Determinants of experience & satisfaction in telehealth psychiatry during the COVID-19 pandemic for patients & providers

Introduction

The objective of this study was to characterize the experiences and overall satisfaction of patients and providers with the March 2020 transition to telehealth in a psychiatric setting (telepsychiatry). The study also investigated how socio-demographic and clinical characteristics impact an individual's experiences and satisfaction with telepsychiatry.

Methods

Responses were collected from 604 patients and 154 providers engaged in clinical care at one of three participating Johns Hopkins Medicine outpatient psychiatric clinics between January 2020-March 2021. Survey data were collected by self-report via Qualtrics or telephone follow-up.

Results

Respondents were predominately female and White. Over 70% of patients and providers were generally satisfied with telepsychiatry. However, providers were more likely to favor in-person care over telepsychiatry for post-pandemic care 48% to 17% respectively, while 35% rated both modalities equivalently. Patients were more evenly divided with 45% preferring telepsychiatry compared to 42% for in-person care, and only 13% rating them equivalently. Among providers, technical difficulties were significantly associated with both less satisfaction and lower preference for telepsychiatry [odds ratio for satisfaction (ORS) = 0.12; odds ratio for preference (ORP) = 0.13]. For patients, factors significantly associated with both lower satisfaction and lower preference for telepsychiatry included technical difficulties (ORS = 0.20; ORP = 0.41), unstable access to the internet (ORS = 0.46; ORP = 0.50), worsening depression (ORS = 0.38; ORP = 0.36), and worsening anxiety (ORS = 0.41; ORP = 0.40). Factors associated with greater satisfaction and higher preference for telepsychiatry among patients included higher education (ORS = 2.13; ORP = 1.96) and a decrease in technical difficulties over time (ORS = 2.86; ORP = 2.35).

Discussion

Patients and providers were satisfied with telepsychiatry. However, there were greater differences between them in preferences for continuing to use telepsychiatry post-pandemic. These findings highlight factors that influence patient and provider preferences and should be addressed to optimize the use of telepsychiatry in the future.

National Network of Depression Centers' Recommendations on Harmonizing Clinical Documentation of Electroconvulsive Therapy

ABSTRACT

Electroconvulsive therapy (ECT) is a highly therapeutic and cost-effective treatment for severe and/or treatment-resistant major depression. However, because of the varied clinical practices, there is a great deal of heterogeneity in how ECT is delivered and documented. This represents both an opportunity to study how differences in implementation influence clinical outcomes and a challenge for carrying out coordinated quality improvement and research efforts across multiple ECT centers. The National Network of Depression Centers, a consortium of 26+ US academic medical centers of excellence providing care for patients with mood disorders, formed a task group with the goals of promoting best clinical practices for the delivery of ECT and to facilitate large-scale, multisite quality improvement and research to advance more effective and safe use of this treatment modality. The National Network of Depression Centers Task Group on ECT set out to define best practices for harmonizing the clinical documentation of ECT across treatment centers to promote clinical interoperability and facilitate a nationwide collaboration that would enable multisite quality improvement and longitudinal research in real-world settings. This article reports on the work of this effort. It focuses on the use of ECT for major depressive disorder, which accounts for the majority of ECT referrals in most countries. However, most of the recommendations on clinical documentation proposed herein will be applicable to the use of ECT for any of its indications.

Daily partner responsiveness and everyday sleep outcomes in breast cancer survivors and their partners

PURPOSE

Breast cancer (BC) survivors and their intimate partners face several adverse consequences from the cancer experience, including sleep disturbance, which is a common side effect of BC and its treatment. Sleep has been conceptualized and examined as an individual phenomenon despite most adults sharing a bed/room with a partner. Limited research has examined the associations between daily relationship processes and sleep in couples coping with cancer. Using an intensive longitudinal design, the present study examined the daily, within-person links between attempted and perceived partner responsiveness and subjective sleep.

METHODS

Immediately following adjuvant treatment, 72 early-stage BC survivors and their intimate partners (144 paired individuals) reported on daily attempted and perceived partner responsiveness each evening and subjective sleep each morning for 21 consecutive days.

RESULTS

Survivor and partner reports of partner responsiveness were associated with their own subjective sleep, such that greater attempted and perceived partner responsiveness were associated with improvements in one's own subjective sleep. Effects of one participant's partner responsiveness on their partner's sleep were not observed.

CONCLUSIONS

Findings suggest that among couples coping with early-stage BC, increased partner responsiveness is associated with subsequent improvements in subjective sleep.

IMPLICATIONS FOR CANCER SURVIVORS

Sleep disturbance is a serious concern for BC survivors and their intimate partners. Future research should assess intimacy processes as a potential method to improve BC survivor and partner sleep.

Long-term physical health outcomes of obsessive-compulsive personality disorder traits

BACKGROUND

Obsessive-compulsive personality disorder (OCPD) is characterized by pervasive and persistent traits including preoccupation with orderliness, perfectionism, and control. Relatively little is known about the potential relationship between OCPD traits and physical health.

METHODS

We investigated the association between OCPD traits and several self-reported medical conditions in 249 individuals followed prospectively from 1981 until 2004/2005 as part of the Epidemiological Catchment Area.

RESULTS

The OCPD trait score was inversely related to hypertension in males, in models unadjusted (OR = 0.66; 95% CI, 0.45-0.90) and adjusted (OR = 0.70; 95% CI, 0.47-0.95) for sociodemographic variables. Perfectionism was inversely related to hypertension in the unadjusted models for men (OR = 0.34; 95% CI, 0.12-0.89). Indecisiveness was positively associated with heart conditions in adjusted models for women (OR = 3.46; 95% CI, 1.11-10.52).

CONCLUSION

OCPD traits are associated with cardiovascular health in both sexes. Further studies are needed to understand the specificity of these relationships, as well as to determine the underlying mechanism.

Prevalence and Perceived Usefulness of Assistive Technology in Mind at Home Dementia Cohort

Dementia is generally characterized by both an increasing dependence in activities of daily living over the course of the illness, and a decreasing ability to self-manage everyday tasks. This places persons at risk for a number of undesirable outcomes including increased risk for injury in the home, increased risk for medical and behavioral complications, risk of premature institutionalization, and excessive burden on family caregivers (CG).3,4 Assistive Technology Devices (AT-Devices) could represent an efficient resource for supporting daily tasks while reducing both CG care burden and adverse risk to the person with dementia (PWD).3,4 In the context of a larger dementia care intervention clinical trial (The MIND at Home program) that involved persons living with dementia at home and their family caregivers, we conducted a supplemental baseline survey on 59 participants and their CGs to better understand the current prevalence of AT-Device use and which devices would be perceived as “most helpful”. Our analysis showed that 51% of our study population used at least 1 of our listed AT-Devices. The most common AT-Device used at baseline were door guards (29%), tablets/smartphones (20%), and constant temperature shower nozzles (13%). Our survey demonstrated devices perceived as most useful included: shower nozzles, GPS locating devices, door guards, and Bluetooth tracking stickers. Individuals who endorsed African-American/Other race were significantly more likely to use at least one AT-Device than those who identified as Caucasian (OR: 4.80; 95% CI: 1.50-17.58). This significance was lost during adjustment for other demographic variables (sex, age, cohabitation status, and dementia severity).

Treatment with epigenetic agents profoundly inhibits tumor growth in leiomyosarcoma

Leiomyosarcomas are rare mesenchymal neoplasms characterized by a smooth muscle differentiation pattern. Due to the extremely poor prognosis in patients, the development of novel chemotherapeutic regimens remains critically important. In this study, multiple leiomyosarcoma cell lines, SK-UT1, SK-LMS1, and MES-SA were treated with varying doses of the DNA Methyltransferase Inhibitors (DNMTi) 5-azacitidine (Aza), 5-aza-2-deoxycytidine (DAC), and guadecitabine (SGI-110). The effect of these epigenetic modulators was measured using both in-vitro and in-vivo models.

Of the three epigenetic modulators, Guadecitabine was the most effective at decreasing cell survival in LMS cell lines. SK-UT1 was found to be the more sensitive to all three epigenetic modulators, while SK-LMS1 and MES-SA were more resistant. The contrast in sensitivity seen was also represented by the increase in apoptosis in Aza and guadecitabine. In parallel with Aza, guadecitabine was observed to also arrest the cell cycle.

Treatment with guadecitabine led to a decrease in growth across the spectrum of sensitivity in LMS cell lines, both in a delayed in vitro and in vivo model; in parallel experiments, apoptotic pathways were activated in sensitive and less sensitive lines. Additional studies are required to explore potential therapeutic applications and mechanisms for leiomyosarcoma treatment.

99mTc-HMPAO brain SPECT in the monitoring of cerebral vasculitis therapy

OBJECTIVE

The central nervous system (CNS) may be involved in a variety of inflammatory diseases of the blood vessels, generally known as vasculitis. The clinical diagnosis of such involvement in early stages is difficult, since a mild cognitive impairment can be the only symptom. It was hypothesized that brain-perfusion SPECT would be able to reveal CNS involvement and to monitor the course of the disease. The purpose of this study was assess if and when an improvement of cerebral perfusion can be registered by SPECT during the follow-up of these diseases.

MATERIAL AND METHODS

Eighteen patients affected by Systemic Lupus Erythematosus (SLE), 22 by undifferentiated vasculitis (UV), 5 by Behcet's disease (BD) and 5 by primary Sjogren's Syndrome (pSS) were enrolled in this prospective study. A ^99mTc-HMPAO brain perfusion SPECT was performed before the treatment and was repeated during the follow-up at different time intervals. Image analysis was performed on 10 cerebral areas using a specific software.

RESULTS

In the SLE patients, no significant improvement of brain perfusion was found. On the contrary, in the UV the cerebral uptake of the tracer significantly improved from the twenty-fourth month (18/22 patients). Patients with BD showed an improvement of scintigraphic findings (5/5 patients), while a similar result was obtained only in 2 of the patients with pSS.

CONCLUSIONS

In conclusion, brain SPECT seems to be able to monitor the disease in UV, indicating the moment when an improvement of the cerebral perfusion is achieved. In SLE patients this scintigraphic technique did not show a significant improvement in CNS perfusion.

Serum uric acid is not independently associated with plasma renin activity and plasma aldosterone in hypertensive adults

BACKGROUND AND AIMS

In experimental investigations conducted in rats, raising serum uric acid (SUA) levels resulted in the stimulation of intrarenal renin expression. Studies in humans exploring the association of SUA with plasma renin activity (PRA) yielded conflicting results. Moreover, little is known about the relationship of SUA with plasma aldosterone concentration (PAC). The study aimed to assess the relationship between SUA levels, PRA, and PAC and the influence of age, gender, body mass index (BMI), and hyperuricemia on these relationships in subjects with essential hypertension (EH).

METHODS AND RESULTS

We enrolled 372 hypertensive patients (mean age 45 ± 12 years, men 67%) with uncomplicated EH that was not pharmacologically treated. The study population was divided in tertiles according to SUA levels. While PRA did not differ significantly across the three tertiles, PAC was higher in subjects belonging to the uppermost tertile of SUA than those in the lower ones (p = 0.0429); however, this difference lost statistical significance after adjustment for age, sex, BMI, and serum creatinine. Univariate correlation analyses showed significant associations of SUA with PRA (r = 0.137; p = 0.008) and PAC (r = 0.179; p < 0.001). However, these relationships were not significant after correcting for confounding factors in multiple linear regression analyses. We did not observe statistically significant effect modification by gender, age, BMI, and hyperuricemia.

CONCLUSION

SUA levels are weakly associated with PRA and PAC in adults with untreated EH. These relationships were lost after adjustment for age, sex, BMI, and serum creatinine.

Structural brain MR imaging changes associated with obsessive-compulsive disorder in patients with multiple sclerosis

BACKGROUND AND PURPOSE

Psychiatric symptoms occur in approximately 30% of patients with MS. Such symptoms include OCD, which may interfere heavily with the patient's daily life. We hypothesized that the widespread involvement of both GM and WM, which characterizes MS, may be responsible for the occurrence of OCD when specific brain structures are affected. The aim of this study was to evaluate the relationship between GM and WM tissue damage and OCD in patients with MS.

MATERIALS AND METHODS

We evaluated 16 patients with relapsing-remitting MS who had been diagnosed with OCD on the basis of the Diagnostic and Statistical Manual of Mental Disorders (4th edition) and 15 age- and sex-matched patients with relapsing-remitting MS with no psychiatric disorders as a CG. The MR study (1.5T) included 3D T1-weighted fast-field echo sequences, DTI (32 directions), and conventional MRI. Images were processed using SPM5, FSL, and Jim 5.0 software to evaluate VBM, TBSS, and global and regional LV, respectively.

RESULTS

The VBM analysis revealed a set of clusters of reduced GM volume in the OCD group, compared with the CG, located in the right inferior and middle temporal gyri and in the inferior frontal gyrus. TBSS did not detect any differences in the FA values between the 2 groups; global and regional LV values also did not differ significantly between the 2 groups.

CONCLUSIONS

Our study suggests that OCD in MS may be caused by damage in the right frontotemporal cortex.

Can Immune Disorders Influence Therapeutical Approach in Treatment of Epilepsy among Neurologists? A First Co-Operative National Recognition in Italy

Functional disturbances of the immune system have been detected more often among persons affected by epilepsy than in the general population. In the February-July period of 2007 a specific questionnaire on the relationship between epilepsy and immunological response was sent to 27 specialized Centres for Epilepsy in nine Italian regions. 15,388 epileptic patients attended twenty-seven Centers during this six-month period. 3.3% (n=502) of these patients suffered an immune disease. This is the first national survey on the relationship between epilepsy and immunological response in current clinical practice.

Financing adolescent health care: the role of Medicaid and CHIP

Financing health care for adolescents involves a combination of public and private sources of payment and, in the public sector, a combination of insurance coverage and categorical programs. In recent years, the importance of health insurance coverage has increased along with the potential for insuring more adolescents. Medicaid and the new State Children's Health Insurance Program (CHIP) offer numerous options for reducing the proportion of uninsured adolescents and for increasing adolescents' access to necessary health care. This article explores the potential of Medicaid and CHIP for meeting adolescents' needs, the extent to which they have done so already, and the gaps or missing links that remain. It also reviews issues that cut across funding sources related to managed care, consent, and confidentiality.

Synergistic effect of glycolic acid on the antioxidant activity of alpha-tocopherol and melatonin in lipid bilayers and in human skin homogenates

Considerable interest has been raised concerning the use of natural compounds in preventing skin aging and photoaging. In the idea that the combined action of agents increasing epidermal turnover with antioxidants could be advantageous in cosmetic and therapeutic treatments, we first investigated if alpha-glycolic acid affected or prevented the antioxidant activity of vitamin E and of melatonin, two compounds found beneficial as topical photoprotectant. Assays were carried out in vitro either in a biomimetic liposomal system, or in human skin homogenates. Lipid peroxidation was monitored spectrophotometrically by the time course of lipid hydroperoxide production in liposomes and by formation of TBA reactive substances (TBARS) in skin homogenates. Glycolic acid, at 25 microM to 1 mM, showed a mild, concentration-dependent antioxidant effect in liposomes, as evaluated by a slight decrease of the peroxidation rate, while, at 1 mM, reduced TBARS production in skin homogenates by 14%. Combinations of either vitamin E or melatonin with glycolic acid, in a 1:5 to 1:200 molar ratio, resulted in a clear synergistic protection of liposomes, more evident for the combination of glycolic acid with vitamin E. An amount of synergism up to 250% and up to 80% was evaluated with vitamin E and melatonin, respectively. Consumption rate of vitamin E during peroxidation of liposomes, in the absence or in the presence of glycolic acid, suggests that regeneration of vitamin E may in part explain the observed synergism. Synergistic antioxidant activity between vitamin E and glycolic acid was also observed in skin homogenates, whereas the effect of glycolic acid on the antioxidant activity of melatonin appeared additive. However, the combination of these three compounds inhibited TBARS production almost completely. Our data provide evidence that glycolic acid can strongly potentiate the antioxidant action of melatonin and vitamin E. This may suggest the advantage of combining alpha-glycolic acid with these antioxidants in skin designed preparations, both to improve penetration and availability of antioxidants to epidermal layers and to enhance their protective potential.

Reaction of melatonin with lipoperoxyl radicals in phospholipid bilayers

Melatonin, at 5 to 500 microM was incorporated in unilamellar soybean phosphatidylcholine (PC) liposomes, the peroxidation of which was induced by 2,2'-azobis (2-amidinopropane-hydrochloride) (AAPH), and measured as production of conjugated diene lipid hydroperoxides. Concentration as low as 5 and 10 microM were poorly effective in reducing lipid peroxidation. Melatonin at 30 to 500 microM caused short inhibition periods, increasing with, but not linearly related to concentration, with a concurrent net decrease of the propagation rate. The time course of melatonin oxidation, measured as loss of fluorescence, was studied during the AAPH-stimulated peroxidation of soybean PC liposomes, or when melatonin was incorporated in nonperoxidable unilamellar dimirystoyl phosphatidylcholine (DMC) liposomes. Consumption kinetics of 30 microM melatonin were linear with time in DMC liposomes and disappearance of melatonin occurred at a rate of 0.058 M(-8) s(-1). On the other hand, the consumption of melatonin during the oxidation of soybean PC liposomes, was not linear with time. The rate of disappearance was calculated as 0.19 M(-8) s(-1) at the beginning of the propagation phase, then it slowed down to reach the same rate observed in DMC liposomes. This evidence suggests a reaction with lipid-derived peroxyl radicals, possibly in addition to reaction with peroxyl radicals derived from AAPH. Scavenging of lipoperoxyl radicals by melatonin was also evident in experiments where melatonin was incorporated in multilamellar soybean PC liposomes and peroxidation was initiated by 2,2 '-azobis (2,4-dimethyl-valeronitrile). The antioxidant activity of melatonin in soybean PC liposomes is much lower than that of alpha-tocopherol, under comparable assay conditions. However, a combination of melatonin and alpha-tocopherol, at 5 microM, resulted in a synergistic antioxidant effect. Time course of alpha-tocopherol consumption, monitored in the absence and in the presence of melatonin, showed a significant decrease of the consumption rate when compounds were combined, indicating some protection by melatonin. Regeneration mechanisms were not evident and depletion of alpha-tocopherol was coincident with the inhibition time.

Guidelines for adolescent health research: a position paper of the society for adolescent medicine

Their ambiguous legal and ethical status has become a barrier to adolescents' appropriate involvement in research from which they may benefit and which is needed to improve adolescent health care and to inform health policy. Involvement of adolescents in research should be based on a scientific and empathetic understanding of their developing capabilities and a careful assessment of risks and benefits. The important role of parents and communities as protectors of adolescents should be respected and enhanced as we acknowledge and respect developing adolescent autonomy. These guidelines provide a framework to interpret the federal regulations for protection of human subjects in light of the unique legal, ethical, developmental, contextual, and racial issues that affect adolescents. The guidelines are designed to protect individual adolescent research subjects and to facilitate important youth research that would promote the health of adolescents.

Significant bacteriuria has prognostic significance in primary biliary cirrhosis

Significant bacteriuria in women has been found to be associated with increased mortality in community-based studies. We have previously reported a high prevalence of significant bacteriuria with a high recurrence rate in females with primary biliary cirrhosis (PBC), particularly those with late stage disease on liver biopsy. During a 5-year period we prospectively screened for significant bacteriuria in 187 women with primary biliary cirrhosis, (median follow-up of 47 months, range 1-83). Significant bacteriuria was found in 30 (17%) in their first urine (index bacteriuria), 90 (48%) died and 15 (8%) had liver transplants. Cox's proportional hazard models showed that age, serum bilirubin, ascites and cirrhosis were independent prognostic variables. Index bacteriuria added significantly to this model (P = 0.069) being independent from other variables, with an increased relative hazard for death of 1.65 (65% increase in risk of death) compared to non-bacteriuric patients. This effect was due mainly to non-cirrhotic patients with significant bacteriuria as shown by using multiplicative variables for histological stage and significant bacteriuria. An index of recurrent bacteriuria was significantly increased in patients with index bacteriuria (P less than 0.001) and in those who died or underwent transplantation (P less than 0.001). In this study, significant bacteriuria defined a specific sub-group of PBC patients with an increased risk of death.