Chronic kidney disease (CKD) is prevalent among US Veterans. Identifying patients undergoing dialysis in real-time is crucial for implementing patient safety measures, including stewardship interventions, such as medication dosing adjustments. Limited feasible and accurate tools exist for near-real-time identification. This study aimed to develop a renal replacement therapy (RRT) flag using structured data in the Veterans Health Administration (VHA) electronic health record (EHR).

Data from Veterans who underwent cardiovascular implantable electronic device (CIED) procedures (9/2015–12/2019) were linked to US Renal Data Systems (USRDS) data. Potential identifiers included outpatient hemodialysis procedure records, community care hemodialysis consults, ICD-10 diagnoses, and serum creatinine (SCr) >4 mg/dL. USRDS served as the comparison standard, and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Logistic regression determined the area under the curve (AUC).

Among 37,706 CIED procedures on 34,994 Veterans, 967 patients (2.6%) were identified by USRDS as ever receiving RRT (hemodialysis and peritoneal dialysis or transplant), with 520 (1.4%) actively receiving RRT at the time of CIED. The RRT flag, combining ≥4 outpatient procedures in the prior 30 days, ≥1 consult in the prior year, and/or SCr >4 mg/dL, achieved an AUC of 0.976 (95% CI: 0.97–0.98), with high sensitivity (0.96; 95% CI: 0.94–0.97) and specificity (0.99; 95% CI: 0.99–1.00). The PPV was 0.70 (95% CI: 0.67–0.74). Performance was slightly lower when consults were replaced with ICD codes.

We developed an accurate electronic flag using structured data to identify active RRT within VHA among Veterans undergoing invasive procedures, supporting patient safety and care adjustments. This flag addresses a crucial patient safety gap and supports expansion of stewardship efforts.

Bipolar depression remains difficult to treat, and people often experience ongoing residual symptoms, decreased functioning and impaired quality of life. Adjunctive therapies targeting novel pathways can provide wider treatment options and improve clinical outcomes. Garcinia mangostana Linn. (mangosteen) pericarp has serotonogenic, antioxidant anti-inflammatory and neurogenic properties of relevance to the mechanisms of bipolar depression.

The current 28-week randomised, multisite, double-blind, placebo-controlled trial investigated mangosteen pericarp extract as an adjunct to treatment-as-usual for treatment of bipolar depression.

This trial was prospectively registered on the Australia New Zealand Clinical Trials Registry (no. ACTRN12616000028404). Participants aged 18 years and older with a diagnosis of bipolar I or II and with at least moderate depressive symptoms were eligible for the study. A total of 1016 participants were initially approached or volunteered for the study, of whom 712 did not progress to screening, with an additional 152 screened out. Seventy participants were randomly allocated to mangosteen and 82 to a placebo control. Fifty participants in the mangosteen and 64 participants in the placebo condition completed the treatment period and were analysed.

Results indicated limited support for the primary hypothesis of superior depression symptom reduction following 24 weeks of treatment. Although overall changes in depressive symptoms did not substantially differ between conditions over the course of the trial, we observed significantly greater improvements for the mangosteen condition at 24 weeks, compared with baseline, for mood symptoms, clinical impressions of bipolar severity and social functioning compared with controls. These differences were attenuated at week 28 post-discontinuation assessment.

Adjunctive mangosteen pericarp treatment appeared to have limited efficacy in mood and functional symptoms associated with bipolar disorder, but not with manic symptoms or quality of life, suggesting a novel therapeutic approach that should be verified by replication.

Early identification of individuals at risk for dementia provides an opportunity for risk reduction strategies. Many older adults (30-60%) report specific subjective cognitive complaints, which has also been shown to increase risk for dementia. The purpose of this study is to identify whether there are particular types of complaints that are associated with future: 1) progression from a clinical diagnosis of normal to impairment (either Mild Cognitive impairment or dementia) and 2) longitudinal cognitive decline.

415 cognitively normal older adults were monitored annually for an average of 5 years. Subjective cognitive complaints were measured using the Everyday Cognition Scales (ECog) across multiple cognitive domains (memory, language, visuospatial abilities, planning, organization and divided attention). Cox proportional hazards models were used to assess associations between self-reported ECog items at baseline and progression to impairment. A total of 114 individuals progressed to impairment over an average of 4.9 years (SD=3.4 years, range=0.8-13.8). A subset of individuals (n=352) underwent repeat cognitive assessments for an average of 5.3 years. Mixed effects models with random intercepts and slopes were used to assess associations between baseline ECog items and change in episodic memory or executive function on the Spanish and English Neuropsychological Assessment Scales. Time in years since baseline, the ECog items, and the interaction were key terms of interest in the models. Separate models for both the progression analyses and mixed effects models were fit for each ECog item that included age at the baseline visit, gender, and years of education as covariates.

More complaints on five of the eight memory items, three of the nine language items, one of the seven visuospatial items, two of the five planning items, and one of the six organization items were associated with progression to impairment (HR=1.25 to 1.59, ps=0.003 to 0.03). No items from the divided attention domain were significantly associated with progression to impairment. In individuals reporting no difficulty on ECog items at the baseline visit there was no significant change over time in episodic memory(p>0.4). More complaints on seven of the eight memory items, two of the nine language items, and three of the seven visuospatial items were associated with more decline in episodic memory (ps=0.003 to 0.04). No items from the planning, organization, or divided attention domains were significantly associated with episodic memory decline. Among those reporting no difficulty on ECog items at the baseline visit there was slight decline in executive function (ps=<0.001 to 0.06). More complaints on three of the eight memory items and three of the nine language items were associated with decline in executive function (ps=0.002 to 0.047). No items from the visuospatial, planning, organization, or divided attention domains were significantly associated with decline in executive function.

These findings suggest that, among cognitively normal older adults at baseline, specific complaints across several cognitive domains are associated with progression to impairment. Complaints in the domains of memory and language are associated with decline in both episodic memory and executive function.

An audit to assess the impact of an Integrated Psychological Medicine Service (IPMS) on healthcare utilization pre & post intervention. We hypothesized that an IPMS approach would reduce healthcare utilization.

The IPMS focusses on integrating biopsychosocial assessments into physical healthcare pathways. It has developed in stages as opportunities presented in different specialities leading to a heterogeneous non-standardised service. The key aim is involvement of mental health practitioners, psychologists & psychiatrists in complex patients with comorbidity or functional presentations in combination with the specialty MDT. This audit is the first attempt to gather data across all involved specialities and complete a randomised deep dive into cases.

Referrals into IMPS from July 2019 to June 2020 pulled 129 referrals, of which a 10% randomised sample of 13 patients was selected to analyse. 5 patients had one year of data either side of the duration of the IPMS intervention (excluding 8 patients with incomplete data sets).

We analysed; the duration & nature of the IPMS intervention, the number, duration & speciality of inpatient admissions & short stays, outpatient attendances, non-attendances & patient cancellations. Psychosocial information was also gathered. One non-randomised patient was analysed as a comparative case illustration.

Randomised patients; patient 78's utilisation remained static, patient 71 post-referral engaged with health psychology & reduced healthcare utilisation. Patient 7 increased healthcare utilisation post-referral secondary to health complications. Patient 54 did not attend & increased healthcare utilisation post-referral. Patient 106 had increased healthcare utilisation post-referral from a new health condition. The randomised sample identified limitations of using healthcare utilisation as an outcome measure when contrasted to the non-randomised case (which significantly reduced healthcare utilisation post-referral).

Correlation only can be inferred from the data due to sample size, limitations & confounding factors e.g. psycho-social life events, acquired illness. Alternative outcome measurements documented (e.g PHQ9/GAD7) were not reliably recorded across pathways.

The results evidenced that single cases can demonstrate highly desirable effects of a biopsychosocial approach but they can also skew data sets if results are pooled due to the small sample size & heterogeneous interventions. With some patients an increase in healthcare utilisation was appropriate for an improved clinical outcome. This audit identified that utilising healthcare utilisation as an outcome measure is a crude tool with significant limitations & the need to agree tailored outcome measures based on the type of intervention to assess the impact of IPMS.

The Everyday Compensation scale (EComp) is an informant-rated questionnaire designed to measure cognitively based compensatory strategies that support both everyday memory and executive function in the context of completing instrumental activities of daily living (IADLs). Although previous findings provided early support for the usefulness of the initial version of EComp, the current paper further describes the development, refinement, and validation of EComp as a new assessment tool of compensation for IADLs.

Confirmatory factor analysis (CFA) was used to examine its factor structure. Convergent and predictive validity was evaluated by examining the relationship between EComp and markers of disease, including diagnosis, cognitive change, and trajectories of functional abilities.

CFA supported a general compensation factor after accounting for variance attributable to IADL domain-specific engagement. The clinical groups differed in compensatory strategy use, with those with dementia using significantly fewer compensatory strategies as compared to individuals with normal cognition or mild cognitive impairment. Greater levels of compensation were related to better cognitive functions (memory and executive function) and functional abilities, as well as slower rates of cognitive and functional decline over time. Importantly, higher levels of compensation were associated with less functional difficulties and subsequently slower rate of functional decline independent of the level of cognitive impairment.

Engagement in compensatory strategies among older adults has important implications for prolonging functional independence, even in those with declining cognitive functioning. Results suggest that the revised EComp is likely to be useful in measuring cognitively based compensation in older adults.

The goal of this study was to gain insights into the decision-making processes used by California public health officials during real-time crises. The decision-making processes used by California public health officials during the 2009 H1N1 influenza pandemic were examined by a survey research team from the University of California Berkeley.

The survey was administered to local public health officials in California. Guidelines published by the Centers for Disease Control and Prevention had recommended school closure, and local public health officials had to decide whether to follow these recommendations. Chi-squared tests were used to make comparisons in the descriptive statistics.

The response rate from local public health departments was 79%. A total of 73% of respondents were involved in the decision-making process. Respondents stated whether they used or did not use 15 ethical, logistical, and political preselected criteria. They expressed interest in receiving checklists and additional training in decision-making.

Public health decision-makers do not appear to have a standard process for crisis decision-making and would benefit from having an organized decision-making model. The survey showed that ethical, logistical, and political criteria were considered but were not prioritized in any meaningful way. A new decision-making tool kit for public health decision-makers plus implementation training is warranted. (Disaster Med Public Health Preparedness. 2015;9:464–471)