Defining the Age of Young Ischemic Stroke Using Data-Driven Approaches.

Introduction: The cut-point for defining the age of young ischemic stroke (IS) is clinically and epidemiologically important, yet it is arbitrary and differs across studies. In this study, we leveraged electronic health records (EHRs) and data science techniques to estimate an optimal cut-point for defining the age of young IS. Methods: Patient-level EHRs were extracted from 13 hospitals in Pennsylvania, and used in two parallel approaches. The first approach included ICD9/10, from IS patients to group comorbidities, and computed similarity scores between every patient pair. We determined the optimal age of young IS by analyzing the trend of patient similarity with respect to their clinical profile for different ages of index IS. The second approach used the IS cohort and control (without IS), and built three sets of machine-learning models-generalized linear regression (GLM), random forest (RF), and XGBoost (XGB)-to classify patients for seventeen age groups. After extracting feature importance from the models, we determined the optimal age of young IS by analyzing the pattern of comorbidity with respect to the age of index IS. Both approaches were completed separately for male and female patients. Results: The stroke cohort contained 7555 ISs, and the control included 31,067 patients. In the first approach, the optimal age of young stroke was 53.7 and 51.0 years in female and male patients, respectively. In the second approach, we created 102 models, based on three algorithms, 17 age brackets, and two sexes. The optimal age was 53 (GLM), 52 (RF), and 54 (XGB) for female, and 52 (GLM and RF) and 53 (RF) for male patients. Different age and sex groups exhibited different comorbidity patterns. Discussion: Using a data-driven approach, we determined the age of young stroke to be 54 years for women and 52 years for men in our mainly rural population, in central Pennsylvania. Future validation studies should include more diverse populations.

Relationship of hepatitis C risk to hepatitis C test acceptance among adult patients participating in an ED hepatitis C screening programme.

BACKGROUND: It is possible that adult ED patients consider their hepatitis C virus (HCV) risk factor history when deciding whether to accept HCV screening. To help address this question, we examined whether self-reporting any HCV risk was more common among ED patients who agreed than who declined HCV screening. Among ED patients who agreed to HCV screening, we also assessed if self-reporting any HCV risk was more common among those whose HCV antibody (Ab) and HCV viral load (VL) test results were positive. METHODS: This study was conducted among adult patients ≥18 years old participating in a universal, ED-based HCV screening programme in New York City between 22 January 2019 and 9 April 2020. Participants were surveyed about their HCV risk factors. Differences in the frequencies of self-reporting any HCV risk were compared according to HCV screening acceptance and by HCV Ab and VL status. RESULTS: Of the 4658 ED patients surveyed, 2846 (61%) accepted and 1812 (39%) declined HCV screening. Among these participants, 38% reported at least one HCV risk factor, most commonly injection drug use. Self-reporting any HCV risk was not more common among those who accepted versus declined HCV screening (40% vs 37%, p<0.7) but was more common among those with HCV Ab positive versus negative test results (36% vs 6%, p<0.001) and HCV VL positive versus negative results (95% vs 5%, p<0.001). CONCLUSION: HCV risk factors were self-reported by more than one-third of ED patients but were not more commonly present among those who accepted HCV screening.

"Lessons Learned" Preventing Recurrent Ischemic Strokes through Secondary Prevention Programs: A Systematic Review.

Recurrent ischemic strokes are a cause of significant healthcare burdens globally. Patients with uncontrolled vascular risk factors are more likely to develop recurrent ischemic strokes. This study aims to compile information gained from current secondary prevention programs. A pre-defined literature search strategy was applied to PubMed, SCOPUS, CINAHL, and Google Scholar databases, and studies from 1997 to 2020 were evaluated for quality, study aims, and outcomes. The search produced 1175 articles (1092 after duplicates were removed) and titles were screened; 55 titles were retained for the full-text analysis. Of the remaining studies, 31 were retained for assessment, five demonstrated long-term effectiveness, eight demonstrated short-term effectiveness, and 18 demonstrated no effectiveness. The successful studies utilized a variety of different techniques in the categories of physical fitness, education, and adherence to care plans to reduce the risk of recurrent strokes. The lessons we learned from the current prevention programs included (1) offer tailored care for underserved groups, (2) control blood pressure, (3) provide opportunities for medication dosage titration, (4) establish the care plan prior to discharge, (5) invest in supervised exercise programs, (6) remove barriers to accessing care in low resource settings, and (7) improve the transition of care.

Second-Generation Antipsychotic Use in Pediatric Emergency Medicine.

ABSTRACT: In recent years, the number of patients presenting to the emergency department with mental health complaints has been growing, alongside an increase in second-generation antipsychotic (SGAs) prescriptions for a variety of mental health conditions. Children treated with SGAs may have abnormalities, such as rapid weight gain and central adiposity, glucose intolerance, dyslipidemia, and hypertension; they may present to the pediatric emergency department with components of metabolic syndrome or type 2 diabetes, and a subsequent significant risk for cardiovascular complications later in life. Pediatric emergency department providers may serve as a safety net for patients to detect SGA-related metabolic complications, especially among vulnerable populations lacking access to primary care or psychiatric services.

Trends in ischemic stroke outcomes in a rural population in the United States.

INTRODUCTION: The stroke mortality rate has gradually declined due to improved interventions and controlled risk factors. We investigated the associated factors and trends in recurrence and all-cause mortality in ischemic stroke patients from a rural population in the United States between 2004 and 2018. METHODS: This was a retrospective cohort study based on electronic health records (EHR) data. A comprehensive stroke database called "Geisinger NeuroScience Ischemic Stroke (GNSIS)" was built for this study. Clinical data were extracted from multiple sources, including EHR and quality data. RESULTS: The cohort included in the study comprised of 8561 consecutive ischemic stroke patients (mean age: 70.1 ± 13.9 years, men: 51.6%, 95.1% Caucasian). Hypertension was the most prevalent risk factor (75.2%). The one-year recurrence and all-cause mortality rates were 6.3% and 16.1%, respectively. Although the one-year stroke recurrence increased during the study period, the one-year stroke mortality rate decreased significantly. Age > 65 years, atrial fibrillation or flutter, heart failure, and prior ischemic stroke were independently associated with one-year all-cause mortality in stratified Cox proportional hazards model. In the Cause-specific hazard model, diabetes, chronic kidney disease and age < 65 years were found to be associated with one-year ischemic stroke recurrence. CONCLUSION: Although all-cause mortality after stroke has decreased, stroke recurrence has significantly increased in stroke patients from rural population between 2004 and 2018. Older age, atrial fibrillation or flutter, heart failure, and prior ischemic stroke were independently associated with one-year all-cause mortality while diabetes, chronic kidney disease and age less than 65 years were predictors of ischemic stroke recurrence.

Alexithymia in People With Recurrent Suicide Attempts.

Background: Alexithymia, an inability to identify or describe emotions, is associated with suicidality yet the correlation with single or repeated suicide attempts is less clear. Aims: We aimed to assess the modifiability of alexithymia following a group psychosocial intervention focused on improving emotional literacy in those with a history of recurrent suicide attempts (RSA). Method: A total of 169 participants with self-reported RSA completed pre- and postgroup assessments of a 20-week group therapy intervention. Questionnaires assessed alexithymia, depression, impulsivity, and hopelessness; the Toronto Alexithymia Scale (TAS-20) was the primary outcome. Data were analyzed using multiple imputation. Results: Participants had on average 7.8 lifetime suicide attempts, 73% were female, and 16.6% had a >13-point reduction in TAS-20 scores after 20 weeks. Directed acyclic graph (DAG) analysis demonstrated significant relationships between alexithymia, depression, hopelessness, problem-solving, and satisfaction with life. Age of onset of suicidality was the only factor predictive of postintervention TAS-20 score in univariate linear regression. Limitations: The study limitations were its sample size, insufficient resources, and missing data. Conclusion: A change in TAS scores indicated that alexithymia can be a modifiable treatment target. Being able to identify and describe feelings may lead to improvement in depression, hopelessness, problem-solving, and satisfaction with life in this population.

Nontargeted Hepatitis C Screening in an Urban Emergency Department in New York City.

BACKGROUND: Previously the Centers for Disease Control and Prevention (CDC) recommended targeted hepatitis C virus (HCV) screening for adults born between 1945 and 1965 and individuals with HCV risk factors. In April 2020, the CDC updated their recommendations to now include all individuals 18 years of age and older in settings with HCV prevalence > 0.1%. Few emergency departments (EDs) currently employ this nontargeted screening approach. OBJECTIVES: We examined how a shift from targeted to nontargeted screening might affect HCV case identification. We hypothesized that nontargeted screening could improve HCV case identification in our ED. METHODS: Retrospective review of prospectively collected nontargeted screening data from June 6, 2018 to June 5, 2019 in a large urban academic ED. Patients 18 years of age and older, triaged to the adult or pediatric ED and able to provide consent for HCV testing, were eligible for study inclusion. RESULTS: There were 83,864 ED visits and 40,282 unique patients deemed eligible for HCV testing. Testing occurred in 10,630 (26.4%) patients, of which 638 (6%) had positive HCV antibody (Ab+) tests and 214 (2%) had a positive viral load (VL+). Birth cohort-targeted screening would have identified 48% of the patients with Ab+ tests and 47% of those who were VL+. Risk-based targeted screening would increase the number of Ab+ patients to 67% and VL+ to 72%. CONCLUSIONS: Nontargeted ED-based HCV screening can identify a large number of patients with HCV infection. A shift from targeted to nontargeted screening may result in fewer missed infections but requires further study.

Finding the Needle in the Hay Stack: Population-based Study of Prediagnostic Symptomatic Interval in Children With CNS Tumors.

Central nervous system (CNS) tumors in children are a devastating diagnosis and delay in diagnosis is well documented in the literature. The aim of this study was to document and characterize time to diagnosis of CNS tumors among children 0 to 17 years of age in a pediatric center. A retrospective chart review was conducted of medical records of children with CNS tumors from 2000 to 2016 in British Columbia, Canada and 148 reports were available for review. Average age at diagnosis was 87.8 months (SD=59.7; median=72). One third (30%) were diagnosed after a single visit to a health care provider and 11 (7.7%) after more than 4 visits. Median time to diagnosis (prediagnostic symptomatic interval [PSI]) was 62 days (average 197±341 d; range, 0 to 2047 d). Longest period was time from first symptom to first health care provider visit (PSI1, median 37 d). Tumors in the posterior fossa and symptoms of ataxia or paresis were associated with a significantly shorter PSI. CNS tumors in children continue to pose a diagnostic challenge with variability in time to diagnosis. Our population-based study suggests variability in time to diagnosis with a need for education of families to identify symptoms associated with CNS tumors.

Sex disparity in long-term stroke recurrence and mortality in a rural population in the United States.

BACKGROUND: Several studies suggest women may be disproportionately affected by poorer stroke outcomes than men. This study aims to investigate whether women have a higher risk of all-cause mortality and recurrence after an ischemic stroke than men in a rural population in central Pennsylvania, United States. METHODS: We analyzed consecutive ischemic stroke patients captured in the Geisinger NeuroScience Ischemic Stroke research database from 2004 to 2019. Kaplan-Meier (KM) estimator curves stratified by gender and age were used to plot survival probabilities and Cox Proportional Hazards Ratios were used to analyze outcomes of all-cause mortality and the composite outcome of ischemic stroke recurrence or death. Fine-Gray Competing Risk models were used for the outcome of recurrent ischemic stroke, with death as the competing risk. Two models were generated; Model 1 was adjusted by data-driven associated health factors, and Model 2 was adjusted by traditional vascular risk factors. RESULTS: Among 8900 adult ischemic stroke patients [median age of 71.6 (interquartile range: 61.1-81.2) years and 48% women], women had a higher crude all-cause mortality. The KM curves demonstrated a 63.3% survival in women compared with a 65.7% survival in men (p = 0.003) at 5 years; however, the survival difference was not present after controlling for covariates, including age, atrial fibrillation or flutter, myocardial infarction, diabetes mellitus, dyslipidemia, heart failure, chronic lung diseases, rheumatic disease, chronic kidney disease, neoplasm, peripheral vascular disease, past ischemic stroke, past hemorrhagic stroke, and depression. There was no adjusted or unadjusted sex difference in terms of recurrent ischemic stroke or composite outcome. CONCLUSION: Sex was not an independent risk factor for all-cause mortality and ischemic stroke recurrence in the rural population in central Pennsylvania.

Pain management for children needing laceration repair.

Question An 8-year-old child who lives in a small town has presented to my practice with a 3-inch laceration on the calf that has been assessed and needs repair with sutures. The family lives 4 hours from the nearest emergency department and I was planning to repair the wound in the office. What is the best way to manage pain in young patients needing sutures for laceration repair?Answer Children are particularly susceptible to experiencing high levels of pain and anxiety during routine emergency procedures such as laceration repair. It is important to consider measures to reduce procedural pain. Using needle-free anesthesia, such as the lidocaine-adrenaline-tetracaine combination, might be effective to anesthetize the area. In instances where lidocaine-adrenaline-tetracaine is not sufficient, additional injected lidocaine or bupivacaine can be used. Buffering lidocaine with bicarbonate, warming the lidocaine ampule, and injecting the compound slowly at a perpendicular angle to the skin will reduce pain associated with the injection.

Contrôle de la douleur lors de la réparation d'une lacération chez l'enfant.

Question Un enfant de 8 ans qui habite un petit village se présente à ma clinique avec une lacération de 3 pouces au mollet qui, après évaluation, nécessite une suture. La famille demeure à 4 heures de route de l'urgence la plus proche, et je prévois réparer la blessure à la clinique. Quelle est la meilleure façon de contrôler la douleur chez de jeunes patients qui ont besoin d'une suture pour traiter une lacération?Réponse Les enfants sont particulièrement susceptibles à l'expérience de forts degrés de douleur et d'anxiété durant des procédures d'urgence courantes comme la réparation d'une lacération. Il importe d'envisager des mesures pour réduire les douleurs causées par l'intervention. L'utilisation d'une anesthésie sans injection, comme le composé de lidocaïne-adrénaline-tétracaïne, pourrait être efficace pour anesthésier la région. Dans les cas où la lidocaïne-adrénaline-tétracaïne ne suffit pas, on peut avoir recours à de la lidocaïne ou de la bupivacaïne additionnelle par injection. Pour réduire la douleur occasionnée par l'injection, on peut tamponner la lidocaïne avec du bicarbonate, réchauffer l'ampoule de lidocaïne, et injecter la solution lentement et perpendiculairement à la peau.

Second-generation antipsychotics in children: Risks and monitoring needs.

Question A 10-year-old male patient presented to my clinic with irritability associated with autism spectrum disorder, and previous therapeutic efforts had not been successful. Treatment with quetiapine has considerably reduced irritability and improved his quality of life; however, the patient's mother has stated that her child's clothes are no longer fitting because his waist size has increased substantially, and that he has gained 5 kg since treatment initiation 8 weeks ago. Should second-generation antipsychotic (SGA) treatment be stopped or continued, and how can these side effects be best mitigated in a family practice setting?Answer Use of SGAs in pediatric patients has increased in recent years, which has brought to light a number of worrisome metabolic side effects that occur in children. Owing to the efficacy of treatment, SGAs must often be continued despite side effects. Even if the drug has been prescribed elsewhere, family physicians should closely monitor these patients following the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children guidelines. When starting an SGA, patients and their families should be educated on the importance of healthy eating and physical activity to preemptively mitigate potential side effects. Recent studies have also shown adjunctive metformin to have a potential role in reducing weight gain.

Antipsychotiques de deuxième génération chez l'enfant: Risques et exigences en matière de surveillance.

Question Un patient de 10 ans est venu en consultation à ma clinique en raison d'une irritabilité associée au trouble du spectre de l'autisme. Les efforts thérapeutiques antérieurs n'avaient pas donné les résultats voulus. Le traitement à la quétiapine a réduit considérablement l'irritabilité et a amélioré la qualité de vie; par contre, sa mère m'a dit que les vêtements de l'enfant ne lui faisaient plus parce que son tour de taille avait considérablement augmenté, et qu'il avait pris 5 kg depuis le début du traitement, 8 semaines auparavant. Faudrait-il cesser le traitement aux antipsychotiques de deuxième génération (ADG) ou le poursuivre? Comment peut-on atténuer les effets secondaires dans un milieu de pratique familiale?Réponse Au cours des dernières années, le recours aux ADG a connu une hausse chez les patients pédiatriques, et cette pratique a fait ressortir un certain nombre d'inquiétants effets secondaires métaboliques chez les enfants. En raison de l'efficacité du traitement, il faut souvent continuer les ADG en dépit des effets secondaires. Par ailleurs, même s'ils ont été prescrits par un autre médecin, les médecins de famille devraient surveiller étroitement ces patients conformément aux lignes directrices de la CAMESA (Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children). Au début d'un traitement aux ADG, les patients et leur famille devraient être informés de l'importance d'une saine alimentation et de l'activité physique pour atténuer les effets secondaires éventuels, à titre préventif. De récentes études ont aussi démontré que la metformine en traitement d'appoint aurait le potentiel de réduire le gain pondéral.

Anhedonia in depression and schizophrenia: A transdiagnostic challenge.

BACKGROUND: Anhedonia, as a dysregulation of the reward circuit, is present in both Major Depressive Disorder (MDD) and schizophrenia (SZ). AIMS: To elucidate the clinical and neurobiological differences between schizophrenia (SZ) and depression (MDD) in regard to anhedonia, while reconciling the challenges and benefits of assessing anhedonia as a transdiagnostic feature under the Research Domain Criteria (RDoC) framework. METHODS: In this review, we summarize data from publications examining anhedonia or its underlying reward deficits in SZ and MDD. A literature search was conducted in OVID Medline, PsycINFO and EMBASE databases between 2000 and 2017. RESULTS: While certain subgroups share commonalities, there are also important differences. SZ may be characterized by a disorganization, rather than a deficiency, in reward processing and cognitive function, including inappropriate energy expenditure and focus on irrelevant cues. In contrast, MDD has been characterized by deficits in anticipatory pleasure, development of reward associations, and integration of information from past experience. Understanding the roles of neurotransmitters and aberrant brain circuitry is necessary to appreciate differences in reward function in SZ and MDD. CONCLUSION: Anhedonia as a clinical presentation of reward circuit dysregulation is an important and relatively undertreated symptom of both SZ and MDD. In order to improve patient outcomes and quality of life, it is important to consider how anhedonia fits into both diagnoses.

Presentation and Neurobiology of Anhedonia in Mood Disorders: Commonalities and Distinctions.

PURPOSE OF REVIEW: To focus on the clinical and behavioral presentation of anhedonia in mood disorders, as well as the differences and commonalities in the underlying neurocircuitry. RECENT FINDINGS: Evidence suggests that depression is characterized by hypofunction of the reward system, while bipolar disorder manifests dysregulation of the behavioral activation system that increases goal-directed reward behavior. Importantly, strong evidence does not exist to suggest significant differences in anhedonia severity between depressed unipolar and bipolar patients, suggesting that there are more nuanced fluctuations in reward processing deficits in bipolar patients depending on their state. Both euthymic unipolar and bipolar patients frequently report residual reward dysfunction, which highlights the potential of reward processing deficits that give rise to the clinical symptom of anhedonia to be trait factors of mood disorders; however, the possibility that therapies are not adequately treating anhedonia could also explain the presence of residual symptoms. Reward processing represents a potential diagnostic and treatment marker for mood disorders. Further research should systematically explore the facets of reward processing in at-risk, affected, and remitted patients.