Acute Brachial Artery Occlusion on Point-of-Care Ultrasound in the Emergency Department: A Case Report.

INTRODUCTION: This is a case report of an acute right brachial artery occlusion found on point-of-care ultrasound in the emergency department (ED) that illustrates the developing role of ultrasound in rapid differentiation and identification of acute vascular emergencies. CASE REPORT: An 87-year-old male with a past medical history of coronary artery bypass graft presented to the ED with acute right upper extremity pain, with point-of-care ultrasound (POCUS) findings consistent with acute right brachial artery occlusion. CONCLUSION: Arterial occlusions are vascular emergencies that can be rapidly identified on POCUS.

Exploring static and dynamic relationships between burden of disease and research funding in the United States.

BACKGROUND: The relationship between burden of disease and research funding has been examined cross-sectionally, but temporal patterns have not been investigated. It is logical to assume that temporal improvements in disability-adjusted life-years (DALYs) reflect benefits from research funding; such assumptions are tempered by an unknown lag time for emergence of benefits from research. METHODS: We studied National Institutes of Health (NIH) research fund allocations and United States DALY estimates for overlapping disease categories (matched disease categories, MDC, N = 38). Using a general linear model, we separately analysed DALYs for MDCs in 2017 in relation to NIH research allocations in 2017 and 2007. We also examined how changes in DALYs were related to cumulative NIH research funding (2006-2017). After regressing DALY change on summed funding, we obtained model residuals as estimates of the discrepancy for each MDC between observed and expected change in burden, given funding. RESULTS: In 2017, there was a positive association between NIH research fund allocations and DALYs for the same year (F1,36 = 16.087, p = 0.0002921; slope = 0.35020; model R2 = 0.3088), suggesting proportionate allocation. There was a positive association between 2017 DALYs and 2007 NIH research allocation, implying a beneficial impact of research (F1,36 = 15.754, p = 0.0003; slope = 0.8845; model R2 = 0.3044). In contrast, there was a nonsignificant association between summed NIH funding and percent change in DALYs over 2006-2017 (F1,36 = 0.199; p = 0.65; beta coefficient = -1.144). When MDCs were ordered based on residuals, HIV/AIDS ranked first. Mental, neurologic or substance abuse (MNS) disorders comprised most residuals in the lower half. CONCLUSIONS: NIH fund allocation is proportional to DALYs for MDCs. Temporal changes in DALYs vary by MDCs, but they are not significantly related to cumulative research outlays. Further analysis of temporal changes in DALYs could help to inform research outlays for MDCs and to study the impact of research.

Validation of screening tools for common mental health disorders in the methadone maintenance population in Hanoi, Vietnam.

BACKGROUND: Common mental health disorders (CMDs), including depression, anxiety and post-traumatic stress disorder (PTSD) may worsen both HIV and drug use outcomes, yet feasible tools to accurately identify CMDs have received limited study in this population. We aimed to validate the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder screen (GAD-7) and Primary Care PTSD screen for DSM-5 (PC-PTSD-5) in a methadone maintenance therapy (MMT) patient population in Hanoi, Vietnam. METHODS: We conducted a cross-sectional survey. The PHQ-9, GAD-7, and PC-PTSD-5 were administered to MMT patients. A blinded interviewer administered the Mini-International Neuropsychiatric Interview (MINI) as the reference gold standard. Total scores of each tool were compared with the MINI diagnoses using a receiver operating characteristic curves, and we identified the optimal respective cut-off scores using the Youden's Index. RESULTS: We enrolled 400 MMT patients. Approximately 99.3% were male (n = 397) and 21.8% (n = 87) were HIV positive. The prevalence of major depressive disorder, generalized anxiety disorder and PTSD, respectively, was 10.5, 4 and 2%. Optimal cut-off scores for the PHQ-9, GAD-7 and PC-PTSD were ≥ 5, ≥3, and ≥ 4 with a sensitivity/specificity of 95.2%/91.9, 93.8%/87.5, and 62.5%/95.2%. CONCLUSIONS: The prevalence of CMDs in the MMT population was lower than expected. A lower cut-off score may be considered when screening for CMDs in this population. Further research should investigate the validity of somatic symptom-based screening tools among other drug-using or MMT populations.

Psychometric performance of the perceived stigma of substance abuse scale (PSAS) among patients on methadone maintenance therapy in Vietnam.

BACKGROUND: People who inject drugs (PWID) and patients on methadone maintenance therapy (MMT) face severe stigma and discrimination. However, there are limited measures assessing stigma towards individuals with substance use disorders or MMT patients, particularly in Vietnam, and few studies have examined the psychometric properties of existing measures. This study aims to examine the performance of the eight-item Perceived Stigma of Substance Abuse Scale (PSAS), created in the United States, among a population of MMT patients in Vietnam. METHODS: A cross-sectional survey was conducted among 400 adult patients enrolled in an urban MMT clinic. Substance use stigma was measured using the PSAS. We conducted confirmatory factor analysis (CFA) and assessed construct validity, reliability and known-group validity. RESULTS: The original eight-item scale was unidimensional, but yielded mixed goodness-of-fit indicators. Ultimately, dropping two items and allowing the errors of the items related to childcare to correlate improved the goodness-of-fit indicators. (RMSEA = 0.025; CFI = 0.999; and SRMR = 0.018). The shortened scale demonstrated acceptable reliability (Cronbach's α = 0.766). The mean stigma scores were significantly higher among individuals not working, but did not significantly vary by length of time in MMT, marital status, education attainment, HIV status, depression, concurrent injection drug use or missed methadone dose. CONCLUSIONS: The shortened six-item scale demonstrated good construct validity and acceptability reliability, but it did not demonstrate many a priori hypothesized known-group validity associations. Further research should consider a mixed-methods validation approach.

Examining common mental health disorders in people living with HIV on methadone maintenance therapy in Hanoi, Vietnam.

BACKGROUND: Injection drug use drives HIV transmission in Southeast Asia, where around a quarter of users are living with HIV. Vietnam developed Methadone Maintenance Therapy (MMT) programs to reduce unsafe drug abuse. Common mental health disorders (CMD), including depression, anxiety and post-traumatic stress disorder (PTSD), can worsen MMT outcomes and are highly prevalent among people living with HIV (PLH). We aimed to characterize HIV and CMD among MMT patients and assess the impact of HIV and CMD on MMT engagement outcomes in Hanoi, Vietnam. METHODS: This cross-sectional study was conducted at an urban MMT clinic in Hanoi. Participants were screened for CMD with the relevant sections of the Mini International Neuropsychiatric Interview (MINI). Tabular comparisons and regression models were used to understand the association of HIV and CMD with substance use and methadone compliance. RESULTS: Of the 400 MMT participants, 22% were living with HIV, 11% a CMD, 27% reported injection drug use, and 27% reported methadone noncompliance. Around 17% of those with HIV also had a CMD. Reporting non injection and injection drug use were each higher among those with CMD regardless of HIV status. In addition, reporting any drug use was much higher among those with both HIV and CMD than among those with neither (73% vs 31%, p value 0.001). While methadone noncompliance was lower among PLH than among those without HIV (16.3% vs 30.1%, p value 0.010), noncompliance was higher among those with CMD than among those without (40.5% vs 25.6%, p value 0.045). Among those without HIV, noncompliance was higher among those with CMD than among those without, but among those with HIV, the opposite relationship was observed. CONCLUSION: There is complex overlap between substance use and methadone noncompliance among MMT patients living with HIV, CMD or both. In this population, we found a high prevalence of CMD and substance use among PLH, and a high prevalence of substance use and methadone noncompliance among those with CMD. Prioritizing provision of mental health care services to MMT patients living with HIV can help improve engagement with substance use disorder treatment and reduce the risk of HIV transmission.

A systematic review of validated screening tools for anxiety disorders and PTSD in low to middle income countries.

BACKGROUND: Anxiety and post-traumatic stress disorder (PTSD) contribute significantly to disability adjusted life years in low- to middle-income countries (LMICs). Screening has been proposed to improve identification and management of these disorders, but little is known about the validity of screening tools for these disorders. We conducted a systematic review of validated screening tools for detecting anxiety and PTSD in LMICs. METHODS: MEDLINE, EMBASE, Global Health and PsychINFO were searched (inception-April 22, 2020). Eligible studies (1) screened for anxiety disorders and/or PTSD; (2) reported sensitivity and specificity for a given cut-off value; (3) were conducted in LMICs; and (4) compared screening results to diagnostic classifications based on a reference standard. Screening tool, cut-off, disorder, region, country, and clinical population were extracted for each study, and we assessed study quality. Accuracy results were organized based on screening tool, cut-off, and specific disorder. Accuracy estimates for the same cut-off for the same screening tool and disorder were combined via meta-analysis. RESULTS: Of 6322 unique citations identified, 58 articles including 77 screening tools were included. There were 46, 19 and 12 validations for anxiety, PTSD, and combined depression and anxiety, respectively. Continentally, Asia had the most validations (35). Regionally, South Asia (11) had the most validations, followed by South Africa (10) and West Asia (9). The Kessler-10 (7) and the Generalized Anxiety Disorder-7 item scale (GAD-7) (6) were the most commonly validated tools for anxiety disorders, while the Harvard Trauma Questionnaire (3) and Posttraumatic Diagnostic Scale (3) were the most commonly validated tools for PTSD. Most studies (29) had the lowest quality rating (unblinded). Due to incomplete reporting, we could meta-analyze results from only two studies, which involved the GAD-7 (cut-off ≥10, pooled sensitivity = 76%, pooled specificity = 64%). CONCLUSION: Use of brief screening instruments can bring much needed attention and research opportunities to various at-risk LMIC populations. However, many have been validated in inadequately designed studies, precluding any general recommendation for specific tools in LMICs. Locally validated screening tools for anxiety and PTSD need further evaluation in well-designed studies to assess whether they can improve the detection and management of these common disorders. TRIAL REGISTRATION: PROSPERO registry number CRD42019121794 .