Leaping through Tree Space: Continuous Phylogenetic Inference for Rooted and Unrooted Trees.

Phylogenetics is now fundamental in life sciences, providing insights into the earliest branches of life and the origins and spread of epidemics. However, finding suitable phylogenies from the vast space of possible trees remains challenging. To address this problem, for the first time, we perform both tree exploration and inference in a continuous space where the computation of gradients is possible. This continuous relaxation allows for major leaps across tree space in both rooted and unrooted trees, and is less susceptible to convergence to local minima. Our approach outperforms the current best methods for inference on unrooted trees and, in simulation, accurately infers the tree and root in ultrametric cases. The approach is effective in cases of empirical data with negligible amounts of data, which we demonstrate on the phylogeny of jawed vertebrates. Indeed, only a few genes with an ultrametric signal were generally sufficient for resolving the major lineages of vertebrates. Optimization is possible via automatic differentiation and our method presents an effective way forward for exploring the most difficult, data-deficient phylogenetic questions.

The Prevalence of Cognitive Impairment and Dementia in Incarcerated Older Adults.

OBJECTIVES: In view of the growing number of older incarcerated persons in the United States, cognitive impairment represents one of the most challenging and costly health care issues facing the U.S. correctional system. This study examined the prevalence and correlates of this growing public health issue in the nation's largest prison system. METHODS: In this study of a random sample of 143 older (≥55 years) adults incarcerated in the Texas prison system, we assessed-using the Montreal Cognitive Assessment (MoCA)-the percentage of inmates who met the MoCA thresholds for mild cognitive impairment (MCI; <23) and dementia (<18). Due to sample size limitations, our multivariable analysis assessed the binary outcome, MoCA <23. RESULTS: Overall, 35.0% of our random sample of incarcerated older adults in Texas met the threshold for MCI and 9.1% met the threshold for dementia. After adjusting for covariates, study participants who were Black (odds ratio [OR] = 4.12, 95% confidence interval [CI] = 1.57-10.82), Hispanic (OR = 4.34, 95% CI = 1.46-12.93), and those with a diagnosis of major depressive disorder (8.56, 95% CI = 1.21-60.72) all had higher prevalence of a positive screen for MCI or dementia. Dementia was underdiagnosed in our study sample of incarcerated adults, with 15.4% of MoCA-diagnosed dementia patients having a dementia diagnosis documented in their medical records. DISCUSSION: Future studies of cognitive impairment in prisons and jails can inform health care planning and resource allocation, such as expansion of access to palliative care, advance care planning, and targeted cognitive screening in older age groups.

Interpretable Computer Vision to Detect and Classify Structural Laryngeal Lesions in Digital Flexible Laryngoscopic Images.

OBJECTIVE: To localize structural laryngeal lesions within digital flexible laryngoscopic images and to classify them as benign or suspicious for malignancy using state-of-the-art computer vision detection models. STUDY DESIGN: Cross-sectional diagnostic study SETTING: Tertiary care voice clinic METHODS: Digital stroboscopic videos, demographic and clinical data were collected from patients evaluated for a structural laryngeal lesion. Laryngoscopic images were extracted from videos and manually labeled with bounding boxes encompassing the lesion. Four detection models were employed to simultaneously localize and classify structural laryngeal lesions in laryngoscopic images. Classification accuracy, intersection over union (IoU) and mean average precision (mAP) were evaluated as measures of classification, localization, and overall performance, respectively. RESULTS: In total, 8,172 images from 147 patients were included in the laryngeal image dataset. Classification accuracy was 88.5 for individual laryngeal images and increased to 92.0 when all images belonging to the same sequence (video) were considered. Mean average precision across all four detection models was 50.1 using an IoU threshold of 0.5 to determine successful localization. CONCLUSION: Results of this study showed that deep neural network-based detection models trained using a labeled dataset of digital laryngeal images have the potential to classify structural laryngeal lesions as benign or suspicious for malignancy and to localize them within an image. This approach provides valuable insight into which part of the image was used by the model to determine a diagnosis, allowing clinicians to independently evaluate models' predictions.

Assessing the Risk of Adjuvant Radiotherapy Initiation Delays With Social Support Surveys.

OBJECTIVE: In patients with head and neck squamous cell carcinoma (HNSCC), initiating postoperative radiotherapy (PORT) greater than 42 days after surgery is associated with a higher risk of poor survival outcomes. Social support has been shown to modulate behaviors related to care-seeking and treatment adherence. In this study, we sought to determine the relationship between social support metrics and PORT delays. STUDY DESIGN: Prospective cohort study. SETTING: Single tertiary medical center. METHODS: Patients with HNSCC who underwent primary surgical excision requiring PORT were prospectively enrolled. Patient-perceived social support metrics were assessed using the Medical Outcomes Study Social Support Survey (MOS-SSS) at initial presurgical evaluation. Associations with PORT delays were evaluated via univariable and multivariable logistic regression analysis. RESULTS: A total of 111 patients met the inclusion criteria for the study. An additional 28 patients were recommended to receive PORT but did not initiate treatment and were included for secondary analysis. All four subscales of the MOS-SSS (positive social interaction, affectionate support, tangible support, and emotional/informational support) were significantly associated with PORT initiation delays on univariable analysis. On multivariable analysis, the overall MOS-SSS score (odds ratio [OR] 2.08, 1.15-4.35, p = .028) was significantly associated with PORT initiation delays. On secondary analysis, lower tangible support was associated with a lack of PORT initiation (OR 1.63, 1.05-2.54, p = .028). CONCLUSION: Social support metrics were significantly associated with PORT delays, which may help promote tighter scheduling and closer monitoring of high-risk patients.

Qualitative Study Assessing Factors for 30-day Readmissions: A Head and Neck Oncology Cohort.

OBJECTIVES: There is a paucity of literature on what contributes to 30-day readmission rates from the patient's perspective in head and neck cancer patients. Post-operatively, these patients are often discharged with multiple surgical sites and home equipment requiring education and a large responsibility upon arriving home. Patients have a unique understanding of the discharge process and rationale behind presenting for care following initial discharge. Understanding the experience of the readmitted patient may be critical in finding effective methods to prevent unnecessary readmissions. METHODS: Through key-informant interviews, we assessed factors that impact readmission rates from the patient perspective. Patients were eligible if they were discharged within the last 30 days and subsequently readmitted following an admission for a head and neck cancer surgery. Inductive coding was used to analyze interview transcripts and develop themes. RESULTS: Thirteen respondents were interviewed. 46% (n = 6) did not feel ready for discharge after the index admission. Out of these 6 patients, 83% (n = 5) felt their readmission could have been avoided. Patients often encountered unexpected events after returning home from the index admission and felt their readmissions were potentially avoidable with more information regarding what to expect at home, prior to discharge. Although medically stable upon discharge, these findings indicate some patients might be discharged sooner than they should be due to factors outside of medical indications. CONCLUSIONS: To address the various biopsychosocial components of patient care in addition to medical aspects, an otolaryngology-specific, prior-to-discharge checklist could aid in lowering 30-day readmissions. Since the amount of education each patient requires to feel competent managing their health at home varies, more work is needed to craft post-education assessments of patient/caregiver competencies for home equipment, prior to discharge to reduce avoidable readmissions.

Prescribing Psychotropic Medications for Justice-Involved Juveniles.

Psychiatric disorders are exceedingly common in justice-involved youth. Relevant justice systems are varied, evolving, complex, and underserved. The intent of this article is to highlight the research and best practices related to managing the psychiatric disorders of justice-involved youths with a particular focus on pharmacotherapy. We review relevant features of the justice system and related case law, how prescribing for these individuals varies from both community settings and for incarcerated adults, effective assessment and medication selection, informed consent, management of nonadherence and medication diversion, and applied evidence for specific psychiatric problems common in these patients. Psychiatrists caring for justice-involved youth will benefit from tools, like this article, for training and orientation to provide timely and effective treatment services and consultation in these settings.

Pilot randomized, controlled, preoperative intervention for nutrition trial in head and neck cancer.

BACKGROUND: Several prospective studies report improved outcomes with pretreatment nutrition interventions prior to radiation therapy for head and neck cancer (HNC), but none have assessed similar interventions before surgery for HNC. METHODS: POINT, a pilot randomized controlled trial, was conducted to evaluate a multimodal nutrition intervention. Patients undergoing primary surgery with free flap reconstruction for HNC were randomly assigned to the control arm or a preoperative multimodal nutrition intervention. RESULTS: POINT included 49 patients. Nutrition risk scores did not change significantly for either the intervention or control group. Control patients had a significant decrease in body weight in the preoperative period (p < 0.001). Conversely, weight among intervention patients did not significantly decrease (p = 0.680). The intervention mitigated weight loss in patients with dysphagia (p = 0.001). CONCLUSIONS: Preoperative nutrition optimization shows potential to reduce weight loss normally experienced by patients with head and neck cancer prior to surgical extirpation, especially among those with subjective dysphagia.

Intrinsic randomness in epidemic modelling beyond statistical uncertainty.

Uncertainty can be classified as either aleatoric (intrinsic randomness) or epistemic (imperfect knowledge of parameters). The majority of frameworks assessing infectious disease risk consider only epistemic uncertainty. We only ever observe a single epidemic, and therefore cannot empirically determine aleatoric uncertainty. Here, we characterise both epistemic and aleatoric uncertainty using a time-varying general branching process. Our framework explicitly decomposes aleatoric variance into mechanistic components, quantifying the contribution to uncertainty produced by each factor in the epidemic process, and how these contributions vary over time. The aleatoric variance of an outbreak is itself a renewal equation where past variance affects future variance. We find that, superspreading is not necessary for substantial uncertainty, and profound variation in outbreak size can occur even without overdispersion in the offspring distribution (i.e. the distribution of the number of secondary infections an infected person produces). Aleatoric forecasting uncertainty grows dynamically and rapidly, and so forecasting using only epistemic uncertainty is a significant underestimate. Therefore, failure to account for aleatoric uncertainty will ensure that policymakers are misled about the substantially higher true extent of potential risk. We demonstrate our method, and the extent to which potential risk is underestimated, using two historical examples.

Assessing Prognostic Value of Quantitative Neck Dissection Quality Measures in Patients With Clinically Node-Negative Oral Cavity Squamous Cell Carcinoma.

Importance: In clinically localized (T1-2) oral cavity squamous cell carcinoma (OCSCC), regional lymph node metastasis is associated with a poor prognosis. Given the high propensity of subclinical nodal disease in these patients, upfront elective neck dissections (END) for patients with clinically node-negative disease are common and associated with better outcomes. Unfortunately, even with this risk-adverse treatment paradigm, disease recurrence still occurs, and our understanding of the factors that modulate this risk and alter survival have yet to be fully elucidated. Objective: To investigate the prognostic value of lymph node yield (LNY), lymph node ratio (LNR), and weighted LNR (wLNR) in patients with clinically node-negative T1-2 OCSCC. Design, Setting, and Participants: In this cohort study, data were collected retrospectively from 7 tertiary care academic medical centers. Overall, 523 patients with cT1-2N0 OCSCC who underwent elective neck dissections after primary surgical extirpation were identified. Exposures: Lymph node yield was defined as the number of lymph nodes recovered from elective neck dissection. Lymph node ratio was defined as the ratio of positive nodes against total LNY. Weighted LNR incorporated information from both LNY and LNR into a single continuous metric. Main Outcomes and Measures: Locoregional control (LRC) and disease-free survival (DFS) were both evaluated using nonparametric Kaplan-Meier estimators and semiparametric Cox regression. Results: On multivariable analysis, LNY less than or equal to 18 lymph nodes was found to be significantly associated with decreased LRC (aHR, 1.53; 95% CI, 1.04-2.24) and DFS (aHR, 1.46; 95% CI, 1.12-1.92) in patients with pN0 disease, but not those with pN-positive disease. Importantly, patients with pN0 disease with LNY less than or equal to 18 and those with pN1 diseasehad nearly identical 5-year LRC (69.7% vs 71.4%) and DFS (58.2% vs 55.7%). For patients with pN-positive disease, LNR greater than 0.06 was significantly associated with decreased LRC (aHR, 2.66; 95% CI, 1.28-5.55) and DFS (aHR, 1.65; 95% CI, 1.07-2.53). Overall, wLNR was a robust prognostic variable across all patients with cN0 disease, regardless of pathologic nodal status. Risk stratification via wLNR thresholds demonstrated greater optimism-corrected concordance compared with American Joint Committee on Cancer (AJCC) 8th edition nodal staging for both LRC (0.61 vs 0.57) and DFS (0.61 vs 0.58). Conclusions and Relevance: Movement toward more robust metrics that incorporate quantitative measures of neck dissection quality and regional disease burden, such as wLNR, could greatly augment prognostication in cT1-2N0 OCSCC by providing more reliable and accurate risk estimations.

Harnessing the Power of Artificial Intelligence in Otolaryngology and the Communication Sciences.

Use of artificial intelligence (AI) is a burgeoning field in otolaryngology and the communication sciences. A virtual symposium on the topic was convened from Duke University on October 26, 2020, and was attended by more than 170 participants worldwide. This review presents summaries of all but one of the talks presented during the symposium; recordings of all the talks, along with the discussions for the talks, are available at https://www.youtube.com/watch?v=ktfewrXvEFg and https://www.youtube.com/watch?v=-gQ5qX2v3rg . Each of the summaries is about 2500 words in length and each summary includes two figures. This level of detail far exceeds the brief summaries presented in traditional reviews and thus provides a more-informed glimpse into the power and diversity of current AI applications in otolaryngology and the communication sciences and how to harness that power for future applications.

Development and Validation of Machine Learning Models for Predicting Occult Nodal Metastasis in Early-Stage Oral Cavity Squamous Cell Carcinoma.

Importance: Given that early-stage oral cavity squamous cell carcinoma (OCSCC) has a high propensity for subclinical nodal metastasis, elective neck dissection has become standard practice for many patients with clinically negative nodes. Unfortunately, for most patients without regional metastasis, this risk-averse treatment paradigm results in unnecessary morbidity. Objectives: To develop and validate predictive models of occult nodal metastasis from clinicopathological variables that were available after surgical extirpation of the primary tumor and to compare predictive performance against depth of invasion (DOI), the currently accepted standard. Design, Setting, and Participants: This diagnostic modeling study collected clinicopathological variables retrospectively from 7 tertiary care academic medical centers across the US. Participants included adult patients with early-stage OCSCC without nodal involvement who underwent primary surgical extirpation with or without upfront elective neck dissection. These patients were initially evaluated between January 1, 2000, and December 31, 2019. Exposures: Largest tumor dimension, tumor thickness, DOI, margin status, lymphovascular invasion, perineural invasion, muscle invasion, submucosal invasion, dysplasia, histological grade, anatomical subsite, age, sex, smoking history, race and ethnicity, and body mass index (calculated as weight in kilograms divided by height in meters squared). Main Outcomes and Measures: Occult nodal metastasis identified either at the time of elective neck dissection or regional recurrence within 2 years of initial surgery. Results: Of the 634 included patients (mean [SD] age, 61.2 [13.6] years; 344 men [54.3%]), 114 (18.0%) had occult nodal metastasis. Patients with occult nodal metastasis had a higher frequency of lymphovascular invasion (26.3% vs 8.1%; P < .001), perineural invasion (40.4% vs 18.5%; P < .001), and margin involvement by invasive tumor (12.3% vs 6.3%; P = .046) compared with those without pathological lymph node metastasis. In addition, patients with vs those without occult nodal metastasis had a higher frequency of poorly differentiated primary tumor (20.2% vs 6.2%; P < .001) and greater DOI (7.0 vs 5.4 mm; P < .001). A predictive model that was built with XGBoost architecture outperformed the commonly used DOI threshold of 4 mm, achieving an area under the curve of 0.84 (95% CI, 0.80-0.88) vs 0.62 (95% CI, 0.57-0.67) with DOI. This model had a sensitivity of 91.7%, specificity of 72.6%, positive predictive value of 39.3%, and negative predictive value of 97.8%. Conclusions and Relevance: Results of this study showed that machine learning models that were developed from multi-institutional clinicopathological data have the potential to not only reduce the number of pathologically node-negative neck dissections but also accurately identify patients with early OCSCC who are at highest risk for nodal metastases.

Decision regret 3 and 6 months after treatment for head and neck cancer: Observational study of associations with clinicodemographics, anxiety, and quality of life.

BACKGROUND: While quality of life (QOL), psychosocial health, and adverse treatment outcomes have been studied in head and neck cancer (HNC) patients, decision regret is an important and understudied complication that can negatively impact future health care decision making. METHODS: Data collected using a HNC patient registry with questionnaires administered at initial consultation visits plus 3 and 6 months after treatment completion was retrospectively analyzed. A visual analog anxiety scale and the University of Washington Quality of Life were given at clinic visits. Decision regret was determined using a validated scale. Demographic and clinical variables were collected retrospectively and at baseline. RESULTS: Patients with higher anxiety and lower self-reported QOL had higher concurrent regret at 3-month (n = 140) and at 6-month (n = 82) post-treatment. Later disease stage at presentation, nonprimary surgical treatment, and lower health literacy were associated with greater regret. CONCLUSIONS: Decision regret was highest in HNC patients with high anxiety, low QOL, and more advanced disease.

Validation of the Modified Rhinoplasty Assessment Scale (Photographic).

OBJECTIVE: To validate the modified Rhinoplasty Assessment Scale (Photographic) (mRASP). STUDY DESIGN: Retrospective cohort study. METHODS: Study design-Photographs for 100 rhinoplasty patients from 2 facial plastic surgeons were compiled. Photos included 6 views. Each facial plastic surgeon reviewed all views. Nasal appearance was evaluated using the mRASP. Statistical analysis-A validation study was conducted, including descriptive statistics, reliability, and construct validity. Mean and standard deviations were used to describe the scores. RESULTS: Eighty female (mean RASP score = 14.89, SD = 7.04) and 20 male (mean RASP score = 19.83, SD = 10.09) patients were included. The mean of the total score on the instrument was 15.88 (SD = 7.98). Cronbach's alpha was .81, and inter-rater reliability measured as a Pearson product-moment correlation was .74. The CFA model fit the frontal view (χ2 = 32.47 (P = .04), CFI = .99, TLI = .99, RMSEA = .05, SRMR = .05), basal view (χ2 = 4.55 (P = .33), CFI = .98, TLI = .96, RMSEA = .03, SRMR = .23), and lateral view (χ2 = 39.52 (P = .40), CFI = 1.0, TLI = 1.0, RMSEA = .0, SRMR = .05) data well. CONCLUSION: The mRASP is a reliable instrument that can be used to assess nasal form via frontal, lateral, and basal photographs of patients. This provides facial plastic surgeons with a validated tool to evaluate rhinoplasty outcomes.

Educational Informed Consent Video Equivalent to Standard Verbal Consent for Rhinologic Surgery: A Randomized Controlled Trial.

BACKGROUND: Informed consent is an integral part of pre-operative counseling. However, information discussed can be variable. Recent studies have explored the use of multimedia in providing informed consent for rhinologic surgery. OBJECTIVE: To measure impact of an educational video (Video) compared to verbal informed consent (Verbal) on knowledge gained, alleviation of concerns, and efficiency. METHODS: Patients undergoing endoscopic sinus surgery (ESS), septoplasty, or ESS+septoplasty were prospectively enrolled and randomized to receive Video or Verbal consent. The Video group watched an educational video; the Verbal group received standard verbal consent from an Otolaryngology resident per institutional protocol. Both groups had the opportunity to discuss questions or concerns with their attending surgeon. Prior to, and after, consent was signed, both groups completed surveys regarding knowledge of purpose, risks, and benefits of surgery as well as surgical concerns. Decision regret and patient satisfaction were also assessed post-operatively. RESULTS: 77 patients were enrolled (39 Video, 38 Verbal). Demographics were not significantly different between groups. Overall knowledge significantly improved (p < 0.005) and concerns significantly decreased (p < 0.001) following consent in both groups. Improvements in these metrics were equivalent between groups (p < 0.02). Furthermore, resident time to complete consent, patient satisfaction, and decision regret were not significantly different between groups. CONCLUSION: Use of an educational video was equivalent to standard verbal informed consent for patients undergoing rhinologic surgery. Otolaryngologists can consider developing procedure-specific videos to allow allocation of time to other tasks, standardized education of patients, and streamlining of the informed consent process.

The Effect of Lateral Pharyngeal Collapse Patterns on Therapy Response in Upper Airway Stimulation Surgery.

OBJECTIVES: Obstructive sleep apnea (OSA) is characterized by repeated upper airway collapse while sleeping which leads to intermittent hypoxemia. Upper airway stimulation (UAS) is a commonly practiced modality for treating OSA in patients who cannot tolerate, or do not benefit from, positive airway pressure (PAP). The purpose of this study is to identify the effect of lateral pharyngeal collapse patterns on therapy response in UAS. METHODS: A retrospective cohort study from a single, tertiary-care academic center was performed. Patients who underwent UAS between October 2016 and July 2019 were identified and analyzed. Drug-induced Sleep Endoscopy (DISE) outcomes between Apnea-Hypopnea Index (AHI) responders and AHI non-responders were compared. Those with complete concentric collapse at the velopharynx were not candidates for UAS. RESULTS: About 95 patients that underwent UAS were included in this study. Pre- to Post-UAS demonstrated significant improvements in Epworth Sleepiness Scale (12.0 vs 4.0, P = .001), AHI (29.8 vs 5.4, P < .001) and minimum oxygen saturation (79% vs 83%, P < .001). No DISE findings significantly predicted AHI response after UAS. Specifically, multiple types of lateral pharyngeal collapse patterns did not adversely effect change in AHI or AHI response rate. CONCLUSION: Demonstration of lateral pharyngeal collapse on DISE, in the absence of complete concentric velopharyngeal obstruction, does not appear to adversely affect AHI outcomes in UAS patients. LEVEL OF EVIDENCE: VI.

Pathology protocol increases lymph node yield in neck dissection for oral cavity squamous cell carcinoma.

BACKGROUND: Lymph node yield (LNY) is a proposed quality indicator in neck dissection for oral cavity squamous cell carcinoma (OCSCC). METHODS: Retrospective series including 190 patients with OCSCC undergoing neck dissection between 2016 and 2018. A change in pathologic grossing protocol was initiated during the study period to assess residual adipose tissue. A generalized linear model was used to assess the impact of multiple variables on LNY. RESULTS: Mean LNY was 28.59 (SD = 17.65). The protocol identified a mean of 10.32 lymph nodes per case. Multivariable analysis identified associations between LNY and use of the pathology protocol (P = .02), number of dissected lymph node levels (P < .001), presence of pathologic lymph nodes (P = .002), body mass index (P = .02), prior neck surgery (P = .001), and prior neck radiation (P = .001). CONCLUSIONS: Assessment of residual adipose tissue within neck dissection specimens improves accuracy of LNY. LNY in neck dissection is influenced by multiple factors including methods of pathologic assessment.

Postoperative Opioid Use and Pain Management Following Otologic and Neurotologic Surgery.

OBJECTIVES: The topic of prescription opioid overuse remains a growing concern in the United States. Our objective is to provide insight into pain perception and opioid use based on a patient cohort undergoing common otologic and neurotologic surgeries. STUDY DESIGN: Prospective observational study with patient questionnaire. SETTING: Single academic medical center. SUBJECTS AND METHODS: Adult patients undergoing otologic and neurotologic procedures by two fellowship trained neurotologists between June and November of 2018 were included in this study. During first postoperative follow-up, participants completed a questionnaire assessing perceived postoperative pain and its impact on quality of life, pain management techniques, and extent of prescription opioid use. RESULTS: A total of 47 patients met inclusion and exclusion criteria. The median pain score was 3 out of 10 (Interquartile Range [IQR] = 2-6) with no significant gender differences (P = .92). Patients were prescribed a median of 15.0 (IQR = 10.0-15.0) tablets of opioid pain medication postoperatively, but only used a median of 4.0 (IQR = 1.0-11.5) tablets at the time of first follow-up. Measured quality of life areas included sleep, physical activity, work, and mood. Sleep was most commonly affected, with 69.4% of patients noting disturbances. CONCLUSIONS: This study suggests that practitioners may over-estimate the need for opioid pain medication following otologic and neurotologic surgery. It also demonstrates the need for ongoing patient education regarding opioid risks, alternatives, and measures to prevent diversion.

The American Academy of Psychiatry and the Law Practice Resource for Prescribing in Corrections.

The practice of prescribing in jails and prisons is often different from that in the community. Serious mental illness is common among inmates, and so are co-morbidities such as substance use, impulse-control, attention-deficit/hyperactivity, and personality disorders. Operational requirements, staffing, and the physical plant of the institution may complicate the provision of treatment according to community standards. Problems related to medication nonadherence, as well as the pursuit of medications for nonmedical reasons, are often seen in these settings and may be managed differently than they are elsewhere. Existing practice resources rarely account for these challenges. Pursuant to a recommendation by the Correctional Committee of the American Academy of Psychiatry and the Law (AAPL), the AAPL Council in May 2015 approved the creation of a task force charged with producing a document on prescribing in correctional facilities.Full Document: Tamburello A, Metzner J, Ferguson E, et al: AAPL practice resource for prescribing in corrections. Journal of the American Academy of Psychiatry and the Law Online Supplement 2018, 46 (2). Available at: http://www.jaapl.org/content/46/2_Supplement.

The changing epidemiology of HIV in the criminal justice system.

Although the rate of HIV infection among US prison inmates is considerably higher than that of the general population, little is known about age-related changes in HIV-infected inmates over the last decade. This study of the nation's largest state prison system examined (1) whether the mean age of the HIV-infected inmate increased over the last decade, and (2) whether the prevalence of HIV and associated comorbidities varied according to age. The study population included all 230,103 inmates incarcerated in the Texas prison system for any duration during 2014. A separate analysis was conducted on all HIV-infected inmates incarcerated between 2004 and 2014. Information on medical conditions and demographic factors was obtained from an institution-wide electronic medical record system. From 2004 to 2014, the mean age of HIV-infected inmates in the prison system increased from 39.3 to 42.5 years, compared to an increase of 36.1-37.9 for all Texas prison inmates. Multivariable logistic regression was used to assess the independent contributions of multiple demographic and clinical covariates in predicting the binary outcome, HIV infection. The model showed that, in 2014, HIV infection was elevated in inmates who were aged 40-49 years (OR = 3.1; 95% CI 2.7-3.3), aged 50-59 years (OR = 2.4; 95% CI 2.1-2.7), African American (OR = 3.0; 95% CI 2.8-3.3), and in those with several chronic diseases, including chronic obstructive pulmonary disease (OR = 1.7; 95% CI 1.5-1.9), hepatitis C (OR = 2.7; 95% CI 2.5-3.1), major depressive disorder (OR = 1.7; 95% CI 1.5-2.1), bipolar disorder (OR = 2.3; 95% CI 1.8-2.8), and schizophrenia (OR = 1.5; 95% CI 1.3-1.8). Among HIV-infected inmates (n = 2960), the percentage with comorbid disease increased in a linear fashion according to age (p < .01). Correctional health systems must adapt to address the evolving epidemiology of HIV among inmate populations.