Continuity of mental disorders in children with chronic physical illness

Data on the chronicity of mental disorder in children with chronic physical illness (CPI) are limited. We examined the prevalence and predictors of homotypic and heterotypic continuity of mental disorder in children with CPI. A sample of 263 children aged 2-16 years with physician-diagnosed CPI were recruited from outpatient clinics (e.g., dermatology, respiratory) at a Canadian pediatric academic hospital and followed for 24 months. Parent and child-reported mental disorders (mood, anxiety, behavioral, attention-deficit hyperactivity disorder [ADHD]) were assessed using the Mini International Neuropsychiatric Interview for Children and Adolescents at baseline, 6, 12, and 24 months. Marginal regression models were computed to identify clinical, parent, and demographic factors associated with mental comorbidity over time. Mental disorder was observed in 24-27% of children with CPI based on child reports and 35-39% based on parent reports. Parent-reported models revealed significant homotypic continuity for all mental disorders (ORs = 4.2-9.5), and heterotypic continuity between mood and anxiety disorders (OR = 2.2), ADHD and behavioral disorders (OR = 5.1), and behavioral and each mental disorder (ORs = 6.7-8.4). Child-reported models revealed significant homotypic continuity for mood (OR = 8.8) and anxiety disorder (OR = 6.0), and heterotypic continuity between anxiety and mood disorders (OR = 12.4). Child disability (ORs = 1.3-1.5) and parent psychopathology (ORs = 1.2-1.8) were the most consistent predictors of both child- and parent-reported mental disorder over time. Mental comorbidity was prevalent and persistent in children with CPI with homotypic and heterotypic continuity common across informants. Child disability and parent psychopathology may be priority targets within integrated family-centered models of care to prevent mental comorbidity in children with CPI.

An audit of high oral broad-spectrum antibiotic prescribing within a Bristol-based general practice

Introduction

Oral broad-spectrum antibiotics (OBSAs), defined here as cephalosporins, fluoroquinolones and co-amoxiclav, are associated with AMR and adverse events in the elderly (ie. over 60s). Despite stringent national and local system-wide approaches aimed at reducing their inappropriate prescribing, the regional care commissioning group (CCG) alerted that OBSA prescribing within this practice between February and August 2021 at up to 14% of antibiotics prescriptions, has exceeded both the national and CCG limit which is 10%.1,2 This necessitates minimising OBSA prescribing among the over 60s in this practice.

Aim

To identify the percentage of inappropriate prescribing of OBSAs at Downend Health Group and investigate factors leading to their high prescribing rates using the following standard: 0% of OBSAs were prescribed inappropriately within a 7-month period, which includes prescribing outside of regional guidance without specialist input or evidence of infection.

Methods

The study design, data collection and analysis were conducted by the foundation trainee, supervised by the lead pharmacist. A retrospective population reporting search was run on our prescribing system (EMIS) to identify active patients over 60 years prescribed OBSAs between February and August 2021. To produce our IT data collection tool, the inclusion criteria were ages over 60 years, name of antibiotic, location of consultation, authorising user and prescribing indication. The search was piloted with 235 patients and narrowed down to 208 patients by adding acute (ie. one-off) prescription type as another inclusion criteria. Inactive and deceased patients at the time of the search were excluded. Data from the search was then compared against the regional guidance and further analysed. Ethics approval was not required for this audit.

Results

The results did not meet the set standard. Out of 208 active patients over 60 years prescribed OBSAs on acute during the defined period, 107 (51%) prescriptions were inappropriate. 63 (30%) prescriptions had the wrong antibiotic choice whereas 44 (21%) prescriptions had no evidence of infection. The top conditions with inappropriate OBSA prescriptions include UTI (22%), diverticulitis without pyrexia (15%) and cellulitis (11%). Furthermore, remote consultations had higher inappropriate prescribing as the error bar comparison between face-to-face vs remote consultations on influencing inappropriate OBSA prescribing showed statistical significance (p < 0.05). Although GPs authorised 188 (90%) of OBSA prescriptions, 15 out of the 20 (75%) OBSA prescriptions authorised by non-GPs were inappropriate. Despite the similar rates of appropriate (51%) and inappropriate (49%) OBSA prescribing among the GPs, four GPs had disproportionately high inappropriate OBSA prescribing.

Discussion/Conclusion

Further to excluding deceased patients from the sample size, another limitation is the lack of investigations to rule out the confounding variables of researcher bias and the potential influence of lockdowns in the high levels of remote consultations. Regardless, the results suggest that the practice can meet the national and CCG OBSA prescribing limit by reducing inappropriate OBSA prescribing from 51% to 0%. Following an internal clinical governance meeting with the authorising users, we will update relevant internal EMIS alerts and antimicrobial stewardship protocols, followed by a reaudit 7-months after implementing the updates.

References

1. Nice.org.uk. 2015. Overview | Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/ng15/ (accessed 14 March 2022).

2. Remedy.bnssgccg.nhs.uk. 2021: REMEDY. Available at: https://remedy.bnssgccg.nhs.uk/media/5026/antimicrobial-rx-guidelines-for-bnssg2019-version-83-including-covid.pdf/ (accessed 14 March 2022).

Mental and psychosocial health among youth after their first psychiatric hospitalization: a feasibility study

OBJECTIVE

This pilot study investigated the feasibility of studying 12-month readmission of youth aged 10-16 years following their first psychiatric hospitalization and changes in youth mental and psychosocial health prospectively.

RESULTS

Inpatient youth with a first psychiatric hospitalization and their parents were recruited from a regional hospital in Canada. Data were collected at recruitment, and at 3-, 6-, and 12-months post-discharge. Repeated measures ANOVA was performed to assess changes in health outcomes. Nineteen eligible youth were approached and 15 (78.9%) consented to participate (13.9 ± 2.0 years, 73.3% female). Eleven youth (73.3%) gave permission to contact their parents, all of whom participated (39.2 ± 7.6 years). Four youth dropped out of the study (26.7%) and six youth-parent dyads completed all four follow-ups. The readmission rate was 20.0% (n = 3) over 12 months. Significant changes in youth-reported symptoms of conduct disorder (F = 3.0, p = 0.06) and adverse childhood experiences (F = 3.4, p = 0.05) were found. Changes in parent-reported youth mental health symptoms (F = 3.1, p = 0.06), particularly among internalizing disorders, youth health-related quality of life (F = 11.3, p < 0.01), and youth disability (F = 2.7, p = 0.08) were significant. This preliminary work demonstrates the feasibility of, and need to, engage youth and their families to understand their mental and psychosocial health during this vulnerable period of time.

Acculturation and Perceived Ethnic Discrimination Predict Elevated Blood Glucose Level in Sub-Saharan African Immigrants in Australia

Sub-Saharan African migrants experience significant sociocultural challenges, including those related to acculturation and perceived ethnic discrimination (PED), in addition to increased risk of non-communicable diseases, such as type 2 diabetes mellitus (T2DM). Although acculturation and PED are each established risk factors for elevated blood glucose level (EGBL) and T2DM, they have not been studied in relation to EBGL risk in a single model. This study aimed to investigate associations between acculturation, PED and EBGL in a sub-Saharan African migrant population in Australia. Face to face survey using a purposive sampling method was used to collect data from 170 adults, aged 18-72 years. A large proportion (41.8%) of the study group was in the integration mode of acculturation, which strongly correlated positively with EBGL/T2DM, although traditional mode correlated inversely with EBGL/T2DM. PED correlated positively with EBG/LT2DM. Immigrants manifesting the integration mode were 4.2 times more likely to have EBGL/T2DM than other acculturation modes. Multiple linear regression showed that the association between integration mode and EBGL/T2DM was mediated by PED. The apparent interaction between PED and acculturation in relation to EBGL/T2DM risk suggests that interventions to lower T2DM risk in this population may benefit from incorporating strategies to address these two important health determinants.

Depression Mediates Association Between Perceived Ethnic Discrimination and Elevated Blood Glucose Levels Among Sub-Saharan African Migrants in Australia

Depression and perceived ethnic discrimination (PED) are both implicated in type 2 diabetes mellitus (T2DM) risk in some migrant populations. The role of these factors remains understudied in sub-Saharan African migrants, who comprise a significant at-risk group for T2DM in Australia. To assess interactions between PED, depression scores and elevated blood glucose levels among sub-Sahara African immigrants in North-Eastern Australia. Face to face surveys were used to assess PED and depressive tendencies in a purposive sample of 170 adults (aged ≥18 year). Fasting blood glucose levels (FBGL) were measured at the time of interviews. Prevalence of elevated FBGL (≥6.1 mmol/L), PED and severe depression (SD) were: 17.6% (n = 30), 14.7% (n = 25) and 18.8% (n = 32), respectively. Prevalence of elevated FBGL, PED and SD were all higher in males than females. The highest prevalence of elevated BGL, PED and SD each occurred in the 40-50 year age group. Strong positive correlations of both high level PED and SD with elevated FBGL were observed. There was also a strong positive association between PED and SD. Depression score was found to mediate partially the strong association between PED and elevated FBGL (β-value for PED dropped from β = 0.452 to β = 0.246, p < 0.01 and the associated between FBGL and SD remained strong β = 0.554, p < 0.01). The strong association between elevated FBGL and PED seems to be moderated by SD, indicating that interventions to attenuate depression and PED may be a useful adjunct to diabetes prevention programs in this population. Interventions targeted to specific age groups may also be warranted.

P2781How to bridge residual distance to target low-density-lipoprotein cholesterol in stroke patients after initial statin therapy?

Background

Current guidelines recommend intensive low-density-lipoprotein cholesterol (LDL-C) lowering to target LDL-C <1.8mmol/L after ischemic stroke (IS). Residual distance to LDL-C target can help select further treatment options after initial statin therapy.

Purpose

We aimed to evaluate residual distance to target LDL-C and the proportion of IS patients who are projected to reach target LDL-C by different statin and non-statin lipid lowering strategies.

Methods

We retrospectively analyzed 5,025 patients admitted with IS or transient ischemic attack who survived 1 year from an academic institution in Hong Kong between Jan 2005 and Sep 2017. Patients were divided into (i) high potency (HP-S; rosuvastatin ≥20mg, atorvastatin ≥40mg or simvastatin ≥80mg); (ii) non-high potency (NHP-S; other statin doses) statin users and (iii) no statin therapy. We calculated the mean distance and percentage LDL-C reduction required to reach target LDL-C. We assumed up-titration from NHP-S to HP-S would further reduce LDL-C by 5–15%; addition of ezetimibe 15–25%; up-titrate to HP-S plus ezetimibe 20–40% and combine statin with proprotein convertase subtilsin-kexin type 9 inhibitor (PCSK-9) 40–60%.

Results

Of 5,025 patients (56.3% males, mean age 69.1±11.5 years), 62.4% (3134/5025) had LDL-C ≥1.8mmol/L at 12-months after index stroke with 16.7% (839/5025), 80.9% (4064/5025) and 2.4% (122/5025) of patients on no statin, NHP-S and HP-S, respectively. 58.1% (2362/4064) of NHP-S and 60.7% (74/122) of HP-S users did not reach LDL-C target. Among these patients, the mean LDL-C was 2.5±0.6 and 2.8±1.0mmol/L; mean residual distance to target 0.7±0.6 and 1.0±1.0mmol/L; and mean percentage LDL-C reduction required to reach target LDL-C goal was 23.3±15.1% and 29.5±18.1%, respectively. The proportion of NHP-S users projected to reach target LDL-C is 34.9% (824/2362) by up-titrating/switching to HP-S, 57.2% (n=1352/2362) by addition of ezetimibe, 84.5% (n=1997/2362) by up-titration to HP-S plus ezetimibe and 98.6% (2330/2362) with PCSK-9 inhibitor (Figure 1). The proportion of HP-S users projected to reach target LDL-C is 43.2% (32/74) by addition of ezetimibe and 94.6% (70/74) with PCSK-9 inhibitor (Figure 1).

Conclusion

The use of high-potency statin is low and more than 50% of statin users did not reach target LDL-C at 12-months after index stroke. Combined up-titration to high-potency statin plus addition of ezetimibe is expected to bridge residual distance to target LDL-C in majority of stroke patients.

Acknowledgement/Funding

Supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme (Asia) Ltd.

P944Comparing therapeutic gap in lipid-lowering management between high-risk cardiovascular patients after acute coronary syndrome, stroke and critical limb ischemia

Background

Guidelines recommend intensive low-density-lipoprotein cholesterol (LDL-C) lowering in high cardiovascular (CV) risk patients with acute coronary syndrome (ACS), stroke and critical limb ischemia (CLI).

Purpose

We evaluated LDL-C goal attainment and lipid-lowering treatment (LLT) in a Chinese population with ACS, stroke and CLI patients.

Methods

We retrospectively evaluated consecutive high CV risk patients discharged between 2013 and 2017 from 3 hospitals in Hong Kong. Lipid profile and LLT were compared among 3 patient groups: ACS, Stroke and CLI.

Results

Of 10,168 high-CV risk patients (mean age 70.6±13.7 years; 62.4% male), 64.0% were ACS, 33.6% stroke and 2.5% CLI. Between baseline and 12-month, mean LDL-C reduced from 2.7±1.1 to 2.0±0.8 mmol/L in ACS patients, 2.7±1.0 to 2.0±0.7 mmol/L in stroke patients and 2.5±1.0 to 2.2±0.9 mmol/L in CLI patients (p<0.01). Proportion of CLI patients (29.9%) who achieved target LDL-C <1.8mmol/L at month 12 was significantly lower than stroke (45.6%) and ACS (48.2%) patients (p<0.01). The mean residual distance to target LDL-C was greatest in CLI (0.8±0.8 mmol/L) compared to stroke (0.6±0.6 mmol/L) and ACS (0.7±0.7 mmol/L) patients (p<0.01). Use of statin therapy on discharge was highest in ACS (88.4%) compared to stroke (78.3%) and CLI (52.6%) patients (p<0.01). But use of high-potency statin (rosuvastatin ≥20mg, atorvastatin ≥40mg or simvastatin ≥80mg) on discharge was very low in stroke (3.0%) and CLI (2.0%) compared to ACS (21.4%, p<0.01) patients. At 12 months 28.8% ACS, 34.3% stroke and 51.4% CLI patients were on no LLT (p<0.01) and the use of high-potency statin did not change significantly (3.0% in stroke, p=0.99; and 1.2% in CLI, p=0.48). Despite the poor achievement in LDL-C target in CLI patients, the proportion of CLI patients switching to high-potency statin (0.8%) was significantly lower than stroke (1.3%) and ACS (5.2%) patients (p<0.01).

Conclusion

This study demonstrated significant therapeutic gaps in lipid-lowering management in high CV risk patients. In particular, CLI patients were less aggressively treated with LLT and hence larger proportion of patient not achieving LDL-C target compared to ACS and stroke patients.

454Potential real-world benefits of low-dose rivaroxaban in Chinese stable cardiovascular patients

Background

Low dose rivaroxaban-plus-aspirin has been shown to reduce cardiovascular (CV) events in patients with stable atherosclerotic vascular disease compared to aspirin alone in the COMPASS trial.

Purpose

We aimed to estimate the potential benefit of low dose rivaroxaban plus aspirin in reduction of major adverse cardiovascular event (MACE, the composite of cardiovascular death, stroke, or myocardial infraction [MI]) among COMPASS-like patients in a Chinese population.

Methods

We retrospectively analyzed 18,693 patients with stable coronary artery disease (CAD) and/or peripheral artery disease (PAD) from 3 hospitals in Hong Kong between 2013 and 2017 for a median follow-up of 36 (IQR 19–52) months. 4,594 (24.6%) COMPASS-like patients were identified based on COMPASS trial inclusion and exclusion criteria. We estimated the absolute risk reduction (ARR) in MACE and number needed to treat (NNT) in COMPASS-like patients based on results from the COMPASS trial (NCT01776424).

Results

Of 4,594 COMPASS-like patients (58.1% males, mean age 75.0±13.0 years), 92.5% patients were diagnosed with CAD, 5.6% PAD, and 1.9% combined CAD/PAD. Overall, 3-year MACE rate was 7.9%; 7.8% in patients with CAD, 6.6% in PAD and 18.4% in combined CAD/PAD (log-rank p<0.01). 3-year CV mortality rate was 3.7% (3.6%, 3.5%, 11.5% in CAD, PAD and combined CAD/PAD respectively, log-rank p<0.01); 3-year stroke rate was 3.2% (3.0%, 4.6%, 6.9% in CAD, PAD and combined CAD/PAD respectively, log-rank p=0.03); and 3-year MI rate was 2.2% (2.3%, 0%, 6.9% in CAD, PAD and combined CAD/PAD respectively, log-rank p<0.01). Among COMPASS-like patients, estimated ARR in MACE with the use of rivaroxaban-plus-aspirin was 1.9% (NNT=53); 0.8% ARR (NNT=123) for CV death, 1.3% ARR (NNT=74) for stroke and 0.3% ARR (NNT=325) for MI.

Conclusion

Our results demonstrated that a significant proportion of “real world” Chinese patients with stable cardiovascular diseases were COMPASS-like patients. Potential clinical benefit of the addition of low dose rivaroxaban to aspirin therapy may be greater in our population than that observed in the trial, with lower number needed to treat.

Contact-Free Screening of Atrial Fibrillation by a Smartphone Using Facial Pulsatile Photoplethysmographic Signals

BACKGROUND

We aimed to evaluate a novel method of atrial fibrillation (AF) screening using an iPhone camera to detect and analyze photoplethysmographic signals from the face without physical contact by extracting subtle beat-to-beat variations of skin color that reflect the cardiac pulsatile signal.

METHODS AND RESULTS

Patients admitted to the cardiology ward of the hospital for clinical reasons were recruited. Simultaneous facial and fingertip photoplethysmographic measurements were obtained from 217 hospital inpatients (mean age, 70.3±13.9 years; 71.4% men) facing the front camera and with an index finger covering the back camera of 2 independent iPhones before a 12-lead ECG was recorded. Backdrop and background light intensity was monitored during signal acquisition. Three successive 20-second (total, 60 seconds) recordings were acquired per patient and analyzed for heart rate regularity by Cardiio Rhythm (Cardiio Inc, Cambridge, MA) smartphone application. Pulse irregularity in ≥1 photoplethysmographic readings or 3 uninterpretable photoplethysmographic readings were considered a positive AF screening result. AF was present on 12-lead ECG in 34.6% (n=75/217) patients. The Cardiio Rhythm facial photoplethysmographic application demonstrated high sensitivity (95%; 95% confidence interval, 87%-98%) and specificity (96%; 95% confidence interval, 91%-98%) in discriminating AF from sinus rhythm compared with 12-lead ECG. The positive and negative predictive values were 92% (95% confidence interval, 84%-96%) and 97% (95% confidence interval, 93%-99%), respectively.

CONCLUSIONS

Detection of a facial photoplethysmographic signal to determine pulse irregularity attributable to AF is feasible. The Cardiio Rhythm smartphone application showed high sensitivity and specificity, with low negative likelihood ratio for AF from facial photoplethysmographic signals. The convenience of a contact-free approach is attractive for community screening and has the potential to be useful for distant AF screening.

Web-based interventions for the management of type 2 diabetes mellitus: a systematic review of recent evidence

INTRODUCTION

The Internet has emerged as a potentially effective medium for information exchange. The Internet's potential has been recognised and web-based education programmes have been steadily adopted in recent years in preventing and managing chronic diseases such as diabetes mellitus. This review provides a descriptive discussion of web-based behavioural interventions for the management of type 2 diabetes mellitus.

METHOD

Systematic literature searches were performed using MEDLINE, EMBASE, PUBMED, PsycINFO, Web of Science and Cochrane Library to retrieve articles published between 2000 and June 2010 which fulfilled all inclusion criteria. Methodological quality assessment and data synthesis were then performed.

RESULTS

Twenty articles representing 13 different studies were reviewed. None of the studies were ranked as low in the methodological quality. Goal-setting, personalised coaching, interactive feedback and online peer support groups were some of the successful approaches which were applied in e-interventions to manage type 2 diabetes mellitus. Strong theoretical background, use of other technologies and longer duration of intervention were proven to be successful strategies as well.

CONCLUSION

The web-based interventions have demonstrated some level of favourable outcomes, provided they are further enhanced with proper e-research strategies.