiation and completion among refugees through early case management and shorter treatment duration.

History of Persecution and Health Outcomes Among U.S. Refugees.

Our goal was to describe the forms of persecution reported by adult refugees in the U.S. and the relationships between persecution and health status among this population. Data were derived from the 2003 New Immigrant Survey, a representative sample of new U.S. lawful permanent residents. Major depression, impairment in daily activities due to pain, poor self-reported health, and declining health were described for refugees who had and had not reported persecution prior to arrival in the U.S. Health status was also examined for refugees who reported different forms of persecution. Half of refugees (46.7 %) in this sample reported that they or an immediate family member had been persecuted. One in three persecuted refugees (31.8 %) reported both incarceration and physical punishment. Major depression, pain-related impairment, poor health, and declining health were twice as common among persecuted refugees than among non persecuted refugees. Notably, despite these adverse experiences, the majority of persecuted refugees did not report poor health outcomes.

Antipsychotic-induced weight gain in first-episode psychosis patients: a meta-analysis of differential effects of antipsychotic medications.

AIM: The first-episode psychosis (FEP) represents a critical period to prevent cardiovascular and metabolic morbidity decades later. Antipsychotic (AP)-induced weight gain is one modifiable factor in this period. The purpose of this study is to conduct a meta-analysis of AP-induced weight and body mass index (BMI) change in FEP. METHODS: A comprehensive literature search identified 28 articles that reported data on AP-specific weight or BMI change in FEP. We conducted a meta-analysis of short- and long-term mean weight and BMI differences between placebo and AP medications. We also performed subgroup and meta-regression analysis to examine weight, BMI outcomes and their relationship with location (Asian vs. Western), sponsorship and baseline weight and BMIs. RESULTS: Compared to placebo, AP-caused mean weight gain was 3.22 kg and 1.4 points BMI in the short-term, and 5.30 kg and 1.86 points BMI in the long term. Clinically significant weight gain risk increased about twofold with AP use. Weight gain was associated with duration of AP use. AP medications were associated with more weight gain in Western samples as opposed to Asian samples. Most AP medications were associated with significant body weight gain and BMI increase in FEP patients, except for ziprasidone. Olanzapine and clozapine caused the highest weight gain compared to placebo. CONCLUSION: Except for ziprasidone, most AP medications were associated with body weight gain and BMI increase in FEP patients. Early and continuing effects of various AP medications on weight gain and BMI increase should be taken into consideration by clinicians.

Antipsychotic-Induced Weight Gain in First-Episode Psychosis Patients: A Meta-Analysis of Differential Effects of Antipsychotic Medications.

(Reprinted with permission from Early Intervention in Psychiatry 2016; 10:193-202).

Smoking Use and Cessation Among People with Serious Mental Illness.

Smoking rates in people with serious mental illness (SMI) are disproportionately high compared to the general population. It is a leading contributor to the early mortality in this population. Smoking cessation rates are low in this group, though patients are motivated to quit. Unfortunately, health care providers do not always prioritize smoking cessation for this population. This review provides an overview of prevalence rates, biological effects that maintain smoking, and evidence-based treatments for smoking cessation in SMI. In addition, objective and qualitative data from a chart review of 78 patients with SMI prescribed smoking cessation treatment at one community mental health center are described. Of these, 30 (38.5 percent) were found to either quit (16/78) or reduce (14/78) smoking. Varenicline appeared to be particularly effective. Review of the literature and results of this study suggest that smoking cessation pharmacotherapies are effective for SMI patients and should be offered to those who smoke.

General Medicine Training in Psychiatry Residency.

With growing awareness of the need for integrated health care settings, psychiatrists may be required to provide clinical care at the primary care and behavioral health interface. This article discusses the curricular changes that could enhance the development of psychiatrists as leaders in integrated primary and behavioral health care. Psychiatrists may be called upon to provide enhanced collaborative care services at primary care or behavioral health settings. This article focuses on the provision of integrated care in behavioral health settings, especially in the public sector. The authors review the additional training in general medicine that would facilitate these skills. They outline the principles and goals to be considered in building such a curriculum. They examine the curricular building blocks of such training and also discuss challenges in implementing these curricular changes. Finally, they discuss the implications of incorporating integrated health care training on the future of psychiatric practice.

An overview of diabetes management in schizophrenia patients: office based strategies for primary care practitioners and endocrinologists.

Diabetes is common and seen in one in five patients with schizophrenia. It is more prevalent than in the general population and contributes to the increased morbidity and shortened lifespan seen in this population. However, screening and treatment for diabetes and other metabolic conditions remain poor for these patients. Multiple factors including genetic risk, neurobiologic mechanisms, psychotropic medications, and environmental factors contribute to the increased prevalence of diabetes. Primary care physicians should be aware of adverse effects of psychotropic medications that can cause or exacerbate diabetes and its complications. Management of diabetes requires physicians to tailor treatment recommendations to address special needs of this population. In addition to behavioral interventions, medications such as metformin have shown promise in attenuating weight loss and preventing hyperglycemia in those patients being treated with antipsychotic medications. Targeted diabetes prevention and treatment is critical in patients with schizophrenia and evidence-based interventions should be considered early in the course of treatment. This paper reviews the prevalence, etiology, and treatment of diabetes in schizophrenia and outlines office based interventions for physicians treating this vulnerable population.

High rates of obstructive sleep apnea symptoms among patients with schizophrenia.

BACKGROUND: Patients with schizophrenia have high rates of obesity and cardiovascular morbidity, which are strongly associated with obstructive sleep apnea (OSA). The prevalence and risk factors for OSA are not well studied in patients with schizophrenia. OBJECTIVE: The purpose of this study was to evaluate the frequency of OSA symptoms in a sample of outpatients with schizophrenia. METHODS: This cross-sectional study was a secondary analysis of data generated from an insomnia study that evaluated 175 outpatients with schizophrenia or schizoaffective disorder in a single, large urban community mental health center. Results of scales evaluating insomnia were used to complete the STOP questionnaire, which is a screening tool for OSA validated in surgical populations. Appropriate statistical analysis was done to compare participants across groups. RESULTS: Patients were classified into high risk for OSA (STOP ≥ 2) (57.7%), and low risk for OSA (STOP score < 2) (42.3%). We also identified patients with a known diagnosis of OSA (14.9%). Patients with diagnosed OSA had significantly higher STOP scores (mean 2.7 vs. 1.6 [t = 6.3; p < 0.001]). Only 23.8% of patients in the high-risk group were diagnosed with OSA. Body mass index was significantly higher in the diagnosed group (F[2,169] = 25; p < 0.001) as was diabetes (χ2 [2, N = 175] = 35, p < 0.001). CONCLUSION: A large number of outpatients with severe mental illness are at high risk for OSA. The STOP questionnaire is easy to use and appears to have a very high clinical utility to detect OSA. Based on our findings, further studies are warranted to validate the tool in patients with severe mental illness.

Status of general medicine training and education in psychiatry residency.

OBJECTIVE: With the current emphasis on integrated care, the role of psychiatrists is expanding to either directly provide medical care or coordinate its delivery. The purpose of this study was to survey general psychiatry programs on the extent of general medicine training provided during residency. METHODS: A short web-based survey was sent to 173 residency program directors to recruit participants for a larger survey. Thirty-seven participants were recruited and surveyed, and of these, 12 (32.4%) responded. The survey assessed the extent of general medicine training and didactics during and after the first postgraduate year and attitudes towards enhancing this training in residency. This study was approved by the local institutional review board. RESULTS: Seventy-five percent of programs require only the minimum 4 months of primary care in the first postgraduate year, and didactics during these months is often not relevant to psychiatry residents. Some programs offer elective didactics on chronic medical conditions in the fourth postgraduate year. Respondents are in favor of enhancing general medicine training in psychiatry but indicate some resistance from their institutions. CONCLUSIONS: These results suggest that very few programs require additional clinical training in relevant medical illnesses after the first postgraduate year. Respondents indicated favorable institutional support for enhancing training, but also expected resistance. The reasons for resistance should be an area of future research. Also important is to determine if enhancing medical didactics improves patient care and outcomes. The changing role of psychiatrists entails a closer look at resident curricula.

Giant cell arteritis presenting as small bowel infarction.

Giant cell arteritis predominantly affects cranial arteries and rarely involves other sites. We report a patient who presented with small bowel obstruction because of infarction from mesenteric giant cell arteritis. She had an unusual cause of her obstruction and a rare manifestation of giant cell arteritis. In spite of aggressive therapy with steroids, she died a month later because of multiple complications. We discuss the diagnosis and management of small bowel obstruction and differential diagnosis of vasculitis of the gastrointestinal tract. We were able to find 11 cases of bowel involvement with giant cell arteritis in the English literature. This case report illustrates that giant cell arteritis can be a cause of small bowel obstruction and bowel infarction. In the proper clinical setting, vasculitides need to be considered early in the differential diagnosis when therapy may be most effective.