Publications by authors named "Martha Sajatovic"

292 Publications

The Targeted Management (TEAM) Intervention for Reducing Stroke Risk in African American Men: Rationale and Study Design of a Prospective Randomized Controlled Trial.

J Multidiscip Healthc 2021 23;14:513-522. Epub 2021 Feb 23.

University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

Background: African American (AA) male survivors of strokes or transient ischemic attacks (TIA) have the highest risk of recurrent stroke when compared to other racial-ethnic men. However, there is a paucity of evidence-based strategies, including organizational, educational, or behavioral interventions, that targets secondary stroke risk reduction in AA men.

Methods: Targeted Management for Reducing Stroke Risk (TEAM) is an ongoing, 6-month prospective, randomized controlled trial that will determine whether a curriculum-guided self-management approach, using peer dyads (men who had a stroke or TIA and their care partners) will improve post-stroke care in AA men.

Results: The study sample will consist of 160 AA men who have experienced a stroke or TIA within 5 years, randomized to TEAM or Wait-list control group. The primary outcome changes in systolic blood pressure (BP) and high-density lipoprotein (HDL), while secondary outcomes include diastolic BP, total cholesterol, low-density lipoprotein, triglycerides, and glycemic control for diabetics. We hypothesize that AA men in TEAM will have significantly lower systolic BP and higher HDL when compared to AA men in the Wait-list control group at 6-month.

Conclusion: Persistent disparities for stroke burden in AA men highlight the need for novel interventions to promote secondary stroke-risk reduction. Building on promising pilot data, TEAM uses a group format, with a nurse and patient co-led intervention focused on AA men and family needs, practice in problem-solving, and attention to emotional and role management. In addition, the TEAM approach may help reduce stroke risk factors and health disparities in AA men.

Clinicaltrialsgov Identifier: NCT04402125.
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http://dx.doi.org/10.2147/JMDH.S288753DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914069PMC
February 2021

COVID-19 and Older Adults with Bipolar Disorder: Problems and Solutions.

Bipolar Disord 2021 Mar 2. Epub 2021 Mar 2.

GGZ inGeest, Department of Psychiatry, Amsterdam UMC, location VU Medical Center, Amsterdam Neuroscience, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.

The implementation of public health measures designed to limit the spread of coronavirus disease 2019 (COVID-19) have been applied particularly stringently to people at high risk of complications, such as individuals older than 70 years and people with concurrent health morbidities like chronic respiratory or cardiovascular diseases. Older adults suffering from mental disorders are an especially high-risk group not only because of their age, but also because the prevalence of chronic somatic conditions is disproportionately high in this group.
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http://dx.doi.org/10.1111/bdi.13069DOI Listing
March 2021

A systematic literature review of recommendations for referral to specialty care for patients with epilepsy.

Epilepsy Behav 2021 Jan 25;116:107748. Epub 2021 Jan 25.

Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States. Electronic address:

Objective: In epilepsy, patients who receive appropriate care receive treatment that differs substantially from those that do not. Given the need for a more detailed assessment of the role of specialty referral in the care of patients with epilepsy, this systematic literature review identified epilepsy care guidelines and recommendations that specifically address when and why people with epilepsy should be referred to specialty care.

Methods: This study identified recent (in the last 10 years) publications that made best-practice recommendations for referring people with epilepsy to a neurologist or epileptologist. We searched six databases in December 2018: MEDLINE (PubMed), Cochrane Library, ProQuest, Web of Science, CINAHL (Ebsco), Scopus (Elsevier). Search terms included "Epilepsy" OR "Seizures," "Guideline" OR "Practice Parameter," and "Referral."

Results: The 15 full-text articles identified included formal guidelines, summaries of these guidelines, or professional commentary that builds upon existing guidelines. Most of these publications came from the U.K and its National Institute for Health and Care Excellence. Overall, the included recommendations for referral varied considerably both for new-onset and refractory epilepsy. Although these recommendations were not consistent, it is reasonable to refer patients following the failure of 2 anti-seizure medication (ASM) trials.

Significance: Guidelines and informal recommendations are not consistent regarding best practices for specialty care referral for patients with epilepsy. These guidelines and recommendations should consider the context of care in real-world settings and suggest pragmatic approaches that optimize seizure control and functioning.
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http://dx.doi.org/10.1016/j.yebeh.2020.107748DOI Listing
January 2021

Recent developments in geriatric psychopharmacology.

Expert Rev Clin Pharmacol 2021 Feb 5:1-15. Epub 2021 Feb 5.

Departments of Psychiatry and Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine , Cleveland, OH, USA.

Introduction: There is a tremendous growing need to address the burden of geriatric psychiatric disorders. Recent developments relevant to geriatric psychiatry have focused on Alzheimer's disease (AD), severe/refractory depression, and cancer/end of life care.

Areas Covered: This is a non-systematic, narrative review (databases and websites for search: PubMed, Google Scholar, Medscape, ClinicalTrials.gov; focusing on the last 6 years), and covers developments in disease-modifying therapies for AD, diagnostic radiotracers for AD, medications for neuropsychiatric symptoms of dementia, ketamine/esketamine, psychedelics, and cannabinoids.

Expert Opinion: The focus of on-going trials of anti-amyloid agents has been on individuals with very early stage AD; several agents are under phase 3 investigation, and aducanumab is under FDA review. Amyloid and tau PET scans have been approved by the FDA to assist in the diagnoses of AD. Promising pharmaceuticals for neuropsychiatric symptoms of dementia include pimavanserin, brexpiprazole, escitalopram, dextromethorphan/quinidine, and lithium. Esketamine, although approved for treatment-resistant depression in general adults, failed to demonstrate efficacy in elderly patients in a phase 3 trial. There is preliminary evidence for benefit of psychedelic-assisted psychotherapy in end-of-life and cancer-related depression/anxiety. Evidence for the use of cannabinoids is currently lacking.
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http://dx.doi.org/10.1080/17512433.2021.1882848DOI Listing
February 2021

Immediate Postoperative Imaging Following Elective Lumbar Fusion Provides Little Clinical Utility.

Spine (Phila Pa 1976) 2021 Jan 21. Epub 2021 Jan 21.

Case Western Reserve University, School of Medicine, Cleveland, OH, USA University Hospitals Cleveland Medical Center, Department of Neurological Surgery, Cleveland, OH, USA.

Study Design: Retrospective review at a single institution of all adult patients who underwent elective lumbar fusion surgery for degenerative spinal disease from 2013-2018. Reoperation rates and change in clinical management due to routine imaging findings were the primary outcomes.

Objective: To investigate what effects immediate routine postoperative imaging has on the clinical management of patients following lumbar fusion surgery.

Summary Of Background Data: The clinical utility of routine postoperative imaging following lumbar fusion surgery remains uncertain. Existing studies on the clinical utility of postoperative imaging in lumbar fusion patients have largely focused on imaging obtained post-discharge. We present a retrospective analysis that to our knowledge is the first study reporting on the clinical utility of routine imaging in lumbar fusion patients during the immediate postoperative period.

Methods: The medical records of patients who had undergone elective lumbar instrumented fusion for degenerative disease from 2013-2018 by neurosurgeons across one regional healthcare system were retrospectively analyzed. Inpatient records and imaging orders for patients were reviewed. Routine immediate postoperative imaging was defined by any lumbar spine imaging prior to discharge in the absence of specific indications.

Results: Analysis identified 115 patients who underwent elective lumbar instrumented fusion for degenerative disease. One-hundred-twelve patients received routine postoperative imaging. Routine imaging was abnormal in four patients (4%). There was one instance (<1%) where routine immediate postoperative imaging led to change in clinical management. Abnormal routine imaging was not associated with either reoperation or development of neurological symptoms postoperatively (p = 0.10), however, new or worsening neurologic deficits did predict reoperation (p < 0.01).

Conclusions: New neurologic deficit was the only significant predictor of reoperation. Routine imaging, whether normal or abnormal, was not found to be associated with reoperation. The practice of routine imaging prior to discharge following elective lumbar fusion surgery appears to provide little utility to clinical management.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003953DOI Listing
January 2021

The Managing Epilepsy Well (MEW) network database: Lessons learned in refining and implementing an integrated data tool in service of a national U.S. Research Collaborative.

Epilepsy Behav 2021 Feb 7;115:107650. Epub 2021 Jan 7.

Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States.

Epilepsy self-management (ESM) is the summative set of behaviors that people with epilepsy use to cope with seizures and optimize health. This report describes the implementation and evolution of the Managing Epilepsy Well Network Database (MEW DB), an integrated data resource intended to advance knowledge on ESM. The MEW DB utilizes a three-tiered (Tier 1-3) system of data organization, with tiers of data generally increasing in ascending complexity or collection burden. A MEW DB Steering Committee (SC) establishes consensus on planned analyses using a standardized new analysis request template. The data management structure facilitates harmonization and integration of additional data, or to update the database as new data become available. The current MEW DB comprises 1,563 people with epilepsy. Mean age was 39.9 years, 64.9% women (N = 1006), 12.8% African American (N = 170), 22.2% Hispanic (N = 306). On average, individuals have lived with epilepsy since their early 20s and are prescribed between 1 and 2 antiepileptic drugs. The MEW DB spans multiple socio-ecological levels to provide a robust multi-tiered framework for studying ESM. A total of 41 common data elements have been identified through iterative consensus. This integrated database takes advantage of an extensive collective background of archival evidence in ESM and brings together engaged investigators to build a dataset that represents diverse types of individuals with epilepsy, targets health domains important to ESM, and facilitates analyses that would not be possible with sites operating independently. Overall, the MEW DB serves the greater mission of this research collaborative and has potential to advance ESM research.
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http://dx.doi.org/10.1016/j.yebeh.2020.107650DOI Listing
February 2021

Cranial Surgical Site Infection Interventions and Prevention Bundles: A Systematic Review of the Literature.

World Neurosurg 2021 Jan 4. Epub 2021 Jan 4.

Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.

Background: Cranial surgical site infections (cSSIs) are associated with significant morbidity. Measures to reduce cSSI are necessary to reduce patient morbidity as well as hospital costs and resource utilization.

Objective: To identify and characterize interventions or bundled interventions aimed at reduction of the incidence of cranial surgical site infections.

Methods: A systematic review of the literature was conducted according to the PRISMA guidelines. The search strategy included randomized trials, quasi-experimental studies, cohort studies, and case series published between 2000 and 2020 that evaluated interventions implemented to reduce cSSI. Bias assessments and data extraction were performed on included studies.

Results: The initial search generated 1249 studies. Application of inclusion and exclusion criteria and review of references yielded 15 single-intervention and 6 bundled-intervention studies. The single interventions included handwashing protocols, use of vancomycin powder, hair washing and clipping practices, and incision closure techniques. Bundled interventions addressed a variety of preoperative, intraoperative, and postoperative changes. Despite a lack of strong evidence to support the adoption of statistically significant interventions, the use of vancomycin powder may be effective in reducing cSSI. In addition, bundled interventions that involved cultural changes, such as increased teaching/education, personal accountability, direct observation, and feedback, showed some success in decreasing SSI rates.

Conclusions: The strength of the conclusions is limited by small sample sizes, study heterogeneity, relatively low cSSI incidence, and high case variability. Some evidence supports the use of intraoperative vancomycin powder in adult noncranioplasty cases and the application of accountability, teaching, and surveillance of faculty, particularly those early in training.
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http://dx.doi.org/10.1016/j.wneu.2020.12.137DOI Listing
January 2021

Differential Medication Attitudes to Antihypertensive and Mood Stabilizing Agents in response to an Automated Text-Messaging Adherence Enhancement Intervention.

J Behav Cogn Ther 2020 Apr 17;30(1):57-64. Epub 2020 Jul 17.

Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, Ohio, 44106, U.S.A.

Objectives: Individuals with serious mental illnesses such as bipolar disorder (BD) are at an increased risk for poor medication adherence compared to the general population. Individuals with BD also have high rates of chronic comorbid medical conditions like hypertension (HTN), diabetes, and cardiovascular disease. Cognitive-behavioral therapies often integrate strategies to improve medication adherence by targeting medication attitudes and self-efficacy, but the pathway toward behavior change needs further investigation.

Methods: This 3-month prospective, single-arm cohort study tested an automated SMS intervention entitled Individualized Texting for Adherence Building- Cardiovascular (iTAB-CV) in 38 participants with BD and HTN. The Tablets Routine Questionnaire (TRQ) measures the percentage of BD and HTN non-adherence over the past week and the past month. Attitudinal and habit measures including the Brief Illness Perception Questionnaire (Brief IPQ), the Medication Adherence Self-Efficacy Scale-Revised (MASES-R), the Self-Report Habit Index (SRHI), the Beliefs about Medicines Questionnaire (BMQ), and the Attitudes toward Mood Stabilizers Questionnaire (AMSQ) were given for BD and HTN medications. Correlational analyses were run to determine the associations between BD and HTN attitudinal and habit indices. Additionally, longitudinal analyses were conducted to determine if attitudes changed over time as a function of a 2-month mobile-health intervention.

Results: Illness attitudes towards BD were worse than towards HTN at the start of the study. Attitudes toward BD and towards mood-stabilizing drugs as well as antihypertensives improved following a mHealth intervention aimed at improving adherence. Furthermore, self-efficacy and habit strength for both BD and HTN drugs were correlated and were responsive to the intervention, with most of the change occurring after the first month of the intervention and not requiring the addition of the explicit reminders.

Conclusion: Participants who received iTAB-CV showed improved attitudes towards BD and mood-stabilizing medication, and had an improvement in self-efficacy and habit strength towards taking both BD and HTN medications. Increased attention to mechanisms of change in mHealth interventions for adherence may facilitate impact. It should be noted that the methodology of the study limits drawing causal conclusions and suggests the need for a randomized control trial.
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http://dx.doi.org/10.1016/j.jbct.2020.03.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785108PMC
April 2020

Use of Telemedicine to Improve Interfacility Communication and Aid in Triage of Patients with Intracerebral Hemorrhage: A Pilot Study.

World Neurosurg 2020 Dec 10. Epub 2020 Dec 10.

Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.

Introduction: Over the past several years there has been a dramatic increase in the implementation of telemedicine technology to aid in the delivery of care across community, inpatient, and emergency settings. This technology has proved valuable for acute life-threatening clinical scenarios. We aimed to pilot a novel neurosurgical telemedicine program within an academic tertiary care center to assist in consultation of patients with high-grade intracranial hemorrhage (ICH) (ICH score 4, 5).

Methods: A quality improvement conceptual framework was developed. Subsequently, a process map and improvement interventions were created. Patients in community hospitals with high-grade ICH or pre-existing Do Not Resuscitate/Do Not Intubate orders with an admitting diagnosis of ICH triggered a TeleNeurosurgery consultation. Patients who met the inclusion criteria, with consent of their decision makers, were enrolled in the study. Post-encounter physician surveys were used to evaluate overall satisfaction with the implementation.

Results: This 18-month pilot study proved feasible, with an enrollment of 63.6% (n = 14 of 22) of patients who met criteria. All patients who were enrolled in the study and participated in TeleNeurosurgery consultation remained at the presenting facility for end-of-life care and palliative medicine consultation. Both community emergency physicians and subspecialists who performed the consultations reported satisfaction with the TeleNeurosurgery consultation process and a perceived benefit both to patients, families, and emergency medicine physicians.

Conclusions: The program proved feasible and several areas in need of improvement within the health system were identified. Emergency physicians reported comfort with the process, program effectiveness, and improved access to care by implementation of this program.
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http://dx.doi.org/10.1016/j.wneu.2020.12.010DOI Listing
December 2020

Antipsychotic Treatment Experiences of People with Schizophrenia: Patient Perspectives from an Online Survey.

Patient Prefer Adherence 2020 28;14:2043-2054. Epub 2020 Oct 28.

The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.

Background: This survey examined the experiences of people living with schizophrenia who have used oral antipsychotics (APs).

Methods: Adults with self-reported physician-diagnosed schizophrenia (N=200), who were members of an online research participation panel and reported taking one or more oral APs within the last year, completed a cross-sectional online survey that focused on direct report of their experiences regarding APs (eg, symptoms, side effects, adherence). Descriptive analyses were conducted for the total survey sample and for subgroups defined a priori by experience with specific, prevalent side effects.

Results: The mean age of the sample was 41.9 (SD=11.0) years, 50% of participants were female, and 32% were nonwhite. Overall ratings were positive for medication effectiveness and convenience but negative for side effects. While most participants reported that APs improved schizophrenia symptoms (92%), 27% reported APs as having done "more harm than good." Almost all participants (98%) reported experiencing side effects of APs, with the most common being anxiety (88%), feeling drowsy/tired (86%), and trouble concentrating (85%). Side effects frequently cited as either "extremely" or "very" bothersome were weight gain (56%), sexual dysfunction (55%), and trouble concentrating (54%). Over 80% reported that side effects had negatively impacted their work and social functioning (eg, social activities or family/romantic relationships). Since initiating treatment, 56% of respondents had stopped taking APs at some point (65% of these due to side effects). Side effects commonly reported as having led to stopping AP treatment were "feeling like a 'zombie'" (22%), feeling drowsy/tired (21%), and weight gain (20%).

Conclusion: Most participants reported improvements in schizophrenia symptoms associated with the use of APs. However, most participants also reported experiencing numerous bothersome side effects that negatively impacted their work, social functioning, and treatment adherence. Results highlight the unmet need for new APs with favorable benefit-risk profiles.
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http://dx.doi.org/10.2147/PPA.S270020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604247PMC
October 2020

Back to the future: surgical rehearsal platform technology as a means to improve surgeon-patient alliance, patient satisfaction, and resident experience.

J Neurosurg 2020 Oct 23:1-8. Epub 2020 Oct 23.

1Department of Neurological Surgery and.

Objective: Informed consent, when performed appropriately, serves many roles beyond simply obtaining the prerequisite medicolegal paperwork to perform a surgery. Prior studies have suggested that patient understanding is poor when verbal communication is the sole means of education. Virtual reality platforms have proven effective in enhancing medical education. No studies exist that have demonstrated the utility of virtual reality-facilitated informed consent (VR-IC) in improving the physician-patient alliance. The aim of this study was to determine the utility of VR-IC among patients providing consent for surgery and the impact of this educational and information technology-based strategy on enhancing the physician-patient alliance, patient satisfaction, and resident-physician perception of the consent process.

Methods: Prospective, single-site, pre- and postconsent surveys were administered to assess patient and resident perception of informed consent performed with the aid of VR-IC at a large tertiary academic medical center in the US. Participants were adult patients (n = 50) undergoing elective surgery for tumor resection and neurosurgical residents (n = 19) who obtained patient informed consent for these surgical procedures. Outcome measures included scores on the Patient-Doctor Relationship Questionnaire (PDRQ-9), the modified Satisfaction with Simulation Experience Scale, and the Maslach Burnout Inventory. Patient pre- and postconsent data were recorded in real time using a secure online research data platform (REDCap).

Results: A total of 48 patients and 2 family members provided consent using VR-IC and completed the surveys pre- and postconsent; 47.9% of patients were women. The mean patient age was 57.5 years. There was a statistically significant improvement from pre- to post-VR-IC consent in patient satisfaction scores. Measures of patient-physician alliance, trust, and understanding of their illness all increased. Among the 19 trainees, perceived comfort and preparedness with the informed consent process significantly improved.

Conclusions: VR-IC led to improved patient satisfaction, patient-physician alliance, and patient understanding of their illness as measured by the PDRQ-9. Using VR-IC contributed to residents' increased comfort in the consent-gathering process and handling patient questions. In an era in which satisfaction scores are directly linked with hospital and service-line outcomes and reimbursement, positive results from VR-IC may augment physician and hospital satisfaction scores in addition to increasing measures of trust between physicians and patients.
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http://dx.doi.org/10.3171/2020.6.JNS201865DOI Listing
October 2020

Antipsychotic Medication in Sub-Saharan Africa: A Systematic Literature Review.

J Clin Psychopharmacol 2020 Nov/Dec;40(6):541-552

From the Case Western Reserve University School of Medicine, Cleveland, OH.

Purpose: There is limited evidence on the use of antipsychotic medications to treat people with schizophrenia in Sub-Saharan Africa (SSA). This systematic literature review identified original research on use of antipsychotic drugs for primary psychotic disorders in SSA, assessed the methodological quality of studies, summarized intervention strategies, and examined patient-level outcomes.

Methods: PubMed, PsychInfo, Cochrane Collaboration, African Journals Online, and CINAHL databases were searched for studies in SSA that focused on antipsychotic treatment for primary psychotic disorders and that investigated at least one patient-level outcome. Articles in English and published before April 2019 were included. Epidemiological studies, drug discontinuation studies, studies with drugs other than antipsychotics, and multicenter studies that did not specify SSA results were excluded. An adapted standardized instrument assessed methodological quality.

Results: Twenty-six articles were reviewed. Three levels of evidence were found: single-group reports, quasi-experimental studies, and randomized controlled trials. Study outcomes included change in psychiatric symptoms, adverse effects, remission rates, or change in functional status. Nine studies reported improvements in psychiatric symptoms with antipsychotic medication. Seven studies investigating adverse effects of antipsychotics found that they were associated with an increase in metabolic syndrome. Two studies reported that remission was achieved in most subjects, and one study reported improvements in functional status.

Conclusions: Despite adverse effects, treatment with antipsychotic medications may be beneficial for individuals with primary psychotic disorders in SSA. Apart from South Africa, there is a scarcity of research on antipsychotics from countries in SSA, and there are numerous important gaps in the literature.
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http://dx.doi.org/10.1097/JCP.0000000000001282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877804PMC
October 2020

Adapting Diabetes Shared Medical Appointments to Fit Context for Practice-Based Research (PBR).

J Am Board Fam Med 2020 Sep-Oct;33(5):716-727

From the Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora (BMK, JR, ALN, P P-B, DEN, JAW); Adult & Child Consortium for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO (BMK, DEN); Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, CO (NR); Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora (NR, PP-B); College of Nursing, University of Colorado Anschutz Medical Campus, Aurora (NR); Case Western Reserve University School of Medicine, Departments of Psychiatry and of Neurology, Cleveland, OH (MS); New Directions Behavioral Healthcare LLC, Overland Park, KS (JAW).

Introduction: Complex behavioral interventions such as diabetes shared medical appointments (SMAs) should be tested in pragmatic trials. Partnerships between dissemination and implementation scientists and practice-based research networks can support adaptation and implementation to ensure such interventions fit the context. This article describes adaptations to and implementation of the Targeted Training in Illness Management (TTIM) intervention to fit the primary care diabetes context.

Methods: The Invested in Diabetes pragmatic trial engaged 22 practice-based research network practices to compare 2 models of diabetes SMAs, based on TTIM. We used surveys, interviews, and observation to assess practice contextual factors, such as practice size, location, payer mix, change and work culture, motivation to participate, and clinical and administrative capacity. The enhanced Replicating Effective Programs framework was used to guide adaptations to TTIM and implementation in participating practices.

Results: Practices varied in size and patient demographics. All practices had integrated behavioral health, but limited health educators or prescribing providers. Adaptations to SMA delivery accommodated the need for flexibility in personnel and reduced scheduling burden. Adaptations to TTIM content were designed to fit general primary care diabetes and Spanish-speaking patients.

Conclusion: Enhanced Replicating Effective Programs is a useful process framework for adaptation, implementation, and testing of diabetes SMAs in primary care. Adapting intervention content, delivery, and training to fit context can help ensure pragmatic trials have both internal and external validity. Attention to intervention fit to context can support continued practice engagement in research and sustainability of evidence-based interventions.
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http://dx.doi.org/10.3122/jabfm.2020.05.200049DOI Listing
January 2020

The relationship between fluid biomarkers and clinical outcomes in sports-related concussions: a systematic review.

Brain Inj 2020 09 10;34(11):1435-1445. Epub 2020 Sep 10.

Department of Neurology, University Hospitals Cleveland Medical Center , Cleveland, OH, USA.

Objectives: The literature on fluid biomarkers for concussion has primarily focused on comparing athletes with and without a diagnosis of concussion and on examining the relationship between fluid biomarkers and exposure to head trauma. This systematic literature review aims to examine the strength of evidence for fluid biomarkers to be associated with clinically relevant outcomes in sports-related concussion.

Methods: A systematic literature review was conducted using EmBASE, PubMed, and CINAHL. English-language articles that included athletes participating in organized sports and reported the relationship between at least one fluid biomarker and at least one clinical outcome measure, or provided data that could be used to analyze this relationship, were included.

Results: Studies of the relationship between fluid biomarkers and clinical outcomes of concussion have yielded small or variable effects. There were significant inconsistencies in methodology including duration of time post-injury of biomarker collection, use of control groups, the number of time points post-injury that biomarkers were collected, and what clinical outcomes were utilized.

Conclusion: There is currently insufficient evidence to support a relationship between any of the included fluid biomarkers and clinical outcome measures of concussion. Future research including clinical outcome measures and using standardized study design and methodology is necessary.
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http://dx.doi.org/10.1080/02699052.2020.1802780DOI Listing
September 2020

Delays and disparities in diagnosis for adults with epilepsy: Findings from U.S. Medicaid data.

Epilepsy Res 2020 10 23;166:106406. Epub 2020 Jun 23.

Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, United States.

Objective: To identify disparities in care pathways and time from first seizure to epilepsy diagnosis, we examined 2010-2014 Medicaid claims (including pharmacy) data from 16 States for individuals with incident epilepsy.

Methods: We identified adults (18-64) with an incident epilepsy diagnosis from 1/2012 through 6/2014. These individuals were enrolled in Medicaid for the entire study period and had no history of anti-epileptic drug (AED) use before their first seizure claim. We identified care pathways and calculated the duration from initial seizure to epilepsy diagnosis. We tested associations between these pathways and race/ethnicity, as well as time differences between care pathways using a Chi-squared and Kruskal-Wallis tests.

Results: The 14,337 adults followed five different care pathways. Their overall median duration from first seizure code to epilepsy diagnosis code was 19.0 months (interquartile range: 4.6, 30.4), and 56.0% filled an AED prescription. Some minorities were more likely to follow pathways with increased durations and delay to diagnosis, and the duration to diagnosis varied significantly across the care pathways.

Significance: The many different care pathways seen in people with epilepsy show substantial and significant time delays between first seizure diagnosis and epilepsy diagnosis, including significant racial/ethnic disparities that warrant attention.
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http://dx.doi.org/10.1016/j.eplepsyres.2020.106406DOI Listing
October 2020

Correlates of Stigma in People with Epilepsy.

J Clin Neurol 2020 Jul;16(3):423-432

Department of Psychiatry and Neurology, Neurological and Behavioral Outcomes Center, Case Western Reserve University School of Medicine and University Hospitals, Cleveland Medical Center, Cleveland, OH, USA.

Background And Purpose: Epilepsy is often associated with substantial stigma. This study evaluated clinical correlates of stigma in a sample of people living with epilepsy (PLWE) considered high risk due to frequent seizures or other negative health events.

Methods: Data were derived from an epilepsy self-management clinical trial. Standardized measures assessed socio-demographics, epilepsy stigma, epilepsy severity, self-efficacy, self-management competency, health literacy, depressive symptoms severity, functional status, social support and quality of life.

Results: There were 120 individuals, mean age of 41.73 (SD=17.08), 81 men (66.9%), and 79 (65.3%) African-American. Individual factors correlated with worse stigma w ere indicative of more severe or poorly controlled seizures (frequent seizures, worse seizure severity scores, more antiepileptic drugs), mental health comorbidity (worse depression severity, other comorbidities) and factors related to individual functioning and perceived competency in managing their health (health literacy, health functioning, self-efficacy, quality of life). Multivariable linear regression found that worse quality of life, and having a mental condition were associated with more stigma (β=6.4 and 6.8, respectively), while higher self-efficacy, health literacy and social support were associated with less stigma (β=-0.06, -2.1, and -0.3, respectively). These five variables explained 50% of stigma variation.

Conclusions: Stigma burden can be substantial among PLWE and may vary depending on contextual factors such as mental health comorbidity. Care approaches that screen for psychiatric comorbidities, address low health literacy, institute promising self-management programs, and employ effective health communication strategies about epilepsy misconceptions, may reduce epilepsy related burden.
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http://dx.doi.org/10.3988/jcn.2020.16.3.423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354984PMC
July 2020

Comparative epidemiology of gliosarcoma and glioblastoma and the impact of Race on overall survival: A systematic literature review.

Clin Neurol Neurosurg 2020 Aug 29;195:106054. Epub 2020 Jun 29.

Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH, USA; Department of Neurological Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, USA.

Objective: Gliosarcoma (GSM) is a rare subtype of glioblastoma (GBM) that accounts for approximately four percent of high-grade gliomas. There is scarce epidemiological data on patients with GSM as a distinct subgroup of GBM.

Methods: A systematic literature review was performed of peer-reviewed databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to evaluate the impact of race and ethnicity on survival in patients with GSM compared to patients with GBM.

Results: Following initial abstract screening, a total of 138 articles pertaining to GSM and 275 pertaining to GBM met criteria for full-text review, with 5 and 27 articles included in the final analysis for GSM and GBM, respectively. The majority of patients in both cohorts were non-Hispanic Whites, representing 85.6 % of total GSM patients and 87.7 % of GBM patients analyzed. Two GSM studies stratified survival by race, with one reporting the longest median survival for the Hispanic population of 10.6 months and the shortest median survival for the Asian population of 9 months. Among the GBM studies analyzed, the majority of studies reported shorter survival and higher risk of mortality among White Non-Hispanics compared to non-White patients; and of the 15 studies which reported data for the Asian population, 12 studies reported this race category to have the longest survival compared to all other races studied. Younger age, female sex, MGMT promoter methylation status, and adjuvant chemoradiation therapy were associated with improved survival in both GSM and GBM cohorts, although these were not further stratified by race.

Conclusion: GSM portends a similarly poor prognosis to other GBM subtypes; however, few studies exist which have examined factors associated with differences in survival between these histologic variants. This review of the literature suggests there is a possible association between race and survival for patients with GBM, however data supporting this conclusion for patients with GSM is lacking. These findings suggest that GSM is a distinct disease from other GBM subtypes, with epidemiologic differences that should be further explored.
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http://dx.doi.org/10.1016/j.clineuro.2020.106054DOI Listing
August 2020

Antipsychotic treatment experiences of people with bipolar I disorder: patient perspectives from an online survey.

BMC Psychiatry 2020 07 6;20(1):354. Epub 2020 Jul 6.

University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, USA.

Background: Oral antipsychotic (AP) medications are frequently prescribed to people with bipolar I disorder (BD-I). A cross-sectional online survey examined the experiences of people living with BD-I with a history of recent AP use.

Methods: Adults with self-reported physician-diagnosed BD-I (N = 200) who received oral APs during the prior year completed a survey on AP-related experiences, including side effects and their perceived burden on social functioning, adherence, and work. Items also assessed preferences for trade-offs (balancing symptom management and side effects) when considering a hypothetical new AP. The perceived impact of specific, prevalent side effects on adherence, work, and preferences for a hypothetical AP were also examined. Analyses were descriptive.

Results: The survey sample had a mean age of 43.2 (SD = 12.4) years, was 60% female, and 31% nonwhite. Almost all participants (98%) had experienced AP side effects. Common self-reported side effects were feeling drowsy or tired (83%), lack of emotion (79%), anxiety (79%), dry mouth (76%), and weight gain (76%). Weight gain was cited as the most bothersome side effect, rated by most participants (68%) as "very" or "extremely bothersome." Nearly half of participants (49%) reported that AP side effects negatively impacted their job performance; almost all (92%) reported that side effects - most commonly anxiety and lack of emotion - negatively impacted social relationships (e.g., family or romantic partners). The most commonly-reported reason for stopping AP use was dislike of side effects (48%). Side effects most likely to lead to stopping or taking less of AP treatment included "feeling like a 'zombie'" (29%), feeling drowsy or tired (25%), and weight gain (24%). When considering a hypothetical new AP, the most common side effects participants wanted to avoid included AP-induced anxiety (50%), weight gain (48%), and "feeling like a 'zombie'" (47%).

Conclusions: Side effects of APs were both common and bothersome, and impacted social functioning, adherence, and work. Findings highlight the prevailing unmet need for new APs with more favorable benefit-risk profiles.
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http://dx.doi.org/10.1186/s12888-020-02767-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371473PMC
July 2020

Outcomes and Clinical Characteristics of Intracranial Hemorrhage in Patients with Hematologic Malignancies: A Systematic Literature Review.

World Neurosurg 2020 Dec 18;144:e15-e24. Epub 2020 Jun 18.

Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.

Background: Many clinical and demographic factors can influence survival of patients with hematologic malignancies who have intracranial hemorrhages (ICHs). Understanding the influence of these factors on patient survival can guide treatment decisions and may inform prognostic discussions. We conducted a systematic literature review to determine survival of patients with intracranial hemorrhages and concomitant hematologic malignancy.

Methods: A systematic literature review was conducted and followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. PubMed/MEDLINE, Web of Science, Ovid, SCOPUS, and Embase databases were queried with the following terms: ("intracranial hemorrhages" OR "brain hemorrhage" OR "cerebral hemorrhage" OR "subdural hematoma" OR "epidural hematoma" OR "intraparenchymal hemorrhage") AND ("Hematologic Neoplasms" OR "Myeloproliferative Disorders" OR "Myelofibrosis" OR "Essential thrombocythemia" OR "Leukemia"). Abstracts and articles were screened according to inclusion and exclusion criteria that were determined a priori.

Results: Literature review yielded 975 abstracts from which a total of 68 full-text articles were reviewed. Twelve articles capturing 634 unique patients were included in the final qualitative analysis. Median overall survival for all patients ranged from 20 days to 1.5 months while median overall survival for the subset of patients having ICH within 10 days of diagnosis of hematologic malignancy was 5 days. Intraparenchymal hemorrhages, multiple foci of hemorrhage, transfusion-resistant low platelet counts, leukocytosis, low Glasgow Coma Scale scores at presentation, and ICH early in treatment course were associated with worse outcomes.

Conclusions: Survival for patients with hematologic malignancies and concomitant ICHs remains poor. Early detection, recognition of poor prognostic factors, and correction of hematologic abnormalities essential to prevention and treatment of ICHs in this patient population.
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http://dx.doi.org/10.1016/j.wneu.2020.06.091DOI Listing
December 2020

Diagnosis, Management, and Clinical Outcomes of Tandem Thoracic and Lumbar Stenosis: A Systematic Literature Review and Case Series.

World Neurosurg 2020 Nov 8;143:546-552.e1. Epub 2020 Jun 8.

Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Neurological Surgery, University Hospitals Cleveland Medical Center.

Background: A scarcity of data has been reported on tandem thoracic lumbar stenosis, which might be related to either the rarity or underdiagnosis of the condition. We have presented a systematic review of the clinical presentation, diagnosis, and treatment patterns for patients with symptomatic tandem thoracic and lumbar stenosis.

Methods: A PubMed/MEDLINE search was performed to find reports of patients with symptomatic tandem thoracic and lumbar stenosis.

Results: The review identified 10 studies with a total of 48 patients with tandem thoracic and lumbar stenosis. Most patients (n = 41; 85%) had had tandem stenosis diagnosed at the initial investigation, with 71% of the reports citing ossification of the ligamentum flavum as a contributing etiology. A few patients (n = 7; 15%) had had thoracic lesions diagnosed after neurologic deterioration that had occurred after lumbar surgery for previously suspected isolated lumbar stenosis. Surgical management varied from isolated thoracic decompression, staged decompression, and simultaneous decompression. Most patients (n = 41; 87%) showed improved neurologic status after surgery.

Conclusion: Ossification of the ligamentum flavum might play a key role in the pathogenesis of the condition. Most patients with tandem thoracic and lumbar stenosis will show improvement after surgical decompression. Although the limited evidence available has raised concerns regarding neurologic deterioration after initial lumbar decompression in patients with coexisting thoracic stenosis, the data are insufficient to definitively determine an optimal surgical strategy. Further research is needed to identify the optimal diagnostic and management criteria for patients with symptomatic tandem thoracic and lumbar stenosis.
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http://dx.doi.org/10.1016/j.wneu.2020.06.021DOI Listing
November 2020

Increased Risk of Dementia Among Veterans With Bipolar Disorder or Schizophrenia Receiving Care in the VA Health System.

Psychiatr Serv 2020 10 10;71(10):998-1004. Epub 2020 Jun 10.

Department of Psychiatry, William S. Middleton Department of Veterans Affairs (VA) Hospital, Madison, Wisconsin, and Department of Psychiatry, University of Wisconsin-Madison, Madison (Ahearn); Office of Mental Health and Suicide Prevention, VA, Washington, D.C. (Szymanski, Katz, McCarthy); Department of Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland (Chen); Department of Psychiatry, Case Western Reserve University, Cleveland (Chen, Sajatovic).

Objective: The Veterans Health Administration (VHA) provides a continuum of care over the life course. Among U.S. adults, bipolar disorder and schizophrenia are associated with increased risk of dementia. To inform service planning, this study assessed the incidence of dementia among veteran VHA patients with bipolar disorder or schizophrenia, with adjustment for comorbid medical conditions.

Methods: Using data from the VHA Corporate Data Warehouse, the authors identified all veterans who received VHA care in 2004 and 2005 without a dementia diagnosis and who were alive and between ages 18 and 100 as of January 1, 2006. Individuals were categorized as having bipolar disorder, schizophrenia, or neither condition on the basis of diagnoses in 2004-2005. Among ongoing VHA users, incidence of dementia was assessed for up to 10 years (2006-2015).

Results: The cohort included 3,648,852 individuals. After analyses controlled for baseline comorbid general medical conditions and substance use disorders, the incidence rate ratios (IRRs) for dementia were 2.92 for those with schizophrenia and 2.26 for those with bipolar disorder, compared with VHA patients with neither condition.

Conclusions: Among veterans receiving VHA care, diagnoses of bipolar disorder and schizophrenia were each associated with increased risk of receiving a new diagnosis of dementia, even when analyses controlled for baseline medical comorbidities. IRRs were elevated for patients with either condition, compared with those with neither condition, and highest for those with schizophrenia. VHA clinicians should evaluate patients for dementia when signs or symptoms of cognitive impairment are present.
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http://dx.doi.org/10.1176/appi.ps.201900325DOI Listing
October 2020

Enhancing Multi-Center Patient Cohort Studies in the Managing Epilepsy Well (MEW) Network: Integrated Data Integration and Statistical Analysis.

AMIA Annu Symp Proc 2019 4;2019:1071-1080. Epub 2020 Mar 4.

Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH.

Self-management techniques that assist patients with chronic conditions, such as epilepsy, diabetes, and arthritis, play an important role in managing and caring for their conditions. The US Center for Disease Control and Prevention (CDC)-funded Managing Epilepsy Well (MEW) Network consists of 11 study sites across the US that aims to develop and disseminate self-management techniques for epilepsy patients. Epilepsy affects more than 65 million patients worldwide with serious negative impact on their own as well as their family member's quality of life. Taking advantage of advances in biomedical informatics, the MEW Network has created an integrated database (MEW DB) using a common data model and two tiers of study variables. The MEW DB consists of 1680 patient data records covering a wide range of patient population nationwide. Therefore, there is growing interest in the use of the MEW DB for different cohort query analysis. To address the challenges in: (1) selecting appropriate MEW research studies based on inclusion/exclusion criteria; (2) creating a patient cohort for given research hypothesis; and (3) performing appropriate statistical tests; we have developed an integrated data query and statistical analysis informatics tool called Insight. The Insight platform features an intuitive user interface to support the three phases of study selection, patient cohort creation, and statistical testing with the use of an epilepsy domain ontology to support ontology-driven query expansion. We evaluate the Insight platform using two user evaluation methods of "first click testing" and "user satisfaction survey". In addition, we performed a time performance test of the Insight platform using four patient datasets and three statistical test. The results of the user evaluation show that Insight platform is strongly approved by the users and the results of the time performance show that there is marginal difference in performance as the volume of patient data increases in the MEW DB.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7153120PMC
September 2020

Health literacy and education level correlates of participation and outcome in a remotely delivered epilepsy self-management program.

Epilepsy Behav 2020 06 2;107:107026. Epub 2020 Apr 2.

Department of Neurology, Neurological & Behavioral Outcomes Center, Case Western Reserve University School of Medicine Cleveland, OH, USA; Department of Psychiatry, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

Significance: Health literacy, the ability to understand necessary health information to make proper health decisions, has been linked to greater frequency of hospitalizations. However, there is limited literature on the associations between health literacy and outcomes in patients with epilepsy, and thus, this secondary analysis investigates the associations between health literacy and outcomes in patients with epilepsy enrolled in the self-management intervention "Self-management for people with epilepsy and a history of negative events" (SMART). We examined the associations between higher health literacy and higher education level and outcomes of the SMART trial.

Methods: This is a secondary analysis of data from the SMART self-management intervention, where individuals were randomized to the SMART intervention or a 6-month waitlist (WL) control. Health literacy was assessed at baseline before randomization using the Rapid Estimate of Adult Literacy in Medicine (REALM-R). Education level was self-reported by participants at baseline. Pearson correlations between REALM-R scores and continuous demographic and clinical variables were conducted. Point-biserial Pearson correlations were computed for REALM-R and dichotomous variables. The effect of education on change in negative health events (NHEs) counts from baseline to six months was conducted using a linear regression. A logistic regression with health literacy and randomization arm as predictors and improvement in NHE (1 = improvement, 0 = no change or increased NHEs at 6 months) as the outcome was conducted.

Results: Lower education and lower income were significantly correlated with lower health literacy (p < 0.001 and p = 0.03). Higher education level was associated with a greater improvement in 6-month seizure counts (r(105) = 0.29, p = 0.002), and a greater improvement in total 6-month NHEs (r(95) = 0.20, p = 0.045). Health literacy was not associated with change in NHEs or with study retention.

Conclusions: The SMART intervention appears effective for individuals regardless of health literacy competency. Nevertheless, individuals with higher levels of education have fewer epilepsy complications, and thus, those with limited education may still require additional support while participating in epilepsy self-management programs.
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http://dx.doi.org/10.1016/j.yebeh.2020.107026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242156PMC
June 2020

Higher dose weekly fluoxetine in hemodialysis patients: A case series report.

Int J Psychiatry Med 2021 Jan 26;56(1):3-13. Epub 2020 Mar 26.

Department of Psychiatry and of Neurology, Case Western Reserve University School of Medicine, Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

Objective: The antidepressant medication fluoxetine at 90 mg dosed weekly is as effective and safe as standard formulation fluoxetine 20 mg dosed daily in patients with major depressive disorder. Weekly fluoxetine has not been well studied in hemodialysis patients, and doses beyond 90 mg/week have not been described in this population. This case series, derived from a larger study on depression in hemodialysis patients, describes the use of weekly fluoxetine at dosages beyond 90 mg/week.

Method: Hemodialysis patients with depressive symptom severity scored ≥10 on the 9-item Patient Health Questionnaire and major depressive disorder confirmed with Mini International Neuropsychiatric Interview were initially prescribed daily fluoxetine for two weeks and then transitioned to weekly fluoxetine. Dosage titration was made at the discretion of the prescribing clinician. Fluoxetine was continued for a total of 12 weeks.

Results: Four women, aged 24 to 65 years, on hemodialysis for 1 to 18 years, were started on weekly fluoxetine that was increased over several weeks up to 180 mg. Side effects included restlessness, dry mouth, sedation, and lightheadedness. Two patients ultimately had their weekly fluoxetine decreased back to 90 mg. However, all four continued weekly fluoxetine as part of poststudy aftercare and no longer met diagnostic criteria for major depressive disorder, current episode.

Conclusions: Weekly fluoxetine at doses of 180 mg may be a reasonable treatment consideration for hemodialysis patients who have partial or insufficient antidepressant response. Side effects may limit tolerance of the 180 mg dose in some individuals. Future research should investigate longer term health outcomes of weekly fluoxetine in this population.
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http://dx.doi.org/10.1177/0091217420913399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529646PMC
January 2021

Community perceptions of barriers to management of chronic psychotic disorders and knowledge and attitudes about long-acting injectable antipsychotic medication: qualitative study in Dar es Salaam, Tanzania.

BJPsych Open 2020 Mar 11;6(2):e27. Epub 2020 Mar 11.

Department of Psychiatry and Neurological and Behavioral Outcomes Center, Case Western Reserve University School of Medicine, USA.

Background: Low- and middle-income countries (LMICs) experience a disproportionate burden from chronic psychotic disorders (CPDs), which are the most disabling conditions among people aged 10-24 in Sub-Saharan Africa. Poor medication adherence is seen in approximately half of individuals with CPDs in Sub-Saharan Africa, and is a major driver of relapse. A CPD treatment approach that combines the use of long-acting injectable (LAI) antipsychotic medications with a brief and practical customised adherence-enhancement behavioural intervention (CAE-L) was recently developed and tested for use in the USA.

Aims: To use a qualitative cross-sectional analysis to gather information on potentially modifiable barriers to management of CPDs, and assess attitudes about LAIs from community participants in Tanzania. Findings were intended to refine the CAE-L curriculum for use in Tanzania.

Method: In-depth interviews and focus groups were conducted with 44 participants (patients with CPD, caregivers, mental healthcare providers). All interviews and focus groups were audiotaped, translated, transcribed and analysed using content analysis, with an emphasis on dominant themes.

Results: Findings indicated that promoting medication adherence and management of CPDs in the Tanzanian setting needs to consider the individual with CPD, the family, the healthcare setting and the broader community context.

Conclusions: Qualitative findings enabled the study team to better understand the real-time barriers to medication adherence, LAI use and management of CPDs more broadly. Refinement of the CAE-L is expected to pave the way for an intervention trial for individuals with CPDs that is culturally and linguistically appropriate to the Tanzanian setting.
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http://dx.doi.org/10.1192/bjo.2020.4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7176827PMC
March 2020

Effects of a remotely delivered group-format epilepsy self-management program on adverse health outcomes in vulnerable people with epilepsy: A causal mediation analysis.

Epilepsy Res 2020 05 24;162:106303. Epub 2020 Feb 24.

Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States; Department of Neurology, School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States; University Hospitals Cleveland Medical Center Neurological Institute, Cleveland, Ohio, United States; Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States. Electronic address:

Background: People with epilepsy frequently experience negative health events (NHEs), such as emergency room visits or hospitalizations for epilepsy-related complications despite significant advances in care. We developed a novel remotely delivered group-format epilepsy self-management program ("Self-management for people with epilepsy and a history of negative health events"; SMART). In a 6-month randomized controlled trial (RCT), SMART participants had significant decreases in NHEs, as well changes in attitudes and behaviors compared to a wait-list (Sajatovic et al., 2018). This secondary analysis from the RCT characterizes the indirect causal effects of SMART on NHE improvements that may be mediated by specific improvements in self-management, self-efficacy, social support, quality of life, and depression symptom severity.

Methods: Participants were adults with epilepsy and a NHE in the prior 6 months. There were 60 participants in each RCT arm (SMART versus wait-list) and assessments were conducted at baseline, 10 weeks and 24 weeks. The outcome was a binary variable measuring NHE improvement at week 24. A counterfactual-based mediation framework was used to determine whether improvements or changes in attitudes and behaviors at specific time points or across the study period, mediated the impact of SMART on NHE improvements.

Results: At week 24, SMART contributed to significant improvements in NHEs compared to those in wait-list (odds ratio = 3.2, p = 0.015). SMART was significantly associated with improvements and changes in aspects of self-management, self-efficacy, quality of life, and depression symptom severity at week 10, and significant improvements between baseline and week 24 in overall self-management and quality of life. Mediation analyses demonstrated that a portion of the effect (∼20-30 %; p < 0.05) of SMART on NHE improvement was also indirectly mediated by early improvements in depression symptom severity and quality of life.

Conclusions: This mediation analysis of the SMART intervention demonstrates that in addition to its direct effect on improving NHEs in people with epilepsy, early improvements in depression symptom severity and quality of life indirectly mediated ∼20-30 % of the intervention's effect. These results demonstrate the promise of self-management approaches as a key component of an optimal healthcare model for people with epilepsy, particularly those with a recent history of NHEs.
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http://dx.doi.org/10.1016/j.eplepsyres.2020.106303DOI Listing
May 2020

Identify depressive phenotypes by applying RDOC domains to the PHQ-9.

Psychiatry Res 2020 Feb 19;286:112872. Epub 2020 Feb 19.

Department of Psychiatry and of Neurology, Case Western Reserve University School of Medicine, Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States.

Major depression consists of multiple phenotypic traits. Our objective was to characterize depressive phenotypes in the patient health questionnaire (PHQ)-9 using the Research Domain Criteria (RDoC) research framework. Cross-sectional data were examined from the 2013-2014 (N = 5397) and 2015-2016 (N = 5164) National Health and Nutrition Examination Survey, a large, nationally representative U.S. sample. Using both factor analysis and qualitative analysis in mapping scale items along RDoC domains, a four factor model was found to be theoretically appropriate and had an excellent model fit for the PHQ-9. The factor structure consisted of phenotypes describing Negative Valence Systems and Externalizing (anhedonia and depression), Negative Valence Systems and Internalizing (depression, guilt and self-harm), Arousal and Regulatory Systems (sleep, fatigue and appetite) and Cognitive and Sensorimotor Systems (concentration and psychomotor). High correlation between these phenotypes did indicate screening and monitoring for depression study population using a single depression score is likely useful in most circumstances. In multiple indicator multiple cause analysis, differences in the means of the phenotypic traits were found by age, race/ethnicity, sex, and number of comorbidities. Future research should explore whether phenotype expression derived from readily available self-rated depression scales can help to inform more personalized care.
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http://dx.doi.org/10.1016/j.psychres.2020.112872DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434666PMC
February 2020

Association of Race with Survival in Intracranial World Health Organization Grade II and III Meningioma in the United States: Systematic Literature Review.

World Neurosurg 2020 06 3;138:e361-e369. Epub 2020 Mar 3.

Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.

Background: Recent literature has shown significant differences in meningioma incidence among different races, but minimal conclusive data exist on the role of race and ethnicity in overall survival for patients with high-grade intracranial meningioma. We conducted a systematic review to investigate the impact of race and ethnicity on survival in patients with high-grade intracranial meningioma.

Methods: A systematic literature review was conducted for studies using Ovid, PubMed, Cochrane, Embase, and Scopus databases. Databases were queried for the following: Meningioma AND [Ethnic OR Demography, OR African American OR Arab OR Hispanic OR Asian, OR White OR race OR racial] AND [survival OR survival analysis OR survival rate OR treatment outcome OR Survivor OR Outcome].

Results: A literature search yielded a total of 412 abstracts, which were screened according to criteria that were determined a priori, and a total of 129 full-text articles were reviewed. Four articles were included in the final analysis, reporting on a total of 13,424 patients. Three studies saw an overall survival benefit in White non-Hispanics compared with Black non-Hispanics, and 1 reported a survival benefit in White non-Hispanics and Black non-Hispanics among patients who received gross total resection. One study additionally reported an increased likelihood of White patients receiving gross total resection when compared with non-White patients.

Conclusions: The limited data available suggest that White patients have improved measures of survival compared with nonw-White patients, for reasons that are likely complex and multifactorial. Further studies are needed to explore these survival differences seen.
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http://dx.doi.org/10.1016/j.wneu.2020.02.120DOI Listing
June 2020

Knowledge and attitudes about sudden death in epilepsy among people living with epilepsy and their healthcare providers in Mulago Hospital, Uganda: A cross-sectional study.

Epilepsia Open 2020 Mar 26;5(1):80-85. Epub 2019 Dec 26.

Department of Medicine College of Health Sciences Makerere University Kampala Uganda.

Objective: The objective of the study was to assess level of knowledge and attitudes of SUDEP among people living with epilepsy (PLWE) and healthcare workers providing epilepsy care in Uganda.

Methods: This cross-sectional study of 48 PLWE and 19 epilepsy care providers used a tailored questionnaire to evaluate epilepsy and SUDEP knowledge, frequency of SUDEP discussion, reasons for not discussing SUDEP, timing of SUDEP discussions, and perceived patient reactions to being provided information on SUDEP.

Results: Median PLWE sample age was 25 (IQR; 19-34) years, 10 (20.8%) were male, median age of onset of epilepsy 12 (IQR; 6-18) years. Half of the PLWE reported that they had never heard of SUDEP. Most PLWE desired detailed information regarding SUDEP and preferred this information during the subsequent visits. Healthcare provider sample mean age was 35.7 (22.8) years, 12 (63.2%) were male and composed of 4 physicians (21.1%). Only 15% (3/20) of providers discussed SUDEP with their patients while 85% (17/20) have never discussed it. The main reasons for not discussing SUDEP were not knowing enough about SUDEP (89.5%) and no adequate support network available (30%). Providers that discussed SUDEP (100%) reported that negative reactions were the most common patient response.

Significance: In this Ugandan sample, most PLWE are not aware of SUDEP and epilepsy care providers rarely discuss SUDEP with their patients or patient caregivers. Negative reactions to SUDEP discussions are common but not universal. There is an urgent need for epilepsy educational programs in clinics and targeted communities addressing SUDEP.
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http://dx.doi.org/10.1002/epi4.12374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7049805PMC
March 2020

Body mass index, residual psychotic symptoms, and inflammation associated with brain volume reduction in older patients with schizophrenia.

Int J Geriatr Psychiatry 2020 07 12;35(7):728-736. Epub 2020 Mar 12.

Department of Psychiatry and Psychiatric Research Center, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.

Obesity, aging, and pathophysiology of schizophrenia (SCZ) may collectively contribute to the gray matter loss in brain regions of SCZ. We attempted to examine the association between volumes of specific brain regions, body mass index (BMI), inflammatory markers, and clinical features in older SCZ patients.

Method: Clinically stable outpatients with schizophrenia (DSM-IV) aged ≥50 years were recruited to undergo whole-brain magnetic resonance imaging. We measured patients' plasma levels of soluble tumor necrosis factor receptor-1, soluble interleukin (IL)-2 receptor (sIL-2R), IL-1β, and IL-1 receptor antagonist (IL-1Ra). Clinical data were obtained from medical records and interviewing patients along with their reliable others.

Results: There were 32 patients with mean age 58.8 years in this study. Multivariate regression analysis found only higher BMI significantly associated with lower volume of total gray matter, bilateral orbitofrontal and prefrontal cortexes, and the right hippocampal and frontal cortexes. Increased intensity of residual symptoms (higher Positive and Negative Syndrome Scale scores) was related to lower volumes of frontal lobe, prefrontal cortex, insula, hippocampus, left hemisphere amygdala, and total white matter. The lower volume of left anterior cingulum was associated with older age and higher sIL-2R plasma level; and higher IL-1Ra level was associated with greater right anterior cingulate volume. Older age at illness onset was significantly associated with the smaller right insula volume.

Conclusions: Higher BMI, more residual symptoms, and inflammatory activity in IL-2 and IL-1 systems may play a role in gray matter loss in various brain regions of schizophrenia across the life span.
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http://dx.doi.org/10.1002/gps.5291DOI Listing
July 2020