Journal Article Annotations
2022, 2nd Quarter
Annotations by Jeylan Close, MD and Sneha Jadhav, MD
July, 2022
The finding:
The authors reviewed current evidence and expert opinion relating to discussions about firearm safety by healthcare providers with families. The authors discuss best evidence-based practices that health care providers (HCP) can employ to increase the likelihood of acceptance, engagement, and behavior change. Recommendations include having a non-judgemental and universal discussion of general safety that includes limiting access to other dangers such as medications in the home. General safety discussions help families feel that firearms are not being specifically targeted and help align on common goals of child safety. Instead of asking a family directly about having firearms, which can make people feel judged or worry about their firearms being documented in the medical record, providers should use normalizing statements and explain that these conversations are held with all patients. The authors also recommend a harm reduction approach: while the gold standard for storage endorsed by the American Academy of Pediatrics (AAP) is “Triple-Safe” storage (firearms locked, unloaded, and with ammunition locked separately), a harm reduction approach may include having their loaded firearm in a quick-access safe as opposed to an unlocked location. Studies show that parents underestimate their child’s knowledge about firearms, where they are located, and if they have handled the firearm. The authors recommend separately asking adolescents about their access to firearms. Additional recommendations include changing phrasing from “means restriction” to “means safety” and asking “How many locking devices would you like?” to normalize firearm ownership and the use of locks.
Strength and weaknesses:
A strength of the article is that it examines evidence relating to multiple facets of firearm safety, including current storage practices, epidemiology of types of firearm risk, barriers to safety discussions, and acceptability of various safety discussion strategies. The article focuses on actionable ways for HCPs to have effective and comprehensive conversations with families. However, the authors do not fully detail the methods of the literature review and do not quantify the difference that their recommendations can make in subsequent firearm safety practices by families. Additionally, the article notes that homicide is a leading cause of firearm death in adolescents, and more data is needed to optimize risk reduction of interpersonal firearm violence.
Relevance:
Firearm injuries were the leading cause of death in youth in 2020, and HCPs are uniquely positioned to have conversations with youth and their families about firearm safety. Type of risk varies by age, with unintentional injuries more common in children ages 1-9, and suicide or homicide is more common in adolescents. C-L psychiatrists should be ready to have age-appropriate conversations about safety and suicide risk reduction and be conscious that HCPs report they avoid conversations of firearm safety due a lack of knowledge, self-efficacy, and the political climate around firearms. The article discusses evidence-based ways to increase acceptability of firearm discussions, includes a table of phrases and tips, and references an AAP online educational module for further education to help healthcare providers feel empowered to have effective comprehensive safety discussions.
The finding:
The article describes a retrospective, multicenter, case-control study that sought to examine the prevalence of neurodiagnostic abnormalities in Down syndrome regression disorder (DSRD) and whether presence of those abnormalities predicts response to certain treatments. DSRD is a cluster of symptoms that has been previously described in the literature but does not have formal diagnostic criteria. For this study, inclusion criteria included developing subacute symptoms with at least 50% loss of prior functionality in 4+ of the following domains: cognitive decline, decreased expressive language, new onset sleep disturbance, loss of ability to perform ADLs, and catatonia or movement disorder other than tics. Exclusion criteria included history of prematurity, neurologic disorder, chemotherapy, or complex congenital heart disease. A comparator group of patients with Down Syndrome (DS) (n=1217) without DSRD were identified, however, the control group only had neuroimaging control data and did not have EEG or LP data. The mean onset of symptoms for patients with DSRD (n=72) was 14, with IQR 12-17. About half of the patients with DSRD were thought to have a possible trigger, such as a proceeding infection. Patients with DSRD were more likely than DS controls to have history of autoimmune disease, thyroid disease, low vitamin D levels, and positive ANA. Of patients with DSRD, 26% had EEG abnormalities, 22% had abnormalities on MRI, and 17% had CSF abnormalities on LP analysis. Although there were some patterns in abnormalities, none were consistent enough to be considered diagnostic or confirmatory for DSRD. Low vitamin D levels were correlated with abnormalities on neurodiagnostic testing. Of the 59 patients with DSRD that had autoimmune encephalopathy testing completed, none had a positive result via serum or CSF. The therapies that were most effective for all patients with DSRD included IVIg (88%), benzodiazepines (77%), and ECT (74%). Patients with abnormalities on neurodiagnostic testing were 4 times more likely to respond to immunotherapy (other than IVIg) than those without. Of note, for patients with onset younger than 8 years, immunotherapy was not effective. Patients with DSRD without neurodiagnostic findings were 5 times as likely to respond to antidepressants and 10 times more likely to respond to ECT.
Strength and weaknesses:
Several limitations pertain to this study’s design as a non-randomized retrospective evaluation of a syndrome that lacks clearly delineated diagnostic criteria. The authors attempted to improve specificity by restricting inclusion to patients with severe functional declines (>50%), which may have introduced a severity bias. The authors utilized multiple reviewers and achieved a high Cohen’s kappa (0.72) for diagnostic agreement, which decreases likelihood of data misinterpretation or misclassification of patients. The median time from symptom onset to diagnostic assessment for patients with DSRD in this study was 2 years. The study found that patients were more likely to have neurodiagnostic abnormalities if their evaluation occurred within two years of symptom onset, so it is possible that some markers were missed for patients who had less timely evaluations.
Relevance:
DSRD is a reliably identifiable symptom cluster that like has heterogenous etiologies. Many of the symptoms in the presentation of DSRD would warrant C-L psychiatry involvement, including cognitive changes, sleep disturbance, and catatonia. Additionally, the indicated treatment options of benzodiazepines, antidepressants, and ECT are within the scope of C-L psychiatry. It is important for C-L psychiatrists to remain abreast of emerging evidence of DSRD neuroimaging and laboratory abnormalities and what treatment options should be considered based on these findings.
The finding:
The study examined outcomes from the use of a high caloric feeling regimen, starting at 2000kcal/day, in 120 patients ages 12-20 admitted with a diagnosis of anorexia nervosa and a BMI ≤15 15 kg/m2. During the study period, caloric intake was increased to target a weight gain goal of 700-1000g per week, with typical daily intakes at 4 weeks of 2800-2900kcal/day. Patients were not routinely given phosphate supplementation prophylactically; however, patients had close monitoring of electrolytes and were given repletion if needed. No patients developed refeeding syndrome or critical deterioration. Average weight gain after 4 weeks was 3.0kg. Throughout the 4 weeks, 8.3% of patients had phosphate levels decrease from normal to low, all of which were normalized with supplementation and without adverse events.
Strength and weaknesses:
A limitation of the study includes its retrospective nature as a chart review from a single hospital in Germany. The study does not have a comparison group with a different feeding regimen. However, the study references prior literature that compares patients initiated on lower caloric regimens (starting around 1200kcal/day) compared to higher (≥1400 kcal/day), which have shown similar results of increased need for phosphate supplementation without increased incidence of refeeding syndrome, as well as more rapid weight gain and reduced inpatient treatment days. The authors note that strengths of this study include its relatively large sample size and inclusion of more severely malnourished patients who were followed for a longer period of time than in other studies.
Relevance:
C-L psychiatrists are often involved with the management of patients being treated for eating disorders in the hospital setting. It is important for psychiatrists to be familiar with best practices for treating eating disorders via nutritional rehabilitation and discussions of nutrition as a main aspect of the treatment plan. The authors note that this study illustrates that it is possible to treat severely malnourished patients with high calorie nutritional rehabilitation, starting at 2000kcal/day (on average 57kcal/kg in this study), with close monitoring of electrolyte imbalances to achieve faster weight gain and potentially shorter inpatient lengths of stay.
The finding:
The discussion of marijuana use and its effects on health, social, and legal well-being have become routine in medical appointments. In this study, the authors found that early marijuana use was associated with multiple adult outcomes after adjusting for race and ethnicity. When childhood psychiatric problems and family adversities were accounted for, only cumulative daily use and persistent use from teenage to adulthood were associated with poorer adult outcomes. Delaying onset of use might mitigate some adverse outcomes but is still problematic. There was no clear association of adolescent use with psychiatric diagnoses in adult life. However, a consistent failure to successfully transition to adult life was noted with persistent use.
Strength and weaknesses:
Strengths of this study are that issues of age, race, ethnicity, duration and severity of use, and the presence of a substance use diagnosis were specifically addressed. These are frequent confounding factors in substance use studies. Multiple end points were assessed: physical health, mental health, social and financial functioning. The authors also address the importance of adverse childhood events. Different trajectories of marijuana use were characterized in understanding outcomes, and assessment of children prior to use of cannabis provided an important baseline characterization often missing in studies. Attrition was low. There were weaknesses to this study. Genetic risk and familial dynamics may contribute to risk of early marijuana use but were not described, and there were insufficient data to prospectively correlate the pattern of use in the future. The study followed participants until age 30 ,which excludes some late life consequences of marijuana use. The study population may not be representative of the entire country based on age and ethnic distribution as well as legal status of marijuana in the state at the time of study.
Relevance:
The availability of prognostic information based on onset and patterns of cannabis use empowers adolescents and adults to make better choices in terms of ongoing cannabis use. Acute consequences of cannabis use which lead to or complicate patients’ hospital courses may offer a window for C-L psychiatrists to offer these insights and treatment options to adolescents and families. The findings may also guide policy advocates to address adult onset cannabis use and use among underserved populations, among whom cannabis may have disproportionately negative consequences.