Clinical Presentation and Outcome of Patients Experiencing Homelessness Presenting With ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Cardiovascular disease remains a major cause of morbidity and mortality among homeless adults. Despite major advances in the management of ST elevation myocardial infarction (STEMI), limited information is available for the clinical presentation and management and outcome of STEMI among patients experiencing homelessness (PEH). METHODS: All patients presenting with STEMI between January 1, 2008 and December 31, 2017 at a PCI capable STEMI network inner city hospital comprised the study population. Baseline characteristics, homeless status and clinical outcomes were determined from hospital records. The primary outcome of in-hospital mortality was compared between PEH and nonhomeless patients using a log-binomial regression model with propensity score adjusted standardised mortality ratio weighting (SMRW). RESULTS: Among 2854 STEMI admissions during the study period, 75 patients (2.6%) were identified as PEH. The PEH group was younger (58 vs 63 years; P = 0.0002), predominantly male (96% vs 76%), and more likely to present with cardiogenic shock or cardiac arrest (17% vs 6%) compared with the nonhomeless group. The in-hospital mortality remained significantly higher among PEH (risk ratio 3.83, 95% confidence interval 1.27-11.60) after propensity score adjustment. CONCLUSIONS: Despite universal health care and contemporary STEMI management, PEH presenting with STEMI experienced a 4-fold higher in-hospital mortality compared with the nonhomeless cohort. Targeted interventions are needed to improve STEMI outcomes in this high-risk group.

Cardiovascular Disease and Homelessness.

Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.

The association between childhood adversity and components of metabolic syndrome in adults with mood disorders: results from the international mood disorders collaborative project.

OBJECTIVE: We sought to determine whether a reported history of childhood adversity is associated with components of the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP-III)-defined metabolic syndrome in adults with mood disorders. METHOD: This was a cross-sectional analysis of adult outpatients (N = 373; n = 230 female, n = 143 male; mean age [SD] = 42.86 [14.43]) from the International Mood Disorders Collaborative Project (University of Toronto and Cleveland Clinic) with DSM-IV-defined major depressive disorder and bipolar I/II disorder. Childhood adversity was measured with the Klein Trauma & Abuse-Neglect self-report scale. The groups with and without childhood adversity were compared to determine possible differences in the rates of metabolic syndrome and its components. Logistic and linear regressions adjusted for age, sex, education, employment status, and smoking were used to evaluate the association between childhood adversity and components of metabolic syndrome. RESULTS: For the full sample, 83 subjects (22.25%) met criteria for metabolic syndrome. Individuals reporting a history of any childhood adversity had higher systolic and diastolic blood pressure (systolic: p = 0.040; diastolic: p = 0.038). Among subjects with a history of sexual abuse, a significant proportion met criteria for obesity (45.28% vs. 32.88%; p = 0.010); a trend toward overweight was found for subjects with a history of physical abuse (76.32% vs. 63.33%; p = 0.074), although this relationship did not remain significant after adjusting for potential confounders. There was no statistically significant difference in the overall rate of dyslipidemia and/or metabolic syndrome between subjects with and without childhood adversity. CONCLUSION: The results herein provide preliminary evidence suggesting that childhood adversity is associated with metabolic syndrome components in individuals with mood disorders.

Aripiprazole for the maintenance treatment of bipolar disorder: a review of available evidence.

We aimed to review and synthesize results reporting on the maintenance efficacy of Aripiprazole in adults with bipolar I disorder. Aripiprazole is FDA approved for the acute and maintenance treatment of bipolar I disorder. Aripiprazole's efficacy during the long-term treatment of bipolar disorder is supported by extension of acute phase studies and long-term (ie, 100-week) double-blind placebo controlled recurrence prevention registration trials. Aripiprazole is not established as efficacious in the acute or maintenance treatment of bipolar depression. Moreover, aripiprazole's efficacy during the acute or maintenance phase of bipolar II disorder has not been sufficiently studied. Aripiprazole has a relatively lower hazard for metabolic disruption and change in body composition when compared to other atypical agents (eg, olanzapine, quetiapine). Moreover, aripiprazole has minimal propensity for sedation, somnolence and prolactin elevation. Aripiprazole is associated with extrapyramidal side effects, notably akathisia, which in most cases is not severe or treatment limiting. Future research vistas are to explore aripiprazole's efficacy in bipolar subgroups; recurrence prevention of bipolar depression; and in combination with other mood stabilizing agents.

Mood disorders and obesity: understanding inflammation as a pathophysiological nexus.

The aim of this review is to evaluate the evidentiary base supporting the hypothesis that the increased hazard for obesity in mood disorder populations (and vice versa) is a consequence of shared pathophysiological pathways. We conducted a PubMed search of all English-language articles with the following search terms: obesity, inflammation, hypothalamic-pituitary-adrenal axis, insulin, cognition, CNS, and neurotransmitters, cross-referenced with major depressive disorder and bipolar disorder. The frequent co-occurrence of mood disorders and obesity may be characterized by interconnected pathophysiology. Both conditions are marked by structural and functional abnormalities in multiple cortical and subcortical brain regions that subserve cognitive and/or affective processing. Abnormalities in several interacting biological networks (e.g. immuno-inflammatory, insulin signaling, and counterregulatory hormones) contribute to the co-occurence of mood disorders and obesity. Unequivocal evidence now indicates that obesity and mood disorders are chronic low-grade pro-inflammatory states that result in a gradual accumulation of allostatic load. Abnormalities in key effector proteins of the pro-inflammatory cascade include, but are not limited to, cytokines/adipokines such as adiponectin, leptin, and resistin as well as tumor necrosis factor alpha and interleukin-6. Taken together, the bidirectional relationship between obesity and mood disorders may represent an exophenotypic manifestation of aberrant neural and inflammatory networks. The clinical implications of these observations are that, practitioners should screen individuals with obesity for the presence of clinically significant depressive symptoms (and vice versa). This clinical recommendation is amplified in individuals presenting with biochemical indicators of insulin resistance and other concurrent conditions associated with abnormal inflammatory signaling (e.g. cardiovascular disease).

Aerobic physical exercise as a possible treatment for neurocognitive dysfunction in bipolar disorder.

BACKGROUND: Neurocognitive dysfunction associated with bipolar disorder (BD) is pervasive, persistent across illness phases, and is demonstrated to predispose and portend psychosocial impairment. Moreover, no approved therapies for various phases of BD have been shown to reliably improve any dimension of neurocognitive performance. In this article, we emphasize that aerobic physical exercise is a viable neurocognitive-enhancing adjunctive treatment for patients with BD. The overarching aim of this review is to emphasize that aerobic physical exercise is a viable neurocognitive-enhancing adjunctive treatment for patients with BD. METHODS: We conducted PubMed and Google Scholar searches of all English-language articles published between January 1966 and February 2010 using the search terms bipolar disorder, major depressive disorder, depression, exercise, and physical activity cross-referenced with each other and the following terms: cognition, executive function, learning, memory, attention, emotion, and behavior. Articles selected for review were based on adequacy of sample size, use of standardized experimental procedures, validated assessment measures, and overall quality. RESULTS: Available studies have documented an array of persisting neurocognitive deficits across disparate bipolar populations. Abnormalities in verbal working memory are highly replicated; deficits in executive function, learning, attention, and processing speed are also a consistent abnormality. The effect sizes of neurocognitive deficits in BD are intermediate between those reported in schizophrenia and major depressive disorder. Several original reports and reviews have documented the neurocognitive-enhancing effects of aerobic exercise in the general population as well as across diverse medical populations and ages. Proposed mechanisms involve nonexclusive effects on neurogenesis, neurotrophism, immunoinflammatory systems, insulin sensitivity, and neurotransmitter systems. Each of these effector systems are implicated in both normal and abnormal neurocognitive processes in BD. CONCLUSION: Available evidence provides a rationale for empirically evaluating the neurocognitive benefits of aerobic exercise in BD.

The rate of metabolic syndrome in euthymic Canadian individuals with bipolar I/II disorder.

OBJECTIVE: To report on the rate of metabolic syndrome, as defined by the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III), in asymptomatic adults with bipolar I/II disorder evaluated at the Mood Disorders Psychopharmacology Unit (MDPU), University Health Network, University of Toronto. To our knowledge, this is the first study reporting on the rate of metabolic syndrome in a Canadian clinical sample and exclusively evaluating asymptomatic individuals. METHODS: This was a post-hoc, cross-sectional analysis of adult bipolar subjects who were primarily enrolled in a clinical intervention study. All subjects in this sample were asymptomatic at the time of assessing metabolic parameters. RESULTS: Data from 99 euthymic bipolar subjects (n=51 female, n=48 male) were included for the analysis. The sample mean age±SD was 38±11.15 years. Thirty-one subjects (32.6%) met criteria for the metabolic syndrome with no significant differences as a function of sex. The waist circumference criterion was met in 37 (41.1%) subjects. Diastolic and systolic blood pressure criteria were met in 26 (27.6%) and 28 (29.7%) subjects, respectively. Thirty-one subjects (36.4%) met the high-density lipoprotein (HDL) criterion, while 33 (38.8%) met the triglyceride criterion. Moreover, five (6.1%) met the criterion for high fasting glucose level (diabetes mellitus or glucose/insulin dysregulation at screening was an exclusion criterion). Men were more likely to have high diastolic (P=0.001) and systolic blood pressure (P=0.007) as well as hypertriglyceridemia (P=0.037). Abdominal obesity, HDL, and fasting glucose levels were not significantly different between men and women. Bipolar individuals with concurrent metabolic syndrome had a later age at first treatment and increased number of total hospitalizations. CONCLUSION: Asymptomatic Canadian individuals with bipolar disorder exhibit a high rate of concurrent metabolic syndrome. The results herein buttress recommendations for risk factor screening and modification, ongoing surveillance, as well as primary and secondary prevention strategies for metabolic abnormalities in individuals with bipolar disorder.

Atypical antipsychotic tolerability and switching strategies in bipolar disorder.

IMPORTANCE TO THE FIELD: Atypical antipsychotics have unequivocally advanced the pharmacotherapy of bipolar disorders. These broad-spectrum treatments offer efficacy against core symptoms of acute mania, mixed state, depressed and maintenance phases of the disorder. Atypical antipsychotics are not, however, a panacea and are associated with several problematic tolerability and safety concerns. For example, emerging evidence militates against the original notion that atypical agents are without risk for extrapyramidal side effects and possibly tardive dyskinesia when compared to their therapeutic predecessors, the conventional antipsychotics. Although classified together, atypical antipsychotics are heterogeneous in their tolerability and safety profile, an issue relevant to individualizing treatment selection and switching antipsychotics for optimal clinical management. AREAS COVERED IN THIS REVIEW: This article reviews relevant adverse events attributable to the use of atypical antipsychotics and strategies for switching these agents, with particular attention to the bipolar disorder population. WHAT THE READER WILL GAIN: The reader will gain both a perspective of treatment-emergent adverse events associated with atypical agents in the treatment of bipolar disorder and a precise analysis of common adverse events that frequently lead to treatment discontinuation and/or switching to a separate agent. TAKE HOME MESSAGE: Atypical antipsychotics provide for a different array of treatment-emergent adverse events than conventional agents. The therapeutic index of treatment is a ratio of the relative benefit divided by the probability of harm (i.e., side effects). Taken together, the atypical antipsychotics offer an improved therapeutic index when compared to conventional agents in bipolar disorder. Nevertheless, atypicals fall short of the ideal, necessitating frequent discontinuation and switching.

Bipolar disorder and metabolic syndrome: an international perspective.

INTRODUCTION: The ubiquity and hazards posed by abnormal body composition and metabolic parameters in the bipolar population are a priority research and clinical issue. Herein, we summarize and synthesize international studies describing the rate of US National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III])- and International Diabetes Federation (IDF)-defined metabolic syndrome and its criterion components in individuals with bipolar disorder. METHODS: We conducted a PubMed search of all English-language articles published between January 2005 and July 2009 with the following search terms: metabolic syndrome and bipolar disorder, mania and manic-depression. Articles selected for review were based on adequacy of sample size, the use of standardized experimental procedures, validated assessment measures, and overall manuscript quality. RESULTS: The rate of metabolic syndrome in individuals with bipolar disorder is increased relative to the general population. Disparate estimates are reported ranging from comparability to approximately twofold greater than the general population. The increased hazard for metabolic syndrome amongst bipolar individuals is now documented in twelve countries from Europe, Australia, Asia, North and South America. The co-occurrence of metabolic syndrome in the bipolar population is associated with a more complex illness presentation, less favourable response to treatment, and adverse course and outcome. The association between metabolic syndrome and bipolar disorder is mediated/moderated by both iatrogenic and non-iatrogenic factors. DISCUSSION: The increased hazard for metabolic syndrome in bipolar populations is due to the clustering of traditional (and emerging) risk factors as well as iatrogenic and health systems factors. Extant data support recommendations for prioritizing, surveillance, prevention, diagnosis and management of metabolic syndrome as routine care of the bipolar patient.