Homicidal ideation and psychiatric comorbidities in the inpatient adolescents aged 12–17

Objectives: Adolescents with a homicidal tendency is a growing concern in the United States. Studies in the past have showcased the relationship between homicidal ideation (HI) and psychiatric illnesses, but very limited information is available on the adolescent and inpatient population. We aim to evaluate the prevalence of demographic characteristics and psychiatric disorders in adolescents with and without HI. Materials and methods: Adolescent (age 12–17) population admitted to the hospital with the diagnosis of homicidal ideation was identified from the 2016–2018 National Inpatient Sample Dataset (NISD). Patients without HI were defined as the control group. The prevalence of psychiatric comorbidities between the groups was compared by applying the Rao-Scott adjusted chi-square test. We used multivariable logistic regression to generate odds ratio (OR) of homicidal ideation as an outcome; we adjusted age, sex, race, socioeconomic status, substance use disorders, alcohol use disorders, and psychiatric comorbidities. Results: A total of 18,935 patients (mean age: 14.5) with HI diagnosis were identified in this study. Majority of the patients were male subjects in the HI group compared to the control group (58.7 vs. 41.2%, p \u3c 0.001). Racially, HI was more prevalent in white race (56.0 vs. 52.6%, p \u3c 0.001) and black race (22.3 vs. 17.8%, p \u3c 0.001), compared to Hispanic race (14.9 vs. 21.3%, p \u3c 0.001). Major depression (Odds ratio [OR]: 2.66, p \u3c 0.001), bipolar disorder (OR: 3.52, p \u3c 0.001), anxiety disorder (OR: 1.85, p \u3c 0.001), ADHD, and other conduct disorders (OR: 4.01, p \u3c 0.001), schizophrenia (OR: 4.35, p \u3c 0.001) are strong predictors of HI. Suicidality was prevalent in 66.9% of patients with HI. Conclusion: We found a higher prevalence of psychiatric illnesses such as depression, anxiety, and bipolar disorder in adolescents with homicidal ideation in the inpatient setting. White and black races were more prevalent in patients with homicidal ideation. Further large-scale longitudinal research studies are warranted to establish the correlation between psychiatric disorders and homicidal ideation among adolescents

Does the extent of collaterals influence the severity of the myocardial injury as assessed by elevation in biomarkers?

Introduction: Quantitative analysis of cardiac biomarkers, troponin I and CPK-MB, estimates the extent of myocardial injury while extent of benefit from coronary collateral circulation (CCC) to protect myocardium during acute myocardial infarction (AMI) needs validation. We analysed if the extent of collaterals had impact on baseline biomarkers at the time of coronary angiogram. Methods: We analysed 3616 consecutive patients who presented with AMI and underwent invasive coronary angiography (CAG) with intent to revascularisation with biomarkers assessment at the time of CAG. CCC to Infarct related artery (IRA) were graded as per Rentrop grading viz. poorly-developed CCC (Grade 0/1 as Group A) and well-developed CCC (Grade 2/3 as Group B). Results: Both groups (A and B) were matched for demographics, traditional risk factors, SYNTAX 1 Score, time to CAG from onset of angina and eGFR. 36.59% of patients had Non-ST segment elevation myocardial infarction (NSTEMI) as compared to 63.41% ST -segment elevation infarction (STEMI). Overall Troponin I (P=0.01, P=0.01) and CPK MB (P=0.00, P=0.002) values were lower in group B in both NSTEMI and STEMI groups respectively. Troponin I and CPK-MB were significantly lower in group B [with NSTEMI for SVD (Single vessel disease) (P=0.05) and DVD (Double vessel disease) (P=0.04),but not for TVD (Triple vessel disease) and with STEMI in SVD (P=0.01), DVD (P=0.01) and TVD (P=0.001)]. Conclusion: Patients with well-developed coronary collaterals had a lower rise in biomarkers in AMI as compared to those with poor collaterals amongst both NSTEMI and STEMI groups

Risk of Suicide in Patients With Major Depressive Disorder and Comorbid Chronic Pain Disorder: An Insight From National Inpatient Sample Data

Background: Approximately 17.3 million adults in the United States have had a minimum of one major depressive episode. Comorbidity of depression and pain can affect individuals of any age, but is more prevalent in the elderly affecting up to 13% of people in the elderly population. Given that depression and suicidal ideation (SI) pose a considerable burden resulting in enormous suffering, there is a need to understand the factors of the relationship between chronic pain (CP), depression, and SI. Objectives: Our primary objective in this study was to compare suicidality (SI/attempt [SA]) between patients with major depressive disorder (MDD) and CP and a matched control group. The secondary objective was to compare length of stay, total hospital costs, and discharge disposition in these populations. Study design: The National Inpatient Sample (NIS) dataset developed by the Healthcare Cost and Utilization Project was used for this study. The NIS is a database of hospital inpatient stays derived from billing data submitted by hospitals to statewide data organizations across the United States. We obtained patient records from the NIS dataset for the years 2006 to 2017. All data were de-identified so Institutional Review Board approval was waived. Methods: We used mean and standard error to describe continuous data and counts (percentage) to describe categorical data. Categorical data were compared using Rao-Scott adjusted chi-square tests and continuous data were compared using Student\u27s t tests. Matching was performed using propensity scores in random order with a caliper size of 0.001. To assess predictors associated with suicidality, logistic regression analysis was performed. Results: A total of 393,481 patients having MDD with CP (MDD+CP) were included in the analysis. The mean age was 49.4 years, and 54.9% of patients were women. Overall, rate of composite outcome of SI/SA was more prevalent in MDD+CP group (51% vs 41%, P \u3c 0.001). Rate of SI was 48% vs 39% (P \u3c 0.001) in the MDD+CP and MDD without CP (MDD-CP) groups, respectively. MDD+CP was one of the strongest predictors of suicidality, responsible for 48% more risk of SI/SA compared to MDD-CP group. In comparison to non-Whites, the rate of suicidality was 7.5% less in White population. Alcohol abuse and substance abuse were associated with 17% and 8% greater risk of SI/SA, respectively. For women, the odds of having SI/SA was 1.20 greater compared to men. Limitations: No information was available on the causal relationship between MDD+CP disorder and SI/SA. Retrospective studies are susceptible to recognition, reporting, and coding bias. There is no information available on medications use or the duration and severity of CP and bipolar disorder, which can all be confounding factors. Conclusions: Psychiatrists and other physicians must be cognizant of the presence of CP and the risk of suicide, especially when patients present with depressive symptoms. The treatment plan for this patient population should include routine screening for pain symptoms and risk assessment for SI

The role of metformin in treatment of weight gain associated with atypical antipsychotic treatment in children and adolescents: A systematic review and meta-analysis of randomized controlled trials

Introduction: Second-generation antipsychotics are associated with significant weight gain. The aim of this systematic review and meta-analysis was to determine the efficacy and safety of metformin for the treatment of weight gain in children and young adults treated with second-generation antipsychotics. Methods: We followed PRISMA guidelines to evaluated studies published before March 2020 in Medline, Google Scholar, PubMed, Cochrane library database, annual scientific sessions of the American Psychiatric Association, American Academy of Child and Adolescent, Psychiatry, and American Society of Clinical Psychopharmacology. Studies included compared metformin with the placebo for management of weight gain in children and adolescents taking atypical antipsychotics. Non-randomized studies, animal experiment studies, editorials, and review studies were excluded. Multiple parameters, including change in anthropometric-biochemical parameters, drug discontinuation rate, and side effects among the groups were assessed. The random-effects method was used for meta-analysis. Results: Four studies with were included in the final analysis (213 patients; metformin: 106; control: 107). After pooled analysis, 12–16 weeks of metformin therapy was associated with a significant reduction in weight [(mean difference (MD): −4.53 lbs, confidence interval (CI): −6.19 to −2.87, p-value \u3c 0.001)], and BMI z score [MD, −0.09, CI: −0.16, −0.03, p-value: 0.004] compared to control. Metformin was also associated with a significant reduction in insulin resistance [MD: −1.38, CI: −2.26 to −0.51, p-value: 0.002]. There were higher odds of nausea-vomiting [OR: 4.07, CI: 1.32–12.54, p-value: 0.02] and diarrhea [OR: 2.93, CI: 1.50–5.71, p-value: 0.002] in the metformin group. However, there was no difference in drug discontinuation rate [OR: 1.45, CI: 0.41–5.06, p-value: 0.56]. Conclusion: Metformin may prove beneficial in the treatment of weight gain in children treated with second-generation antipsychotics. The pooled treatment effect showed a significant reduction in BMI Z-score and weight in just 12–16 weeks. The limitations include small sample size, variation in metformin dose, and duration of treatment. This meta-analysis should be interpreted as promising, and further larger studies are warranted before drawing a conclusion

Clinical profile of patients with prosthetic heart valve thrombosis undergoing fibrinolytic therapy and NYHA class as a predictor of outcome

Background: Prosthetic heart valve thrombosis (PHVT) is a potentially fatal complication of heart valve replacement with mechanical prostheses mainly due to thrombosis.Aim: The study aimed to evaluate the clinical profile of the patients presenting with PHVT undergoing fibrinolytic therapy and analyzing patients with respect to New York Heart Association (NYHA) functional class on presentation and its association with outcome of fibrinolytic therapy.Settings & design: This was prospective, observational study conducted from June, 2016 to April, 2017. Total 133 patients with prosthetic heart valve thrombosis were included. Materials and methods: Routine blood investigations included complete hemogram, liver and renal function tests. Prothrombin time with INR was done on admission. The diagnosis of PHVT was assessed by fluoroscopy and/or echocardiography (transthoracic/transesophageal). Follow-up at 6 months was scheduled for all patients.Statistical analysis: Parametric values between two groups were performed using the independent sample t-test or chi-square test, as appropriate. Univariate and multivariate logistic regression was used to find out factors associated with outcome.Results: All patients received fibrinolytic therapy in which 108 (81.2%) were treated with streptokinase and 25 (18.8%) were treated with urokinase. On presentation, 48.9% patients were in NYHA class III, 41.4% in NYHA class IV and 9.77% in NYHA class II. Fibrinolytic therapy was successful in 105 patients (78.9%) and it failed in 28 patients (21.1%). Mortality in NYHA class II was 0%, NYHA class III was 4.6% and in NYHA class IV was 23.6%. During 6 months follow up prosthetic heart valve thrombosis recurred in 12 (11.43%) patients.Conclusion: From our single centre experience, fibrinolytic therapy is fairly effective first line therapy for prosthetic heart valve thrombosis and NYHA functional class on presentation can predict the outcome of fibrinolytic therapy

A Review of the Mechanism of Antagonism of N-methyl-D-aspartate Receptor by Ketamine in Treatment-resistant Depression

The biochemical processes involved in depression go beyond serotonin, norepinephrine, and dopamine. The N-methyl-D-aspartate (NMDA) receptor has a major role in the neurophysiology of depression. Ketamine, one of the prototypical NMDA antagonists, works rapidly in controlling depressive symptoms, including acutely suicidal behavior, by just a single injection. Ketamine may rapidly increase the glutamate levels and lead to structural neuronal changes. Increased neuronal dendritic growth may contribute to synaptogenesis and an increase in brain-derived neurotrophic factor (BDNF). Activation of the mechanistic target of rapamycin (mTOR), as well as increased levels of BDNF, may increase long-term potentiation and result in an improvement in the symptoms of depression. The mechanisms of ketamine’s proposed effect as an off-label treatment for resistant depression are outlined in this paper

Common Methods of Suicide and Self-Inflicted Poisoning/Injury by Individuals With Major Depressive Disorder and Bipolar Disorder: A Nationwide Inpatient Sample Analysis

Objective: Individuals with major depressive disorder (MDD) and bipolar disorder (BD) are at increased risk of suicide. The objective of this study was to examine the prevalence of different methods of suicide and self-inflicted poisoning/injury in individuals with MDD or BD. Methods: This study used a US National Inpatient Sample dataset from years 2012-2015. Data were collected from discharge records of patients aged ≥ 18 years admitted for MDD or BPD. The prevalence of different methods of suicide and self-inflicted poisoning/injury was evaluated. Highly prevalent subtypes of depression and bipolar disorder among the 2 groups were investigated, and psychiatric comorbidities were compared. Results: We identified 13,556 unweighted records of patients admitted to the hospital for MDD diagnosis, and 6,506 unweighted records of patients admitted for BD diagnosis. Suicide and self-inflicted poisoning/injury by cutting instrument was highly prevalent among both groups, with a greater prevalence among patients with BD compared to MDD (35.5% vs 30.8%, P \u3c .001). Use of tranquilizers/other psychotropic agents (29.2% vs 29.4%, P = .72) and other specified drugs and medicinal substances (14.3% vs 14.0%, P = .546) was high among both groups; however, there was no significant difference. Analgesics (16.7% vs 11%, P = .000), other sedatives and hypnotics (4.9% vs 3.7%, P \u3c .001), other and unspecified solid and liquid substances (3.9% vs 3.3%, P = .037), and hanging by strangulation and suffocation (3.7% vs 2.5%, P \u3c .001) were more prevalent in patients in the MDD group. Conclusions: The results indicate that it is critical to investigate and understand the methods used by individuals with MDD and BD to commit suicide. Restricting access to the most prevalent forms of self-injury could be a practical suicide prevention approach

Does Insomnia Increase the Risk of Suicide in Hospitalized Patients with Major Depressive Disorder? A Nationwide Inpatient Analysis from 2006 to 2015

Introduction. Insomnia is an important symptom associated with major depressive disorder (MDD). In addition, it is one of the risk factors for suicide. Studies have shown the relationship be-tween insomnia and suicidal behavior in patients with MDD. However, this association has not been evaluated in a large sample of hospitalized patients. Objectives. To evaluate the suicidal be-havior in MDD patients with insomnia compared to those without insomnia. Methods. From the National Inpatient Sample (NIS 2006–2015) database using the ICD-9 code, patients’ data were obtained with the primary diagnosis of MDD and comorbid diagnosis of insomnia disorders (MDD+I). These patients were compared with MDD patients without insomnia disorders (MDD–I) by performing a 1:2 match for the primary diagnosis code. Suicidal ideation/attempt da-ta were compared between the groups by multivariate logistic regression analysis. Results. After the diagnostic code matching, 139061 patients were included in the MDD+I group and 276496 patients in the MDD–I group. MDD+I patients were older (47 years vs. 45 years, p < 0.001) com-pared to the MDD–I group. The rate of suicidal ideation/attempt was 56.0% in the MDD+I group and 42.0% in the MDD–I group (p < 0.001). After adjusting for age, sex, race, borderline personal-ity disorders, anxiety disorders, and substance use disorders, ‘insomnia’ was associated with 1.71 times higher odds of suicidal behavior among MDD patients admitted to the hospital. (Odds ratio: 1.71, 95% confidence interval 1.60–1.82, p < 0.001). Conclusions. Insomnia among MDD patients is significantly associated with the risk of suicide. MDD patients with insomnia need to be closely monitored for suicidal behavior

Bullying Victimization Among Children With Mental, Emotional, Developmental, or Behavioral Problems: A US Population-Based Study.

Bullying victimization among children remains a pervasive problem. Bullying victimization can make it difficult for children with psychiatric problems to cope and might result in worsened outcomes.1,2 Bullying victimization in children is associated with increased risk of anxiety, depression, sleep difficulties, lower academic achievement, and dropping out of school.3 We hypothesized that vulnerable children with mental, emotional, developmental, or behavioral (MEDB) problems may be at increased risk of bullying victimization. Thus, we aim to identify the prevalence and odds of bullying victimization among US children with 1 or more MEDB problems compared to children without