Evaluation Outcomes of Delirium and Abrupt Discontinuation of Psychiatric Medications of the Adult Acute Care Patient

PURPOSE: Delirium remains a common consequence of critical illness and is known to cause negative patient outcomes during an intensive care unit (ICU) stay. Hence, the purpose of this project is to evaluate the outcomes of patients taking psychiatric medications whose medications are abruptly discontinued upon admission to an ICU. Specifically, the outcomes of interest will be altered mental status, length of hospital stay, restraint use and mortality. METHODS: A correlational analysis using a retrospective chart audit was conducted on 602 patients admitted to the Neurological/ Neurosurgical ICUs at the University of Kentucky Chandler Hospital from January 2015 to December 2015. The proportion of patients who experience delirium in the ICU was examined using frequencies and percentages. Chi-square analysis was used to assess differences in the proportion of patients who experience delirium and the associations between demographics (age, gender, and race), restraint use, admitting diagnosis, mortality, and those who were/were not admitted with psychiatric medication. Differences in age and length of stay were examined using independent sample t-tests. RESULTS: Those who had psychiatric medications on admission were significantly more likely to be female (65.9% vs. 44.7%) and to have a diagnosis of a mood disorder (29.5% vs. 12.1%) and anxiety (21.6% vs. 9.3%) disorder. There were no significant differences in length of stay, delirium and/or altered mental status, restraint use, and mortality between those with and without psychiatric medications on admission. As compared to those without delirium, those with delirium were significantly more likely to have a Glasgow coma scale score of 13 or less (68.6% vs. 43.9%), to have restraint use (74.5% vs. 37.2%), to be on an antipsychotic (37.3% vs. 11.6%) or anxiolytic (70.6% vs. 35.9%) medication, and have longer length of stay (19.9 days vs. 9.6 days). CONCLUSION: There is limited research concerning the treatment of delirium and pre-existing psychiatric conditions. Further research is needed to assess if abrupt discontinuation of psychiatric medications has any association with delirium

Diagnosis of common health conditions among autistic adults in the UK: evidence from a matched cohort study

Background: Autistic people are disproportionately likely to experience premature mortality and most mental and physical health conditions. We measured the incidence of diagnosed conditions accounting for the most disability-adjusted life years in the UK population according to the Global Burden of Disease study (anxiety, depression, self-harm, harmful alcohol use, substance use, migraine, neck or back pain, and gynaecological conditions). Methods: Participants were aged 18 years or above and had an autism diagnosis recorded in the IQVIA Medical Research Database between 01/01/2000 and 16/01/2019. We included 15,675 autistic adults without intellectual disability, 6437 autistic adults with intellectual disability, and a comparison group matched (1:10) by age, sex, and primary care practice. We estimated crude incidences and incidence rate ratios (IRRs) adjusted for age and sex. Findings: Autistic adults without intellectual disability experienced a higher incidence (IRR, 95% CI) of self-harm (2.07, 1.79–2.40), anxiety (1.91, 1.76–2.06), depressive disorders (1.79, 1.67–1.92), and substance use (1.24, 1.02–1.51) relative to comparison participants. Incidences of harmful alcohol use (1.01, 0.85–1.18), migraine (0.99, 0.84–1.17), and gynaecological conditions (1.19, 0.95–1.49) did not differ. Neck or back pain incidence was lower (0.88, 0.82–0.95). Autistic adults with intellectual disability experienced a higher incidence of self-harm (2.08, 1.69–2.56). Incidences of anxiety (1.14, 1.00–1.30), gynaecological conditions (1.22, 0.93–1.62), and substance use (1.08, 0.80–1.47) did not differ, and lower incidences were found for depressive disorders (0.73, 0.64–0.83), harmful alcohol use (0.65, 0.50–0.84), migraine (0.55, 0.42–0.74), and neck or back pain (0.49, 0.44–0.55). Interpretation: Although our findings cannot be directly compared to previous prevalence studies, they contrast with the higher frequency of mental and physical health conditions in autistic adults reported in studies that directly assessed and/or surveyed autistic people about co-occurring conditions. The present findings may suggest under-diagnosis of common conditions in autistic people, particularly those with intellectual disability. Improved detection should be a clinical and policy priority to reduce health inequalities. Funding: Dunhill Medical Trust, Economic and Social Research Council, National Institute of Health and Care Research

Decision-making involvement, self-efficacy, and the relationship to transition readiness in youth with sickle cell disease

Transition from pediatric to adult healthcare settings poses significant risks to morbidity and mortality for adolescents and young adults with sickle cell disease. Increasing transition readiness, the acquisition of disease-specific knowledge and self-management skills, has been proposed as strategy to improve health outcomes for adolescents and young adults (AYA) after transition. To date, few studies have looked at factors that may influence transition readiness, a measure of disease-specific knowledge and self-management, in AYAs with sickle cell disease. This limits healthcare providers' and researchers' abilities to develop interventions specific to the unique needs of the population. This dissertation study examined the relationships between decision-making involvement, self-efficacy of sickle cell disease self-management, and transition readiness in AYAs with sickle cell disease prior to transition to adult healthcare settings. This study found that higher levels of expressive behaviors such as sharing opinions and ideas in decision-making were associated with higher levels of AYA healthcare responsibility. Self-efficacy was positively associated with transition readiness but inversely related to AYA healthcare responsibility. Parent involvement was negatively associated with AYA healthcare responsibility. Future research interventions that increase AYA involvement in decision-making regarding disease management, increase self-efficacy, and safely reduce parent involvement may positively influence their capacity for self-management.Includes bibliographical reference

Exploring the relationship between age and health conditions using electronic health records: from single diseases to multimorbidities

Background Two enormous challenges facing healthcare systems are ageing and multimorbidity. Clinicians, policymakers, healthcare providers and researchers need to know “who gets which diseases when” in order to effectively prevent, detect and manage multiple conditions. Identification of ageing-related diseases (ARDs) is a starting point for research into common biological pathways in ageing. Examining multimorbidity clusters can facilitate a shift from the single-disease paradigm that pervades medical research and practice to models which reflect the reality of the patient population. Aim To examine how age influences an individual’s likelihood of developing single and multiple health conditions over the lifecourse. Methods and Outputs I used primary care and hospital admission electronic health records (EHRs) of 3,872,451 individuals from the Clinical Practice Research Datalink (CPRD) linked to the Hospital Episode Statistics admitted patient care (HES-APC) dataset in England from 1 April 2010 to 31 March 2015. In collaboration with Professor Aroon Hingorani, Dr Osman Bhatti, Dr Shanaz Husain, Dr Shailen Sutaria, Professor Dorothea Nitsch, Mrs Melanie Hingorani, Dr Constantinos Parisinos, Dr Tom Lumbers and Dr Reecha Sofat, I derived the case definitions for 308 clinically important health conditions, by harmonising Read, ICD-10 and OPCS-4 codes across primary and secondary care records in England. I calculated the age-specific incidence rate, period prevalence and median age at first recorded diagnosis for these conditions and described the 50 most common diseases in each decade of life. I developed a protocol for identifying ARDs using machine-learning and actuarial techniques. Finally, I identified highly correlated multimorbidity clusters and created a tool to visualise comorbidity clusters using a network approach. Conclusions I have developed case definitions (with a panel of clinicians) and calculated disease frequency estimates for 308 clinically important health conditions in the NHS in England. I have described patterns of ageing and multimorbidity using these case definitions, and produced an online app for interrogating comorbidities for an index condition. This work facilitates future research into ageing pathways and multimorbidity

A retrospective study investigating risk factors for sudden unexpected death in the young

Sudden unexpected death in the young (SUDY) is the unanticipated demise of individuals aged between 1 and 40 years. In South Africa, these deaths are referred for forensic investigation. The primary aim of this study was to retrospectively investigate the frequency of known risk factors in SUDY cases admitted to Salt River Mortuary in Cape Town and explore differences between males and females. There were 1 088 SUDY cases identified with 0.9% (10/1 088) missing files. Reviewed cases were n=1 078, 62.6% (675/1 078) males, and 37.4% (403/1 078) females; 83.5% (901/1 078) adults and 16.4% (177/1 078) children, accounting for 5.6% of total admissions between 1 January 2010 and 31 December 2015. Despite the predominance of males, significantly more females (61.8%) were obese (p < 0.05). At least one primary medical condition was present in 53.7% of cases, with the leading conditions being tuberculosis (11.9 % of adult males), epilepsy (11.7% of adult males; 10.3% of female children), HIV (10.7% of adult females) and asthma (11.1% of male children). In the subset of the study population where information was available, before death, 74% of individuals were reported to have experienced prodromal symptoms; 37.6% of males and 32.4% of females did not seek medical intervention following symptoms. Information regarding a family history of sudden death was known in 237/1078 cases. In 3.2% of these cases, a family history of sudden death was reported. Significantly more males than females reported the use of tobacco, alcohol, and other illicit drugs (p < 0.05). More females were unemployed (p < 0.05). Interventions based on lifestyle modification, social support, pharmacologic needs, and awareness should be targeted at individuals with the above profiles, especially those with a family history of sudden death, as they may be high-risk groups. Findings from this study contribute new and relevant local reference data for SUDY risk profiles of males and females admitted to Salt River Mortuary

A SURVEY OF CANNABIS CONSUMPTION AND IMPLICATIONS OF AN EXPERIMENTAL POLICY MANIPULATION AMONG YOUNG ADULTS

The purpose of this online cross-sectional study was to identify cannabis user profiles by administration method and examine how differential cannabis policies influence intentions among young adults. Participants were assigned randomly to one of three hypothetical cannabis policy conditions (recreationally legal; medically legal; illegal). Within conditions, participants completed measures regarding cannabis use, including administration methods, cannabis attitudes, norms, perceived behavioral control, self-efficacy, and intentions. Latent class analysis (LCA) was used to determine sub-groups of past 30-day cannabis users by administration method followed by sub-group comparisons. Condition effects on intentions and associated variables were examined using ANCOVA. Four classes (Low-Blunt, Low-Bong, Mod-Poly, High-Poly) differing in demographics and tobacco use were identified. Recreationally and medically legal policy conditions resulted in more favorable cannabis attitudes, higher selfefficacy, and higher intentions to use compared to the illegal policy condition. Results inform cannabis intervention efforts and longitudinal research on the effects of cannabis policy changes

Antiepileptic drug utilization : need of sex-specific information and decision support

Antiepileptic drugs are used for the treatment of epilepsy and for other neurological and psychiatric conditions, and therefore is prescribing of antiepileptic drugs a concern for physicians from many disciplines. The age and sex-specific prevalence, as well as the role of sex and gender aspects, vary between the conditions for which antiepileptic drugs are used. The overall aim of this thesis was to gain more understanding of the use of antiepileptic drugs on various diagnoses, focusing on sex/gender differences, and to explore physicians' perceptions of sex and gender in decision making on drug treatment. The first two studies describe the antiepileptic drugs used in epilepsy and other conditions. Clear age and gender differences in the use of specific anti-epileptics were observed. The use of antiepileptic drugs in children and adolescents was mainly limited to epilepsy and the individual antiepileptic drugs prescribed appeared to be in accordance with approved indications and treatment guidelines. However, some antiepileptic drugs were used off-label in children and adolescents. The third study evaluated the effect of a warning issued by the European Medicines Agency in November 2014 on restricted prescribing of valproic acid to girls and women of childbearing potential. The analyzes showed that the warning only affected the prescribing in girls and women with a psychiatric diagnosis. Prescribing to girls and women with epilepsy had decreased long before the warning was issued, which could indicate an increased awareness of the teratogenic risk of valproic acid among neurologists treating women with epilepsy. The fourth study examined how primary care physicians perceive sex/gender and gender equality related to drug prescribing. The results showed that physicians experienced insufficient knowledge of sex/gender differences in drug treatment, although their expressed clinical experience indicated some awareness. The patient's sex was considered during diagnosing while drug prescribing decisions followed the regional recommendation lists because these were believed to be evidence-based and gender-neutral. Overall, physicians wanted more education and knowledge about sex and gender in drug treatment. However, finding reliable information about sex and gender aspects for individual drugs may be difficult. This can be facilitated by the web-based knowledge base Janusmed Sex and Gender, as described in the fifth study. In summary, this thesis demonstrates sex differences in use of certain antiepileptic drugs, which probably reflect the different benefit and risk from these between men and women. Knowledge of how antiepileptic drugs are prescribed and used in women and men with different diagnoses may be useful in discussions on rational drug prescribing and to propose measures to improve prescribing behavior. As shown in this thesis, regulatory measures may be one approach to improve rational prescribing and to highlight the importance of the patient's sex. Another approach may be to get acquainted with sex and gender-related pharmacological information through the knowledge base Janusmed Sex and Gender