Alcohol consumption is associated with the severity and outcome of acute liver injury/failure.

BACKGROUND & AIMS: Non-medical factors which contribute to the severity of acute liver failure (ALF) remain poorly defined. The association of alcohol consumption on the severity of presentation and outcome were determined in patients with ALF and acute liver injury (ALI) in a large, multicentre registry. METHODS: Alcohol consumption during the 6 months prior to study entry was analysed in 1170 patients enrolled in the ALF Study Group Registry. Consumption was categorized as none/minimal (<3 alcoholic beverages/week) or at least moderate (≥3/week). Clinical characteristics, the severity of liver injury at presentation (ALI or ALF) and outcome were compared. RESULTS: In patients with acetaminophen (APAP) overdose, at least moderate alcohol consumption was associated with higher peak aminotransferases, bilirubin, creatinine and INR on admission, compared to no/minimal consumption. In patients with non-APAP ALI/ALF, at least moderate alcohol consumption was associated with higher peak aminotransferases and creatinine. In APAP, non-APAP or all aetiologies, at least moderate alcohol consumption was associated with a 75%, 89% and 82% higher odds, respectively, of presenting as ALF rather than ALI (all P < .005). At least moderate alcohol consumption increased the odds of death by 45% (P = .01) across all aetiologies. In multivariate analysis, older age, non-Caucasian race, peak INR, peak bilirubin and at least moderate alcohol consumption were significantly associated with death. Finally, in Kaplan-Meier analysis of patients with all aetiologies, at least moderate alcohol consumption was associated with decreased time-dependent survival (P = .002). CONCLUSION: Alcohol consumption adversely affects the presentation and outcome of both APAP- and non-APAP-induced ALI/ALF.

Psychiatric consultation requests by inpatient medical teams: an observational study.

BACKGROUND: We describe the way psychiatric issues are addressed by inpatient medical teams through analysis of discussions of patients with behavioral health concerns and examination of teams' subsequent consultation practices. METHODS: We observed morning rounds for nine inpatient medical teams for approximately month-long periods, for a total of 1941 observations. We compared discussions of patients admitted for behavioral health related medical conditions between those who did and did not receive a psychiatric consultation, developing categories to describe factors influencing consultation or other management. RESULTS: Out of 536 patients, 40 (7.5%) received a psychiatry consult. Evaluation of a known concern (i.e., substance use, affective disorder, or suicidal ideation) was the most common reason for referral (41.7%). Requests for medication review were second (30.6%). Thirty patients with concomitant behavioral and medical health issues did not receive a psychiatry consult. Cirrhosis with active substance use was the most common medical diagnosis (15), followed by alcohol withdrawal (9). CONCLUSIONS: Four primary themes emerged from our data: positive identification of behavioral health issues by physicians, medication management as a primary reason for referral, patient preference in physician decision-making, and poor management of substance abuse. Our results identify two potential areas where skills-building for inpatient physicians could have a positive impact: management of medication and of substance abuse management.

Who Is Food Insecure? Implications for Targeted Recruitment and Outreach, National Health and Nutrition Examination Survey, 2005-2010.

INTRODUCTION: Food insecurity is negatively associated with health; however, health needs may differ among people participating in food assistance programs. Our objectives were to characterize differences in health among people receiving different types of food assistance and summarize strategies for targeted recruitment and outreach of various food insecure populations. METHODS: We examined health status, behaviors, and health care access associated with food insecurity and receipt of food assistance among US adults aged 20 years or older using data from participants (N = 16,934) of the National Health and Nutrition Examination Survey from 2005 through 2010. RESULTS: Food insecurity affected 19.3% of US adults (95% confidence interval, 17.9%-20.7%). People who were food insecure reported poorer health and less health care access than those who were food secure (P < .001 for all). Among those who were food insecure, 58.0% received no assistance, 20.3% received only Supplemental Nutrition Assistance Program (SNAP) benefits, 9.7% received only food bank assistance, and 12.0% received both SNAP and food bank assistance. We observed an inverse relationship between receipt of food assistance and health and health behaviors among the food insecure. Receipt of both (SNAP and food bank assistance) was associated with the poorest health; receiving no assistance was associated with the best health. For example, functional limitations were twice as prevalent among people receiving both types of food assistance than among those receiving none. CONCLUSION: Receipt of food assistance is an overlooked factor associated with health and has the potential to shape future chronic disease prevention efforts among the food insecure.

Victimization and Distress in Indigenous Maya Women: A Qualitative Investigation of Gender-Based Violence and Mental Health Outcomes in Rural Guatemala.

Purpose: There is currently scant research exploring Indigenous Guatemalan women's experiences of gender-based violence and mental health outcomes, but existing research suggests further exploration in this area is necessary. The current study aimed to address this gap by analyzing the experiences with violence and subsequent well-being of Indigenous Maya women in rural Guatemala. Methods: Data were collected in an ethnographic project on mental health in Panajachel, Guatemala, consisting of a cross-sectional survey on violence exposure and mental health history, followed by semi-structured interviews to elaborate on the experiences. Interviews with seven Kaqchikel Maya women who had been exposed to violence provided the qualitative basis for this study, supplemented by the survey results. Descriptive statistics of survey results and thematic analysis of interviews are presented. Results: The survey results pointed to a deep relationship between violence victimization and mental health issues. Recurring themes in the interviews included symptoms of post-violence emotional distress including fear, sadness, physical ailments, and suicidal ideation; the role of the women as mothers; lack of legal and mental health support; and the importance of spirituality and religion. Conclusions: These results highlight the importance of examining emotional distress as separate from diagnostic psychiatric disorders in addressing women's mental health post-violence. This exploratory study provides examples of violence exposure, mental health, and resource availability among Guatemalan Maya women and suggests possibilities for future investigation.

Suicidal ideation in an ethnically mixed, highland Guatemalan community.

Reported suicide rates in Latin America remain low, but there is evidence to suggest they may be increasing, particularly among indigenous populations. To better understand who may be at risk for suicide, we examined the prevalence of suicidal ideation and explored factors contributing to suicidal thoughts in an ethnically mixed, highland Guatemalan community. The data presented in this article are from a mixed methods ethnographic field project conducted over 15 months from 2010 to 2011 in Panajachel, Guatemala. We surveyed a random sample of 350 community members. Survey questions included standardized modules from the Mini-International Neuropsychiatric Interview, as well as questions on experiences of violence and mental health care. We also conducted semi-structured interviews with 13 self-selected survey participants with current suicidal ideation. These interviews included questions regarding survey responses, experiences of mental illness, and access to mental health care. A total of 55 survey participants (N = 350; 15.7%) scored positive for suicidality. Ethnic identity, gender, psychiatric illness, and experiences of violence were all correlated to suicidal ideation. Qualitative interview data highlight distinctions between genders within prominent themes of religion, family, experiences of violence, and seeking resources. Three key findings emerged from our research that are relevant to the literature: 1) ethnic identity may be both a critical risk and a protective factor for suicide in some indigenous people; 2) intersections between violence and gender highlight different patterns in suicidal ideation; and 3) high rates of suicidal ideation and other psychiatric comorbidities underscore the need for greater access to mental health services.

Process evaluation of serial screening criteria to identify injured patients that benefit from brief intervention: practical implications.

BACKGROUND: The aim of the current study is to evaluate the effectiveness of serial screening methods for the identification of injured patients at risk for alcohol problems and are most likely to benefit from brief interventions. We hypothesize that blood alcohol concentration (BAC) alone is not sufficient to effectively identify at-risk drinkers in the trauma care setting. METHODS: During a 2-year period, patients admitted to an urban Level I trauma center for treatment of an injury were screened for alcohol problems. Screening consisted of four serial screening criteria: (1) clinical indication of acute intoxication including positive BAC; (2) self-reported drinking 6 hours before injury; (3) at-risk drinking as defined by National Institutes on Alcohol Abuse and Alcoholism or (4) by responding yes to one or more items on the CAGE within the last year. RESULTS: In all, 11,028 patients were seen. Fifty-eight percent were eligible for screening and 90% of eligible patients were screened. Of screened patients, 41% screened positive for an alcohol-related injury. Of patients that did not have a BAC drawn, 39% (n = 935) went on to screen positive using serial screening procedures. Additionally, 36% (n = 339) of patients with a negative BAC went on to screen positive using serial screening procedures. CONCLUSIONS: This evaluation clearly suggests that BAC alone is not sufficient to identify patients who are most likely to benefit from brief alcohol interventions. Self-reported drinking in conjunction with BAC facilitates identification and intervention of injured patients with alcohol problems.

Psychosocial and behavioral factors in acetaminophen-related acute liver failure and liver injury.

OBJECTIVES: Acetaminophen overdoses result in nearly 500 deaths annually and a much larger number of hospitalizations. Suicidal overdoses are exceeded in number in the United States by unintentional overdoses. We evaluated clinical, demographic and psychosocial factors among unintentional and intentional overdose patients whose acetaminophen (APAP) toxicity had resulted in acute liver failure. We hypothesized that APAP overdose patients would be more likely to suffer from behavioral health issues and display higher impulsivity scores than the general population. METHODS: Within 4days of admission and initial recovery of alertness, we administered a detailed questionnaire that included questions on APAP intake (e.g., dose taken, intent, other substances ingested), the Mini International Neuropsychiatric Interview modules on depression, alcohol use, substance use, and pain disorders and The Barratt Impulsiveness Scale-11. RESULTS: The group included 44 intentional (single time point ingestions with the intent to self-harm) and 51 unintentional (multiple time point ingestions to manage pain or other condition) APAP patients enrolled in the Acute Liver Failure Study Group registry between 2007 and 2013. Both groups were characterized by similar frequencies of chronic pain, depressive symptoms at time of ingestion and alcohol and substance use disorders, all at higher rates than the general population. Overall, APAP patients scored higher than the general population for Non-planning aspects of impulsivity, with no apparent differences between other impulsivity scores or between intentional and unintentional APAP patients. CONCLUSIONS: Depression, mismanagement of problematic chronic pain, frequent substance abuse, and increased impulsivity appear to provide the substrate for many APAP overdoses.

Family and Social Context Contributes to the Interplay of Economic Insecurity, Food Insecurity, and Health.

In this study, we show how household health, economic instability, and food insecurity are inextricably linked; disruptions in individual health or income create cumulative and interdependent challenges faced by multiple household members. Drawing upon semi-structured focus groups with English- and Spanish-speaking clients of an urban food pantry, we demonstrate: (1) the impact of economic scarcity on health, (2) the impact of one household member's health on the health and food security of all household members, and (3) food sharing behaviors among family and social networks, including multi-generational families and non-kin individuals. We identify the gap between household-level assessments of food insecurity and individual-level health reports, which may obscure poor health among other household members. Understanding the social and family context of health and food insecurity may inform future interventions that address the interrelated challenges of diverse and disadvantaged households and communities.

Relationships within inpatient physician housestaff teams and their association with hospitalized patient outcomes.

IMPORTANCE: Improving inpatient care delivery has historically focused on improving individual components of the system. Applying the complexity science framework to clinical systems highlights the important role of relationships among providers in influencing system function and clinical outcomes. OBJECTIVE: To understand whether inpatient medical physician teams can be differentiated based on the relationships among team members, and whether these relationships are associated with patient outcomes, including length of stay (LOS), unnecessary length of stay (ULOS), and complication rates. DESIGN: Eleven inpatient medicine teams were observed daily during attending rounds for 2- to 4-week periods from September 2008 through June 2011. Detailed field notes were taken regarding patient care activities, team behaviors, and patient characteristics and outcomes. Behaviors were categorized using the Lanham relationship framework, giving each team a relationship score. We used factor analysis to assess the pattern of relationship characteristics and assessed the association between relationship characteristics and patient outcomes. SETTING: Observations occurred at the Audie L. Murphy Veterans Affairs Hospital and University Hospital in San Antonio, Texas. PARTICIPANTS: Physicians were chosen based on rotation schedules, experience, and time of year. Patients were included based on their admission to the inpatient medicine teams that were being observed. MAIN MEASURES: Relationship scores were based on the presence or absence of 7 relationship characteristics. LOS, ULOS, and complication rates were assessed based on team discussions and chart review. The association between relationships and outcomes was assessed using the Kruskal-Wallis rank sum test. RESULTS: We observed 11 teams over 352.9 hours, observing 1941 discussions of 576 individual patients. Teams exhibited a range of 0 to 7 relationship characteristics. Relationship scores were significantly associated with complication rates, and presence of trust and mindfulness among teams was significantly associated with ULOS and complication rates. CONCLUSIONS: Our findings are an important step in understanding the impact of relationships on the outcomes of hospitalized medical patients. This understanding could expand the scope of interventions to improve hospital care to include not only process improvement but also relationships among providers.