Journal of the Academy of Consultation-Liaison Psychiatry最新文献

Background: Adverse childhood experiences (ACEs) are associated with the development of negative health behaviors and medical illnesses. ACE's association with poor health outcomes has been well documented in the general population; however, this relationship remains less clear in liver transplant (LT) recipients.

Objective: The aims of this study were to determine the prevalence of ACE and the influence of ACE on LT outcomes.

Methods: A retrospective electronic medical record review of all LT recipients over 11 years at an academic LT center. Demographic, diagnostic, and disease characteristics were extracted and compared for a history of ACE. Associations between a history of ACE and extracted variables were statistically tested using Student's t-test, chi-square tests, or Fisher's exact test, where appropriate. Graft and patient survival were tested using log-rank tests.

Results: Of the 1172 LT recipients, 24.1% endorsed a history of ACE. Females (P = 0.017) and recipients with lower levels of education (P < 0.001) had a higher frequency of ACE. Those with a history of ACE had a higher prevalence of hepatitis C virus (P < 0.001) and higher pretransplant body mass index (P < 0.001). Recipients with a history of ACE had higher prevalence of mood (P < 0.001), anxiety (P < 0.001), post traumatic stress disorder (P < 0.001), alcohol use (P < 0.001), and cannabis use (P < 0.001) disorders, as well as higher Patient Health Questionnaire-9 (P < 0.001) and General Anxiety Disorder-7 (P < 0.001) scores pre- and post-transplant. Those with ACE had a higher incidence of recorded relapses to alcohol by 3 years post-transplant (P = 0.027). Mean lab values, graft survival, and patient survival were not significantly different between those with and without a history of ACE except for total bilirubin at 6 months (P = 0.021).

Conclusions: One-quarter of LT recipients have experienced ACE. ACE was associated with a history of psychiatric diagnoses, substance use disorders, elevated Patient Health Questionnaire-9 and General Anxiety Disorder-7 scores, and a higher prevalence of relapse to alcohol use after transplant. This population may benefit from increased/improved access to appropriate mental health and substance use services and support in the peri- and post-transplant period.

We are in a youth mental health crisis with unprecedented and staggeringly high rates of suicidal ideations and suicide behaviors in preteens. In the United States, 14.5% of children aged 9-10 have experienced suicidal thoughts and behaviors, including 1.3% with a suicide attempt. American Academy of Pediatrics guidelines call for universal suicide risk screening of youth aged 12 years and older during preventative health care visits and screening in preteens aged 8-11 years when clinically indicated. However, what constitutes a clinical indication at 8-11 years can be difficult to systematically detect, and pediatric practitioners may not be equipped with necessary age-specific assessment tools. This is compounded by the lack of emphasis on preteen suicide risk screening (and focus on adolescents), which leaves practitioners without age-appropriate resources to make clinical determinations for at-risk preteens. The objective of this project was to develop an evidence-informed suicide risk screening pathway for pediatric practitioners to implement with preteen patients in outpatient settings. Suicide risk assessment in younger children (<8 years) is also briefly addressed. We convened a group of researchers and practitioners with expertise in preadolescent suicide, pediatric medicine, behavioral health screening integration with primary care, and child development. They reviewed the empirical literature and existing practice guidelines to iterate on a multi-informant clinical suicide risk screening pathway for preteens that includes both caregivers and preteens in the screening process. We also developed tools and accompanying guidelines for a preteen suicide risk screening workflow and risk determination to aid practitioners in deciding who, when, and how to screen. Finally, we provide scripts for introducing suicide risk screening to caregivers and preteens and to discuss screening findings.

Background: Pediatric catatonia is associated with a high degree of morbidity and mortality in children. However, pediatric catatonia is highly responsive to treatment if rapidly identified and appropriate interventions are administered. To our knowledge, there are no current publications which propose a systematic approach for the management of pediatric catatonia.

Objective: The aim of our report was to create multidisciplinary clinical care roadmap for catatonia in the inpatient pediatric setting within Vanderbilt University Medical Center (VUMC).

Methods: At VUMC, we formed a team of pediatric providers from child and adolescent psychiatry, rheumatology, neurology, pediatric hospital medicine, and pediatric psychology. Our team met on a regular basis over the course of 2022-2024 to review the current literature on pediatric catatonia and develop a consensus for clinical assessment and management.

Results: We determined consensus recommendations from our VUMC multidisciplinary team for the following domains of pediatric catatonia inpatient clinical care: initial assessment of pediatric catatonia in the inpatient pediatric settings, medical and psychiatric work up for pediatric catatonia, the lorazepam challenge in pediatric populations, behavioral and environmental considerations, and the use of electroconvulsive therapy and alternative psychopharmacologic interventions in pediatric catatonia.

Conclusion: Pediatric catatonia is a condition associated with a high degree of morbidity and mortality but is responsive to treatment if diagnosed and treated early. The inpatient pediatric medical setting provides a unique opportunity for identification and treatment. Our clinical care roadmap provides tools for inpatient clinicians at VUMC to identify pediatric catatonia and initiate an evidence-based approach to medical workup, management, and clinical care. This approach has the potential to significantly improve longitudinal outcomes and quality of life improvements for children at VUMC with catatonia and their families.

Background: In 2021, suicide was the second leading cause of death in early adolescent Americans ages 10-14. Research into suicidal behavior in this age group is limited. We report on prior psychiatric care, attempt method, and attempt outcomes in a cohort of 164 early adolescents accrued by first suicide attempt coming to medical attention.

Methods: Our cohort constitutes a subsample from a previously reported retrospective-prospective study identified through the Rochester Epidemiology Project that recruited individuals making first suicide attempts coming to medical attention (index attempt [IA]) during a 22-year period (1/1/1986-31/12/07). Among 1490 all-age index attempters followed until 12/31/2010, 164 (11.0%) were aged 10-14.

Results: 3/164 died on IA (1.8% of the cohort; two females, one male). Nearly half (72/164, 43.9%) had no prior psychiatric history. Females were less likely than males to have seen a mental health provider (P = 0.029) or been prescribed psychiatric medications (P < 0.001) prior to IA. Medication overdose was the most common attempt method in females (81/128, 63.3%), while cutting or piercing wounds were the most common method in males (13/36, 36.1%). Females were significantly more likely than males to overdose (P = 0.001). Of IA survivors, 19.9% (32/161) were initially medically hospitalized, 52.8% (85/161) were psychiatrically hospitalized-initially or in transfer-and 37.2% (60/161) were discharged without hospitalization.

Conclusion: Medication overdoses accounted for over half of all IAs and were significantly more common in females. While IA mortality was low relative to older patients from the all-age-cohort, morbidity was substantial with nearly a fifth of attempts severe enough to warrant medical hospitalization and more than half initial or eventual psychiatric hospitalization. These findings emphasize the importance of both means restriction and identification of early adolescents at risk before they make their first attempt.

Background: In critically ill patients, delirium is a prognostic indicator of morbidity and mortality.

Objective: This study investigates the impact of a delirium diagnosis on outcomes after left ventricular assist device (LVAD) implantation.

Methods: This retrospective study included all adult patients who received LVADs at our institution between January 2016 and December 2020. We compared preimplantation characteristics between the two groups, with and without a diagnosis of delirium, and compared their outcomes, including 1-month, 6-month, and in-hospital mortality, as well as reintubation rate, length of stay, discharge disposition, and readmission rates.

Results: In total, 361 patients (26.7% women and 75.8% African American) received durable LVADs. Ninety-four patients (26.1%) were diagnosed with delirium during the index admission. Preimplantation demographic characteristics, past medical and psychiatric conditions, Interagency Registry for Mechanically Assisted Circulatory Support Profile, and laboratory values did not differ between the two groups with and without a diagnosis of delirium; older age (59 vs 56; P = 0.03) was associated with delirium. Delirium diagnosis was associated with higher 1-month (P = 0.007), 6-month (P = 0.004), and in-hospital mortality (P < 0.001), unplanned reintubations (P < 0.001), and a lower likelihood of discharge home (P = 0.03). Total hospital and intensive care unit length of stay were higher in patients with a diagnosis of delirium, though these results were not statistically significant. Readmission to the hospital after index admission was quicker in patients with a diagnosis of delirium, but this result was not statistically significant.

Conclusions: In this study, a diagnosis of delirium during the LVAD implantation admission was associated with higher mortality, adverse postsurgical outcomes, and unfavorable discharge dispositions. Future prospective research is needed to validate the prognostic implications of delirium in both the short and long term. Additionally, there is a need to identify modifiable risk factors associated with delirium to promote early diagnosis and implement evidence-based management strategies to enhance outcomes within this population.