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Background and Objectives: Epilepsy is common among older adults, but previous incident studies have had limited ability to make comparisons across key subgroups. We aimed to provide updated epilepsy incidence estimates among older adults, comparing across age, sex, and race/ethnicity., Methods: Using a random sample of 4,999,999 US Medicare beneficiaries older than 65 years, we conducted a retrospective cohort study of epilepsy incidence using administrative claims for 2016-2019. Sampled beneficiaries were enrolled in the Fee-for-Service (FFS) program in each of 2016-2018 and had no epilepsy claims in those years. Non-Hispanic Black and Hispanic beneficiaries were oversampled to ensure adequate cases for detailed comparisons. Incidence in 2019 was identified in the Master Beneficiary Summary File as ≥1 inpatient claim or ≥2 outpatient nondrug claims occurring at least 1 day apart ( ICD-10 G40.x). Incidence models were estimated by age, sex, race/ethnicity, and combinations thereof, with adjustment for the racial/ethnic oversampling., Results: We identified 20,545 incident epilepsy cases. The overall epilepsy incidence rate (IR) was 393 per 100,000 (99% CI 385-400). Incidence peaked at ages 85-89 (504 [481-529]) and was higher for men (396 [385-407]) than women (376 [366-385]). The sex difference in IRs was constant with age. Incidence was higher for non-Hispanic Black (678 [653-702]) and Hispanic (405 [384-426]), and lower for non-Hispanic Asian/Pacific Islander (272 [239-305]) beneficiaries, compared with non-Hispanic White beneficiaries (354 [299-408]). The age-specific IRs significantly differed by race/ethnicity and sex, but only among non-Hispanic Black beneficiaries-where men had higher rates at younger ages and women at older ages., Discussion: We found higher epilepsy IRs among those enrolled in the Medicare FFS system 2016-2019 than previous studies using Medicare claims data from at least a decade ago. The risk of epilepsy onset is higher for those in their late 80s, men, and non-Hispanic Black and Hispanic older adults. There is also evidence that these age-graded risks operate differently for Black men and Black women. Efforts to provide care and services that improve quality of life for older adults living with epilepsy should consider differences by multiple social characteristics simultaneously: age, sex, and race/ethnicity.

Background: Bedside procedures represent a substantial proportion of the neurosurgical resident's responsibilities. Although music interventions in healthcare have classically been employed for the benefit of the patient, there is evidence in support of its positive effects on healthcare workers as well., Objectives: We aimed to create a novel framework-the shared music experience (SME)-which allows for patient and provider to discuss and mutually select a musical playlist during bedside procedural interventions., Methods: A single-center prospective pilot study with nested design was carried out during a 6-month period. One sample was neurosurgery residents at our institution, while the other was patients undergoing nonemergent bedside procedures. Primary endpoints included change in neurosurgery residents' and patients' perception of patient-provider alliance. Secondary endpoints include quantitative and qualitative analysis of feedback from residents and patients about the SME framework., Results: Twelve out of 13 (92.3%) eligible neurosurgery residents were enrolled. Twenty-eight SMEs were carried out. Twenty-six of 28 patients (92.9%) replied that they did enjoy the SME. Patients who partook in SMEs had a significant increase in metrics of patient-clinician alliance as measured by the mARM-5. All 7 residents who participated in at least 1 SME reported having enjoyed performing procedures within the framework and affirmed they would either ''often'' (2/7, 28.6%) or ''always'' (5/7, 71.4%) implement SME in future practice., Conclusions: The SME is a novel intervention that can be employed to help patients and providers find common ground through music and foster the patient-clinician relationship during bedside procedures., (Copyright © 2024. Published by Elsevier Inc.)

Aims: Epilepsy self-management (ESM), the overall approach of reducing seizures and optimizing whole-health, is a targeted approach to improve population health for people with epilepsy (PWE). "Self-management for people with epilepsy and a history of negative health events" (SMART) is an 8-session group-format, remotely delivered ESM. This report describes the evolution of SMART development, testing and scale-up, taking advantage of ESM team expertise, community relationships and infrastructure established by social service agencies that deliver support to PWE., Methods: This is a case-study dissemination and implementation (D&I) science-to-service model using the RE-AIM framework approach (Reach, Effectiveness, Adoption, Implementation, and Maintenance) focused on 5 dimensions of individual- and setting-level outcomes important to program adoption, impact and sustainability. Performance evaluations include participation representativeness, ESM attendance and acceptability as well as change in relevant health outcomes., Results: SMART D & I is implemented via a collaboration of 3 unique regional, epilepsy-focused nonprofit social service organizations and a university team that developed SMART. The ongoing collaboration is expanding SMART delivery to PWE across 13 U.S. states. Thus far, we have trained 17 Nurse and Peer Educators (NEs and PEs). PEs (N = 10) have a mean age 51.1 (SD 10.4) years and a mean age of epilepsy diagnosis of 29.4 (SD 19.3). Of 128 participants offered SMART, and who provided age data (N = 86) mean age was 37.7 years (SD 14.4). Of participants who provided data on gender and race (N = 89), 65 were women (73.9 %), 18 African-American (20.2 %). Mean age of epilepsy diagnosis was 19.4 years (SD 16.6) and 59 (52.2 %) of PWE reported having seizures in the last 30 days pre-SMART sessions. Among those with attendance data (N = 103), mean number of SMART groups attended was 5.7 (SD 2.3). Mean values for past 30-day seizure frequency, 9-item Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Inventory (GAD-7) and 10-item Quality of Life in Epilepsy Scale (QOLIE-10) for PWE that provided both pre and post SMART data were 7.6 (SD 15.8) vs 2.8 (SD 3.4) p = 0.3, 7.63 (SD 6.6) vs 6.3 (SD 5.7) p = 0.95, 6.6 (SD 5.7) vs 6.67(SD 5.3) p = 0.47 and 2.8 (SD 0.8) vs 2.7 (SD 1.0) p = 0.07 respectively., Conclusions: Implementing ESM using a RE-AIM/Iterative RE-AIM framework links intervention developers and community partners. While PWE have substantial barriers to health, including frequent seizures, they are able engage in the SMART program. Although a major limitation to patient-level evaluation is challenges in collecting post-SMART follow-up data, preliminary findings suggest a trend for improved quality of life., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Lifestyle interventions are strategies used to self-manage medical conditions, such as epilepsy, and often complement traditional pharmacologic and surgical therapies. The need for integrating evidence-based lifestyle interventions into mainstream medicine for the treatment of epilepsy is evident given that despite the availability of a multitude of treatments with medications and surgical techniques, a significant proportion of patients have refractory seizures, and even those who are seizure-free report significant adverse effects with current treatments. Although the evidence base for complementary medicine is less robust than it is for traditional forms of medicine, the evidence to date suggests that several forms of complementary medicine including yoga, mindfulness meditation, cognitive behavioral therapy, diet and nutrition, exercise and memory rehabilitation, and music therapy may have important roles as adjuncts in the treatment armamentarium for epilepsy. These topics were discussed by a diverse group of medical providers and scientists at the "Lifestyle Intervention for Epilepsy (LIFE)" symposium hosted by Cleveland Clinic. PLAIN LANGUAGE SUMMARY: There are many people with epilepsy who continue to have seizures even though they are being treated with medication or brain surgery. Even after seizures stop, some may experience medication side effects. There is research to suggest that certain lifestyle changes, such as yoga, mindfulness, exercise, music therapy, and adjustments to diet, could help people with epilepsy, when used along with routine treatment. Experts discussed the latest research at the "Lifestyle Intervention for Epilepsy (LIFE)" symposium hosted by Cleveland Clinic., (© 2024 The Author(s). Epilepsia Open published by Wiley Periodicals LLC on behalf of International League Against Epilepsy.)

Background and Purpose: Stigma is a pervasive barrier for people living with epilepsy (PLWE) and can have substantial negative effects. This study evaluated clinical correlates of perceived stigma in a research sample of PLWE considered to be at high risk due to frequent seizures or other negative health events., Methods: Analyses were derived from baseline data from an ongoing Centers for Disease Control and Prevention (CDC)-funded randomized controlled trial (RCT) testing an epilepsy self-management approach. Standardized measures assessed socio-demographics, perceived epilepsy stigma, epilepsy-related self-efficacy, epilepsy self-management competency, health literacy, depressive symptom severity, functional status, social support and epilepsy-related quality of life., Results: There were 160 individuals, mean age of 39.4, (Standard deviation/SD=12.2) enrolled in the RCT, 107 (66.9 %) women, with a mean age of epilepsy onset of 23.9 (SD 14.0) years. The mean seizure frequency in the prior 30 days was 6.4 (SD 21.2). Individual factors correlated with worse perceived stigma were not being married or cohabiting with someone (p = 0.016), lower social support (p < 0.0001), lower self-efficacy (p < 0.0001), and lower functional status for both physical health (p = 0.018) and mental health (p < 0.0001). Perceived stigma was associated with worse depressive symptom severity (p < 0.0001). Multivariable linear regression found significant independent associations between stigma and lower self-efficacy (β -0.05; p = 0.0096), lower social support (β -0.27; p = 2.4x10 -5 , and greater depression severity (β 0.6; p = 5.8x10 -5 )., Conclusions: Perceived epilepsy stigma was positively correlated with depression severity and negatively correlated with social support and self-efficacy. Providers caring for PLWE may help reduce epilepsy stigma by screening for and treating depression, encouraging supportive social relationships, and providing epilepsy self-management support. Awareness of epilepsy stigma and associated factors may help reduce some of the hidden burden borne by PLWE., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Individuals with bipolar disorder (BD) have high rates of suboptimal medication adherence, medical illness, and premature mortality, largely from cardiovascular causes. This analysis examined the association between adherence to antihypertensive and BD medications and clinical symptoms in patients with BD and comorbid hypertension (HTN) from an ongoing trial to optimize adherence., Method: Inclusion criteria were a BD diagnosis, treatment with antihypertensives, adherence challenges, and poorly controlled HTN. Adherence was measured via self-report using the Tablets Routine Questionnaire and using eCAP, an electronic pillcap which captures openings. Average systolic blood pressure (SBP) was calculated from 12 readings over 1 week. The Montgomery-Asberg Depression Rating Scale (MADRS) and the Brief Psychiatric Rating Scale (BPRS) assessed BD symptoms., Results: A total of 83 participants with BD and HTN were included. Adherence to BD and antihypertensive medications were positively correlated. eCAP openings showed more missed doses than self-reported antihypertensive adherence. BD medication adherence was positively correlated with BPRS at baseline; antihypertensive adherence was negatively correlated with SBP at screening. Antihypertensive adherence improved and SBP decreased between screening and baseline., Conclusions: Adherence levels fluctuated over time and differed based on measurement method in people with comorbid BD and HTN. Self-reported BD adherence was positively related to global psychiatric symptoms and antihypertensive adherence was related to better SBP control. Monitoring both medication and blood pressure led to change in self-reported adherence. BD symptom severity may indicate poor adherence in patients with BD and should be considered in treatment planning., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Author M.S.: Research grants within past 3 years: Intra-Cellular, Merck, Otsuka, Alkermes, International Society for Bipolar Disorders (ISBD), National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Patient-Centered Outcomes Research Institute (PCORI). Consultant in the past year: Alkermes, Otsuka, Janssen, Lundbeck, Teva, Neurelis. Royalties: Springer Press, Johns Hopkins University Press, Oxford Press, UpToDate.

Background: Antipsychotic medications are effective treatments for schizophrenia (SZ) and bipolar I disorder (BD-I), but when presented with different treatment options, there are tradeoffs that individuals make between clinical improvement and adverse effects. As new options become available, understanding the attributes of antipsychotic medications that are valued and the tradeoffs that individuals consider when choosing among them is important., Methods: A discrete-choice experiment (DCE) was administered online to elicit preferences across 5 attributes of oral antipsychotics: treatment efficacy (i.e., improvement in symptom severity), weight gain over 6 months, sexual dysfunction, sedation, and akathisia. Eligible respondents were aged 18-64 years with a self-reported clinician diagnosis of SZ or BD-I., Results: In total, 144 respondents with SZ and 152 with BD-I completed the DCE. Of those with SZ, 50% identified themselves as female and 69.4% as White, with a mean (SD) age of 41.0 (10.1) years. Of those with BD-I, most identified themselves as female (69.7%) and as White (77.6%), with a mean (SD) age of 40.0 (10.7) years. In both cohorts, respondents preferred oral antipsychotics with better efficacy, less weight gain, no sexual dysfunction or akathisia, and lower risk of sedation. Treatment efficacy was the most important attribute, with a conditional relative importance (CRI) of 31.4% for respondents with SZ and 31.0% for those with BD-I. Weight gain (CRI = 21.3% and 23.1%, respectively) and sexual dysfunction (CRI = 23.4% and 19.2%, respectively) were adverse effects in this study that respondents most wanted to avoid. Respondents with SZ were willing to accept 9.8 lb of weight gain or > 25% risk of sedation for symptom improvement; those with BD-I were willing to accept 8.5 lb of weight gain or a > 25% risk of sedation., Conclusions: In this DCE, treatment efficacy was the most important attribute of oral antipsychotic medications among respondents with SZ and BD-I. Weight gain and sexual dysfunction were the adverse effects respondents most wanted to avoid; however, both cohorts were willing to accept some weight gain or sedation to obtain better efficacy. These results highlight features that patients value in antipsychotic medications and how they balance benefits and risks when choosing among treatments., (© 2024. The Author(s).)

The unpredictability of bipolar disorder is highly distressing for family caregivers, who differ in their needs and preferences for stress-reducing or educational interventions. Applying Ryan and Sawin's model, this study examined associations between caregiver demographics (age, gender, and race) as contextual factors and caregiver needs and preferences for three interventions as process factors within a preliminary descriptive analysis of 306 family caregivers from a randomized clinical trial. Caregiver needs for education about bipolar disorder, biofeedback, and Resourcefulness Training © were determined by established cut scores on validated measures of bipolar knowledge, heart rate variability, and resourcefulness. Frequencies for need and preference for intervention were compared by caregiver age, gender, and race. Discrepancies between caregiver need and preference for interventions were analyzed. Non-White caregivers showed greater need for education ( X 2 =33.68, p  < 0.001). Middle-aged caregivers showed greatest need for biofeedback ( X 2 =19.58, p  < 0.001). Need for Resourcefulness Training © was similar across age, gender, and race. We found 58% needed biofeedback, 34% education, and 18% Resourcefulness Training © ; 46% of those in the preference group chose Resourcefulness Training © . Further caregiver intervention research should consider the effect of caregiver needs and preferences on their health. The findings support the essentiality of assessing caregiver demographics, needs, and preferences before implementing interventions.

Objective: Few studies have addressed medication adherence in adolescents and young adults (AYAs) with bipolar disorder (BD). This 6-month prospective randomized-controlled trial (RCT) tested customized adherence enhancement for adolescents and young adults (CAE-AYA), a behavioral intervention for AYAs versus enhanced treatment as usual (ETAU)., Methods: Inclusion criteria were AYAs age 13-21 with BD type I or II with suboptimal adherence defined as missing ≥20% of medications. Assessments were conducted at Screening, Baseline, and weeks 8, 12 and 24. Primary outcome was past 7 day self-reported Tablets Routine Questionnaire (TRQ) validated by electronic pillbox monitoring (SimpleMed). Symptom measures included the Hamilton Depression Rating Scale (HAM-D) and Young Mania Rating Scale (YMRS)., Results: The mean sample age (N = 36) was 19.1 years (SD = 2.0); 66.7% (N = 24) female, BD Type I (81%). The mean missed medication on TRQ for the total sample was 35.4% (SD = 28.8) at screening and 30.4% (SD = 30.5) at baseline. Both CAE-AYA and ETAU improved on TRQ from screening to baseline. Baseline mean missed medication using SimpleMed was 51.6% (SD = 38.5). Baseline HAM-D and YMRS means were 7.1 (SD = 4.7) and 6.0 (SD = 7.3), respectively. Attrition rate at week 24 was 36%. Baseline to 24-week change on TRQ, adjusting for age, gender, educational level, living situation, family history, race, and ethnicity, showed improvement favoring CAE-AYA versus ETAU of 15%. SimpleMed interpretation was limited due to substantial missing data. There was a significant reduction in depression favoring CAE-AYA., Conclusions: CAE-AYA may improve adherence in AYAs with BD, although conclusions need to be made cautiously given study limitations., Clinical Trials Registration: ClinicalTrials.gov identifier: NCT04348604., (© 2024 The Author(s). Bipolar Disorders published by John Wiley & Sons Ltd.)

Objectives: To compare the prevalence of physical morbidities between older aged patients with bipolar disorder (OABD) and non-psychiatric comparisons (NC), and to analyze sex differences in prevalence., Methods: OABD was defined as bipolar disorder among adults aged ≥50 years. Outcomes analyzed were the prevalence of diseases affecting the cardiovascular, respiratory, gastrointestinal, genitourinary, renal, musculoskeletal, and endocrine systems. The analysis used cross-sectional data of OABD participants (n = 878; mean age 60.9 ± 8.0 years, n = 496 (56%) women) from the collaborative Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) dataset and NC participants recruited at the same sites (n = 355; mean age 64.4 ± 9.7 years, n = 215 (61%) women)., Results: After controlling for sex, age, education, and smoking history, the OABD group had more cardiovascular (odds ratio [95% confidence interval]: 2.12 [1.38-3.30]), renal (5.97 [1.31-43.16]), musculoskeletal (2.09 [1.30-3.43]) and endocrine (1.90 [1.20-3.05]) diseases than NC. Women with OABD had more gastrointestinal (1.56 [0.99-2.49]), genitourinary (1.72 [1.02-2.92]), musculoskeletal (2.64 [1.66-4.37]) and endocrine (1.71 [1.08-2.73]) comorbidities than men with OABD, when age, education, smoking history, and study site were controlled., Conclusions: This replication GAGE-BD study confirms previous findings indicating that OABD present more physical morbidities than matched comparison participants, and that this health burden is significantly greater among women., Competing Interests: Declaration of competing interest VB-M has received honoraria from Angelini, unrelated to the present work. JBL has received grant funding from NIH, AHA, and Merck. EV has received grants and served as consultant, advisor or CME speaker for the following entities: AB-Biotics, AbbVie, Adamed, Angelini, Biogen, Biohaven, Boehringer-Ingelheim, Celon Pharma, Compass, Dainippon Sumitomo Pharma, Ethypharm, Ferrer, Gedeon Richter, GH Research, Glaxo-Smith Kline, HMNC, Idorsia, Johnson & Johnson, Lundbeck, Medincell, Merck, Novartis, Orion Corporation, Organon, Otsuka, Roche, Rovi, Sage, Sanofi-Aventis, Sunovion, Takeda, and Viatris, outside the submitted work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Prior studies have examined chronic conditions in older adults with prevalent epilepsy, but rarely among those with incident epilepsy. Identifying the chronic conditions with which older adults present at epilepsy incidence assists with the evaluation of disease burden in this patient population and informs coordinated care development. The aim of this study was to identify preexisting chronic conditions with excess prevalence in older adults with incident epilepsy compared to those without., Methods: Using a random sample of 4 999 999 fee-for-service Medicare beneficiaries aged >65 years, we conducted a retrospective cohort study of epilepsy incidence in 2019. Non-Hispanic Black and Hispanic beneficiaries were oversampled. We identified preexisting chronic conditions from the 2016-2018 Medicare Beneficiary Summary Files and compared chronic condition prevalence between Medicare beneficiaries with and without incident epilepsy in 2019. We characterized variations in preexisting excess chronic condition prevalence by age, sex, and race/ethnicity, adjusting for the racial/ethnic oversampling., Results: We observed excess prevalence of most preexisting chronic conditions in beneficiaries with incident epilepsy (n = 20 545, weighted n = 19 631). For stroke, for example, the adjusted prevalence rate ratio (APRR) was 4.82 (99% CI:4.60, 5.04), meaning that, compared to those without epilepsy, beneficiaries with incident epilepsy in 2019 had 4.82 times the stroke prevalence. Similarly, beneficiaries with incident epilepsy had a higher prevalence rate for preexisting neurological conditions (APRR = 3.17, 99% CI = 3.08-3.27), substance use disorders (APRR = 3.00, 99% CI = 2.81-3.19), and psychiatric disorders (APRR = 1.98, 99% CI = 1.94-2.01). For most documented chronic conditions, excess prevalence among beneficiaries with incident epilepsy in 2019 was larger for younger age groups compared to older age groups, and for Hispanic beneficiaries compared to both non-Hispanic White and non-Hispanic Black beneficiaries., Significance: Compared to epilepsy-free Medicare beneficiaries, those with incident epilepsy in 2019 had a higher prevalence of most preexisting chronic conditions. Our findings highlight the importance of health promotion and prevention, multidisciplinary care, and elucidating shared pathophysiology to identify opportunities for prevention., (© 2024 The Author(s). Epilepsia published by Wiley Periodicals LLC on behalf of International League Against Epilepsy.)

Background: Screening for depression can be challenging among hemodialysis patients due to the overlap of depressive symptoms with dialysis or kidney disease related symptoms. The aim of this study was to understand these overlapping symptoms and develop a depression screening tool for better clinical assessment of depressive symptoms in dialysis patients., Methods: We surveyed 1,085 dialysis patients between March 1, 2018 and February 28, 2023 at 15 dialysis facilities in Northeast Ohio with the 9-item patient health questionnaire (PHQ-9) and kidney disease quality of life (KDQOL) instrument. To evaluate overlap across questionnaire items, we used structural equation modeling (SEM). We predicted and transformed factor scores to create a hemodialysis-adjusted PHQ-9 (hdPHQ-9). In exploratory analysis ( N  = 173), we evaluated the performance of the hdPHQ-9 relative to the PHQ-9 that also received a Mini-International Neuropsychiatric Interview., Results: Our study sample included a high percentage of Black patients (74.6%) and 157 (14.5%) survey participants screened positive for depression (PHQ-9 ≥ 10). The magnitude of overlap was small for (respectively, PHQ-9 item with KDQOL TM item) fatigue with washed out, guilt with burden on family, appetite with nausea and movement with lightheaded. The hdPHQ-9 showed reasonably high sensitivity (0.81 with 95% confidence interval [CI] 0.58, 0.95) and specificity (0.84 with 95% CI 0.77, 0.89); however, this was not a significant improvement from the PHQ-9., Conclusion: There is little overlap between depressive symptoms and dialysis or kidney disease symptoms. The PHQ-9 was found to be an appropriate depression screening instrument for dialysis patients.

Background: Alzheimer's disease and related dementias (ADRD) present growing global health challenges, especially in aging populations, such as Uganda. In Uganda, familial caregiving, predominantly undertaken by female relatives, is the primary form of support provided to patients with ADRD. Cultural stigma around dementia and limited access to support services amplify caregivers' challenges. This study examined psychological distress, depression, and quality of life (QoL) among family caregivers of patients with ADRD in Wakiso District, Uganda., Methods: This cross-sectional study involved 90 caregivers from three sub-counties in Wakiso, selected through purposive sampling to capture diverse experiences. Participants included caregivers aged 18 years and older who were knowledgeable and had cared for a person with ADRD for not less than six months, with those providing more than 70% of physical care being prioritised. Data were collected using the Kessler Psychological Distress Scale, the Caregiver Dementia Quality of Life Measurement Scale, and the Center for Epidemiologic Studies Depression Scale, with an 80% response rate achieved through local collaboration. The statistical analyses focused on psychological distress, QoL, and depression., Results: The study included 82.2% females and 17.8% males, with a median age of 52 years for females and 35 years, respectively. Females were more likely to be single or widowed, whereas males were more likely to be married. The study revealed a high prevalence of psychological distress and depression among caregivers (64.4%) regardless of sex. The analysis indicated that having children was a significant predictor of better QoL (OR 3.04, 95% CI 1.79-5.66, p = 0.034) and a lower risk of depression (OR 0.10, 95% CI 0.01-0.86, p = 0.036). No other sociodemographic factors were significantly associated with health outcomes across the models., Conclusion: Our findings revealed a heavy burden of psychological distress and depression among Ugandan caregivers of patients with ADRD, highlighting the need for structured support systems, including mental health services and gender-responsive interventions in low-resource settings., (© 2024. The Author(s).)

Background: Given the importance of medication adherence among individuals with bipolar disorder (BD), this analysis from an ongoing randomized controlled trial (RCT) examined the relationship between BD symptoms, functioning and adherence in 69 poorly adherent adults with BD., Method: Study inclusion criteria included being ≥ 18 years old with BD Type 1 or 2, difficulties with medication adherence and actively symptomatic as measured by Brief Psychiatric Rating Scale (BPRS) score ≥ 36, Young Mania Rating Scale (YMRS) > 8 or Montgomery Asberg Depression Rating Scale (MADRS) > 8. Adherence was measured in 2 ways: 1) the self-reported Tablets Routine Questionnaire (TRQ) and 2) electronic pill container monitoring (eCap pillbox). BD symptoms and functioning were measured with the MADRS, YMRS, Clinical Global Impressions Scale (CGI), and Global Assessment of Functioning (GAF). Only screening and baseline data were examined., Results: Mean age was 42.32 (SD = 12.99) years, with 72.46% (n = 50) female and 43.48% (n = 30) non-white. Mean past 7-day percentage of days with missed BD medications using TRQ was 40.63% (SD = 32.61) and 30.30% (SD = 30.41) at screening and baseline, respectively. Baseline adherence using eCap was 42.16% (SD = 35.85) in those with available eCap data (n = 41). Worse adherence based on TRQ was significantly associated with higher MADRS (p = 0.04) and CGI (p = .03) but lower GAF (p = 0.02). eCAP measured adherence was not significantly associated with clinical variables., Conclusion: While depression and functioning were approximate markers of adherence, reliance on patient self-report or BD symptom presentation may give an incomplete picture of medication-taking behaviors., (Copyright © 1964–2024 by MedWorks Media Inc, Los Angeles, CA All rights reserved. Printed in the United States.)

At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy, and their representatives to develop minimum sets of standardized outcomes and outcome measurement methods for clinical practice. Using modified Delphi consensus methods with consecutive rounds of online voting over 12 months, a core set of outcomes and corresponding measurement tool packages to capture the outcomes were identified for infants, children, and adolescents with epilepsy. Consensus methods identified 20 core outcomes. In addition to the outcomes identified for the ICHOM Epilepsy adult standard set, behavioral, motor, and cognitive/language development outcomes were voted as essential for all infants and children with epilepsy. The proposed set of outcomes and measurement methods will facilitate the implementation of the use of patient-centered outcomes in daily practice., (© 2024 The Authors. Epilepsia published by Wiley Periodicals LLC on behalf of International League Against Epilepsy.)

At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. Therefore, the International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy and their representatives to develop minimum sets of standardized outcomes and outcomes measurement methods for clinical practice that support patient-clinician decision-making and quality improvement. Consensus methods identified 20 core outcomes. Measurement tools were recommended based on their evidence of strong clinical measurement properties, feasibility, and cross-cultural applicability. The essential outcomes included many non-seizure outcomes: anxiety, depression, suicidality, memory and attention, sleep quality, functional status, and the social impact of epilepsy. The proposed set will facilitate the implementation of the use of patient-centered outcomes in daily practice, ensuring holistic care. They also encourage harmonization of outcome measurement, and if widely implemented should reduce the heterogeneity of outcome measurement, accelerate comparative research, and facilitate quality improvement efforts., (© 2024 The Authors. Epilepsia published by Wiley Periodicals LLC on behalf of International League Against Epilepsy.)

Importance: Long-acting injectable (LAI) antipsychotics have the potential to improve adherence and symptom control in patients with schizophrenia, promoting long-term recovery. Paliperidone palmitate (PP) once every 6 months is the first and currently only LAI antipsychotic with an extended dosing interval of 6 months., Objective: To assess long-term outcomes of PP received once every 6 months in adults with schizophrenia., Design, Setting, and Participants: In a 2-year open-label extension (OLE) study of a 1-year randomized clinical trial (RCT), eligible adults with schizophrenia could choose to continue PP every 6 months if they had not experienced relapse after receiving PP once every 3 or 6 months in the 1-year, international, multicenter, double-blind, randomized noninferiority trial. The present analysis focused on patients receiving PP every 6 months in the double-blind trial through the OLE study (November 20, 2017, to May 3, 2022)., Intervention: Patients received a dorsogluteal injection of PP on day 1 and once every 6 months up to month 30., Main Outcomes and Measures: End points included assessment of relapse and change from the double-blind trial baseline to the OLE end point in Positive and Negative Syndrome Scale (PANSS) total and subscale, Clinical Global Impression-Severity (CGI-S) Scale, and Personal Social Performance (PSP) Scale scores. Treatment-emergent adverse events (TEAEs), injection site evaluations, and laboratory tests were also assessed., Results: Among 121 patients (83 [68.6%] male), mean (SD) age at baseline was 38.6 (11.24) years and mean (SD) duration of illness was 11.0 (9.45) years. At screening of the double-blind study, 101 patients (83.5%) were taking an oral antipsychotic and 20 (16.5%) were taking an LAI antipsychotic. Altogether, 5 of 121 patients (4.1%) experienced relapse during the 3-year follow-up; reasons for relapse were psychiatric hospitalization (2 [1.7%]), suicidal or homicidal ideation (2 [1.7%]), and deliberate self-injury (1 [0.8%]). Patients treated with PP every 6 months were clinically and functionally stable, and outcomes were well maintained, evidenced by stable scores on the PANSS (mean [SD] change, -2.6 [9.96] points), CGI-S (mean [SD] change, -0.2 [0.57] points), and PSP (mean [SD] change, 3.1 [9.14] points) scales over the 3-year period. In total, 101 patients (83.5%) completed the 2-year OLE. At least 1 TEAE was reported in 97 of 121 patients (80.2%) overall; no new safety or tolerability concerns were identified., Conclusions and Relevance: In a 2-year OLE study of a 1-year RCT, results supported favorable long-term outcomes of PP once every 6 months for up to 3 years in adults with schizophrenia.

Aims: Despite advances in care, people with epilepsy experience negative health events (NHEs), such as seizures, emergency department (ED) visits and hospitalizations. This analysis using baseline data from an epilepsy self-management clinical trial targeting people from rural regions and other underserved populations assessed the relationship between demographic and clinical variables vs. NHEs., Methods: Data to evaluate disparities and clinical correlates was collected using patient surveys from a baseline sample of 94 participants in a larger prospective study of 160 individuals with epilepsy who experienced an NHE within the last six months. Demographic characteristics, mental and physical functional status assessed using 36-Item Short Form Health Survey questionnaire version 2 (SF-36v2), depression assessed with the 9-item Patient Health Questionnaire (PHQ-9), quality of life assessed with the 10-item Quality of Life in Epilepsy Inventory (QOLIE-10), self-efficacy assessed the Epilepsy Self-Efficacy Scale (ESES), social support assessed with the Multidimensional Scale of Perceived Social Support (MSPSS), self-management assessed with the Epilepsy Self-Management Scale (ESMS), and stigma assessed with the Epilepsy Stigma Scale (ESS) were all examined in association with past 6-month total NHE frequency as well as NHE sub-categories of past 30-day and 6-month seizure counts, self-harm attempts, ED visits and hospitalizations. An exploratory evaluation of NHE correlates in relation to the Rural Urban Continuum Code (RUCC) residence classification compared 3 subgroups of increasing rurality. Descriptive statistics were generated for demographic and clinical variables and NHEs, and exploratory analyses compared the distribution of demographic, clinical, and NHE variables by RUCC categorization., Results: The mean age was 38.5 years (SD 11.9), predominantly female (N= 62, 66.0%) and white (N=81, 86.2%). Just a little under half (N=43, 45.7%) of participants had annual incomes of less than $25,000, and 40% (N=38) were rural residents (RUCC >3). The past 6-month NHEs count was 20.4 (SD 32.0). Seizures were the most common NHE with a mean 30-day seizure frequency = 5.4 (SD 11.8) and 6-month seizure frequency of 18.7 (SD 31.6). Other NHE types were less common with a past 6-month self-harm frequency of 0.16 (SD 1.55), ED visit frequency of 0.72 (SD 1.10), and hospitalization frequency of 0.28 (SD 1.02). There were few significant demographic and clinical correlates for total and sub-categories of NHEs. Worse physical health status, as measured by the physical component summary (PCS) of the SF-36v2, was significantly associated with 6-month seizure counts (p=.04). There were no significant differences between the 3 RUCC subgroups on demographic variables. However, past 30-day seizure count, past 6-month seizure count and total past 6-month NHE counts were all higher among individuals from more rural settings (p-values <.01 for each)., Conclusions: Rural adults with epilepsy were more likely to have a greater number of seizures and more epilepsy complications in general. Worse physical health function was also associated with more epilepsy complications. However, this analysis found few other demographic and clinical correlates of cumulative NHEs among adults with epilepsy. Additional efforts are needed to investigate health disparities among people with epilepsy who live in rural regions or who have poor physical health function., (Copyright © 2024 Elsevier B.V. All rights reserved.)

The onset of the COVID-19 pandemic saw a significant surge in the utilization of telemental health (TMH) services. This narrative review aimed to investigate the efficacy of TMH for serious mood disorders prior to the COVID-19 pandemic. A search across databases was conducted for randomized controlled trials focusing on TMH interventions for mood disorders, encompassing major depressive disorder (MDD) and bipolar disorder (BD). Study and patient characteristics, interventions, and outcomes were extracted. From a pool of 2611 papers initially identified, 17 met the inclusion criteria: 14 focused on MDD, while 4 addressed BD. Among these, 6 papers directly compared TMH interventions to in-person of same treatment, revealing improved access to care and higher rates of appointment follow-up with TMH. Additionally, 6 papers comparing TMH to treatment as usual demonstrated improvements in mood outcomes. Conversely, 3 papers comparing different TMH interventions found no discernible differences in outcomes. Notably, 3 studies evaluated TMH as an adjunct to usual care, all reporting enhancements in depression outcomes. Overall, preliminary evidence suggests that prior to COVID-19, TMH interventions for serious mood disorders facilitated improved access to care and follow-up, with comparable clinical outcomes to traditional in-person interventions. The discussion addresses limitations and provides recommendations for future research in this domain., (© 2024. The Author(s).)

Background: Diabetes self-management education and support can be effectively and efficiently delivered in primary care in the form of shared medical appointments (SMAs). Comparative effectiveness of SMA delivery features such as topic choice, multi-disciplinary care teams, and peer mentor involvement is not known., Objective: To compare effects of standardized and patient-driven models of diabetes SMAs on patient-level diabetes outcomes., Design: Pragmatic cluster randomized trial., Participants: A total of 1060 adults with type 2 diabetes in 22 primary care practices., Interventions: Practice personnel delivered the 6-session Targeted Training in Illness Management (TTIM) curriculum using either standardized (set content delivered by a health educator) or patient-driven SMAs (patient-selected topic order delivered by health educators, behavioral health providers [BHPs], and peer mentors)., Main Measures: Outcomes included self-reported diabetes distress and diabetes self-care behaviors from baseline and follow-up surveys (assessed at 1st and final SMA session), and HbA1c, BMI, and blood pressure from electronic health records. Analyses used descriptive statistics, linear regression, and linear mixed models., Key Results: Both standardized and patient-driven SMAs effectively improved diabetes distress, self-care behaviors, BMI (- 0.29 on average), and HbA1c (- 0.45% (mmol/mol) on average, 8.3 to 7.8%). Controlling for covariates, there was a small, significant effect of condition on overall diabetes distress in favor of standardized SMAs (F(1,841) = 4.3, p = .04), attributable to significant effects of condition on emotion and regimen distress subscales. There was a small, significant effect of condition on diastolic blood pressure in favor of standardized SMAs (F(1,5199) = 4.50, p = .03). There were no other differences between conditions., Conclusions: Both SMA models using the TTIM curriculum yielded significant improvement in diabetes distress, self-care, and HbA1c. Patient-driven diabetes SMAs involving BHPs and peer mentors and topic selection did not lead to better clinical or patient-reported outcomes than standardized diabetes SMAs facilitated by a health educator following a set topic order., Nih Trial Registry Number: NCT03590041., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Cognitive deficits in bipolar disorder (BD) impact functioning and are main contributors to disability in older age BD (OABD). We investigated the difference between OABD and age-comparable healthy comparison (HC) participants and, among those with BD, the associations between age, global cognitive performance, symptom severity and functioning using a large, cross-sectional, archival dataset harmonized from 7 international OABD studies., Methods: Data from the Global Aging and Geriatric Experiments in Bipolar Disorder (GAGE-BD) database, spanning various standardized measures of cognition, functioning and clinical characteristics, were analyzed. The sample included 662 euthymic to mildly symptomatic participants aged minimum 50years (509 BD, 153 HC), able to undergo extensive cognitive testing. Linear mixed models estimated associations between diagnosis and global cognitive performance (g-score, harmonized across studies), and within OABD between g-score and severity of mania and depressive symptoms, duration of illness and lithium use and of global functioning., Results: After adjustment for study cohort, age, gender and employment status, there was no significant difference in g-score between OABD and HC, while a significant interaction emerged between employment status and diagnostic group (better global cognition associated with working) in BD. Within OABD, better g-scores were associated with fewer manic symptoms, higher education and better functioning., Limitations: Cross-sectional design and loss of granularity due to harmonization., Conclusion: More research is needed to understand heterogenous longitudinal patterns of cognitive change in BD and understand whether particular cognitive domains might be affected in OABD in order to develop new therapeutic efforts for cognitive dysfunction OABD., Competing Interests: Declaration of competing interest FK reports no conflict of interest. Dr. Sajatovic has research grants from Otsuka, the International Society for Bipolar Disorders (ISBD), NIH, and the Centers for Disease Control and Prevention (CDC). She is a consultant to Otsuka, Janssen, Lundbeck, Teva, Neurelis and has received publication royalties from Springer Press, Johns Hopkins University Press, Oxford Press and UpToDate. Dr. Rej has salary support from the Fonds de Recherche Quebec - Sante, Grant from Mitacs, Steering Committee for Abbvie, Shareholder of Aifred Health. Dr. Mulsant holds and receives support from the Labatt Family Chair in Biology of Depression in Late-Life Adults at the University of Toronto. During the past five years, he has received research support from Brain Canada, the Canadian Institutes of Health Research, the CAMH Foundation, the Patient-Centered Outcomes Research Institute (PCORI), the US National Institute of Health (NIH), Capital Solution Design LLC (software used in a study founded by CAMH Foundation), and HAPPYneuron (software used in a study founded by Brain Canada). He has also been an unpaid consultant to Myriad Neuroscience., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Stroke education materials are crucial for the recovery of stroke patients, but their effectiveness depends on their readability. The American Medical Association (AMA) recommends patient education materials be written at a sixth-grade level. Studies show existing paper and online materials exceed patients' reading levels and undermine their health literacy. Low health literacy among stroke patients is associated with worse health outcomes and decreased efficacy of stroke rehabilitation., Objective: We reviewed the readability of paper (i.e brochures, factsheets, posters) and online (i.e American Stroke Association, Google, Yahoo!) stroke patient education materials, reading level of stroke patients, accessibility of online health information, patients' perceptions on gaps in stroke information, and provided recommendations for improving readability., Method: A PRISMA-guided systematic literature review was conducted using PUBMED, Google Scholar, and EbscoHost databases and "stroke", "readability of stroke patient education", and "stroke readability" search terms to discover English-language articles. A total of 12 articles were reviewed., Results: SMOG scores for paper and online material ranged from 11.0 - 12.0 grade level and 7.8 - 13.95 grade level respectively. Reading level of stroke patients ranged from 3rd grade to 9th grade level or above. Accessibility of online stroke information was high. Structured patient interviews illustrated gaps in patient education materials and difficulty with comprehension., Conclusion: Paper and online patient education materials exceed the reading level of stroke patients and the AMA recommended 6th grade level. Due to limitations in readability, stroke patients are not being adequately educated about their condition.

Purpose: Evidence supporting secondary stroke in sub-Saharan Africa is scarce. This study describes the incidence of stroke recurrence and associated risk factors in sub-Saharan Africa., Methods and Materials: Scientific databases were systematically searched from January 2000 to December 2022 for population-based observational studies, case-control or cohort studies of recurrent stroke involving adults aged 18 years and above in sub-Saharan Africa (SSA). We assessed the quality of the eligible studies using the Critical Appraisal Skills Program (CASP) checklist for observational studies., Results: Six studies met the inclusion criteria and were included in this study. Stroke recurrence rates in SSA ranged from 9.4% to 25%. Majority of the studies were conducted from Western Africa and showed that stroke recurrence rates are high within sub-Saharan Africa ranging from 2% to 25%. The known stroke risk factors such as hypertension, chronic alcohol consumption, etc., remained the leading causes of stroke recurrence. The studies reported a higher mortality rate ranging from 20.5 -23% among those with recurrent strokes compared to primary strokes., Conclusion: This systematic review is an update and summary of the available literature on stroke recurrence within sub-Saharan Africa. Further studies are warranted to assess the outcomes and burden of stroke recurrence in SSA., Competing Interests: Professor Martha Sajatovic reports grants from Merck, Otsuka, Alkermes, International Society for Bipolar Disorders (ISBD), National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Patient-Centered Outcomes Research Institute (PCORI); personal fees from Alkermes, Otsuka, Janssen, Lundbeck, Teva, Neurelis; royalties from Springer Press, Johns Hopkins University Press, Oxford Press, UpToDate; compensation for preparation of/participation in continuing medical education activities from American Physician’s Institute (CMEtoGo), Psychopharmacology Institute, American Epilepsy Society, Clinical Care Options, American Academy of Child and Adolescent Psychiatry, Neurocrine, outside the submitted work. The authors report no other conflicts of interest in this work., (© 2024 Mbalinda et al.)

Background: Psychotic disorders are prevalent among people with epilepsy compared to the general population. However, there is limited information regarding psychosis among people with epilepsy in Uganda. This study therefore determined the prevalence and associated factors of psychosis among adults with epilepsy attending Butabika National Referral Mental Hospital in Uganda., Methods: This was a cross-sectional study involving adults with epilepsy. The diagnosis of psychosis was assessed using the Mini-International Neuropsychiatric Interview, module for Psychotic disorders. Logistic regression analysis identified factors associated with psychosis., Results: Out of 250 participants, 6.8% had psychosis and 13.6% had depression. Psychosis was significantly associated with older age, greater perceived stigma and substance use., Conclusion: Psychosis affects nearly 7% of adults with epilepsy in Uganda especially among those who are older, with perceived stigma and substance use. Routine screening and early intervention to management of psychosis in PWE is highly recommended., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: There is a dearth of studies evaluating the utility of reporting prognostication among nursing home (NH) residents with cancer., Objective: To study factors associated with documented less than six-month prognosis, and its relationship with end-of-life (EOL) care quality measures among residents with cancer., Methods: The Surveillance, Epidemiology, and End Results linked with Medicare, and the Minimum Data Set databases was used to identify 20,397 NH residents in the United States with breast, colorectal, lung, pancreatic, or prostate cancer who died between July 2016 and December 2018. Of these, 2205 residents (10.8%) were documented with less than six-month prognosis upon NH admission. Main outcomes were more than one hospitalization, more than one emergency department visit, and any intensive care unit admission within the last 30 days of life as aggressive EOL care markers, as well as admission to hospice, receipt of advance care planning and palliative care, and survival. Specificity and sensitivity of prognosis were assessed using six-month mortality as the outcome. Propensity score matching adjusted for selection biases, and logistic regression examined association., Results: Specificity and sensitivity of documented less than six-month prognosis for mortality were 94.2% and 13.7%, respectively. Residents with documented less than six-month prognosis had greater odds of being admitted to hospice than those without (adjusted odds ratio: 3.27, 95% confidence interval: 2.86-3.62), and lower odds to receive aggressive EOL care., Conclusion: In this cohort study, documented less than six-month prognosis was associated with less aggressive EOL care. Despite its high specificity, however, low sensitivity limits its utility to operationalize care on a larger population of residents with terminal illness., Competing Interests: The authors report no conflicts of interest. Additional disclosures: S.M.K. reported receiving grants from the American Cancer Society, the Centers for Disease Control and Prevention, and the National Institutes of Health (NIH) and contracts from the Cleveland Clinic Foundation, including a subcontract from Celgene Corporation outside the submitted work. S.L.D. reported receiving grant funding from the NIH. M.S. reported receiving grants from Otsuka, the International Society for Bipolar Disorders, the NIH, the Centers for Disease Control and Prevention, and the Patient-Centered Outcomes Research Institute; personal fees from Alkermes, Otsuka, Sunovion, Janssen, Lundbeck, Teva, Clinical Education Alliance, and Health Analytics; and royalties from Springer Press, Johns Hopkins University Press, Oxford Press, and UpToDate outside the submitted work. J.R. reported receiving grants from NIH/National Cancer Institute during the conduct of the study; holding stock in Vinya Intelligence Inc., outside the submitted work; and having a patent issued for U.S. 270,799 B2 “In-home remote monitoring systems and methods for predicting health status decline.” No other disclosures were reported., (© Long Vu et al., 2024; Published by Mary Ann Liebert, Inc.)

Introduction: Post-traumatic seizures (PTS) are common among patients with depressed skull fractures (DSF). Understanding the burden of post traumatic seizures and the factors associated among adult patients with DSF is important to improve clinical care., Objective: To determine the prevalence and factors associated with post-traumatic seizures among adult patients with DSF at Mulago National Referral hospital (MNRH)., Methods: A cross-sectional study was conducted among 333 study participants between March 2021 and February 2022. Socio-demographic, clinical laboratory factors and anti-seizure medications were collected using a study questionnaire. Data was analysed to determine the prevalence of PTS and factors associated with occurrence of PTS among patients with DSF., Results: The mean age (±SD) of study participants was 31.2, (±10.5) years, with a male to female ratio of 10.4:1. Nearly half of the study participants had attained secondary level of education, while 31.6 % (105) were peasants (subsistence farmers). The overall prevalence of PTS among DSF study participants was 16.2 % (54participants). Late presentation of PTS was the highest at 9.0 % (30) followed by early PTS at 3.9 % [13] and immediate PTS at 3.3 % [11]. Moderate Glasgow coma score (GCS: 9-13), p < 0.015, severe traumatic brain injury (GCS: 3-8), p < 0.026 at the time of admission and midline brain shift (≥5mm), p < 0.009 were associated with PTS. Phenytoin (94.3 %) was the most commonly used ASM followed by phenobarbitone (1.4 %) and Valproate (1.1 %) among study participants., Conclusion: Patients with moderate and severe traumatic brain injury and midline brain shift were associated with post traumatic seizures. Early identification and intervention may reduce the burden of posttraumatic seizures in this category of patients., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: The Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE-BD) project pools archival datasets on older age bipolar disorder (OABD). An initial Wave 1 (W1; n = 1369) analysis found both manic and depressive symptoms reduced among older patients. To replicate this finding, we gathered an independent Wave 2 (W2; n = 1232, mean ± standard deviation age 47.2 ± 13.5, 65% women, 49% aged over 50) dataset., Design/methods: Using mixed models with random effects for cohort, we examined associations between BD symptoms, somatic burden and age and the contribution of these to functioning in W2 and the combined W1 + W2 sample (n = 2601)., Results: Compared to W1, the W2 sample was younger (p < 0.001), less educated (p < 0.001), more symptomatic (p < 0.001), lower functioning (p < 0.001) and had fewer somatic conditions (p < 0.001). In the full W2, older individuals had reduced manic symptom severity, but age was not associated with depression severity. Age was not associated with functioning in W2. More severe BD symptoms (mania p ≤ 0.001, depression p ≤ 0.001) were associated with worse functioning. Older age was significantly associated with higher somatic burden in the W2 and the W1 + W2 samples, but this burden was not associated with poorer functioning., Conclusions: In a large, independent sample, older age was associated with less severe mania and more somatic burden (consistent with previous findings), but there was no association of depression with age (different from previous findings). Similar to previous findings, worse BD symptom severity was associated with worse functioning, emphasizing the need for symptom relief in OABD to promote better functioning., (© 2024 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

Objective: Sex-specific research in adult bipolar disorder (BD) is sparse and even more so among those with older age bipolar disorder (OABD). Knowledge about sex differences across the bipolar lifespan is urgently needed to target and improve treatment. To address this gap, the current study examined sex differences in the domains of clinical presentation, general functioning, and mood symptoms among individuals with OABD., Methods: This Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) study used data from 19 international studies including BD patients aged ≥50 years (N = 1,185: 645 women, 540 men).A comparison of mood symptoms between women and men was conducted initially using two-tailed t tests and then accounting for systematic differences between the contributing cohorts by performing generalized linear mixed models (GLMMs). Associations between sex and other clinical characteristics were examined using GLMM including: age, BD subtype, rapid cycling, psychiatric hospitalization, lifetime psychiatric comorbidity, and physical health comorbidity, with study cohort as a random intercept., Results: Regarding depressive mood symptoms, women had higher scores on anxiety and hypochondriasis items. Female sex was associated with more psychiatric hospitalizations and male sex with lifetime substance abuse disorders., Conclusion: Our findings show important clinical sex differences and provide support that older age women experience a more severe course of BD, with higher rates of psychiatric hospitalization. The reasons for this may be biological, psychological, or social. These differences as well as underlying mechanisms should be a focus for healthcare professionals and need to be studied further., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objects: Studies of older age bipolar disorder (OABD) have mostly focused on "younger old" individuals. Little is known about the oldest OABD (OOABD) individuals aged ≥70 years old. The Global Aging and Geriatric Experiments in Bipolar Disorder (GAGE-BD) project provides an opportunity to evaluate the OOABD group to understand their characteristics compared to younger groups., Methods: We conducted cross-sectional analyses of the GAGE-BD database, an integrated, harmonized dataset from 19 international studies. We compared the sociodemographic and clinical characteristics of those aged <50 (YABD, n = 184), 50-69 (OABD, n = 881), and ≥70 (OOABD, n = 304). To standardize the comparisons between age categories and all characteristics, we used multinomial logistic regression models with age category as the dependent variable, with each characteristic as the independent variable, and clustering of standard errors to account for the correlation between observations from each of the studies., Results: OOABD and OABD had lower severity of manic symptoms (Mean YMRS = 3.3, 3.8 respectively) than YABD (YMRS = 7.6), and lower depressive symptoms (% of absent = 65.4%, and 59.5% respectively) than YABD (18.3%). OOABD and OABD had higher physical burden than YABD, especially in the cardiovascular domain (prevalence = 65% in OOABD, 41% in OABD and 17% in YABD); OOABD had the highest prevalence (56%) in the musculoskeletal domain (significantly differed from 39% in OABD and 31% in YABD which didn't differ from each other). Overall, OOABD had significant cumulative physical burden in numbers of domains (mean = 4) compared to both OABD (mean = 2) and YABD (mean = 1). OOABD had the lowest rates of suicidal thoughts (10%), which significantly differed from YABD (26%) though didn't differ from OABD (21%). Functional status was higher in both OOABD (GAF = 63) and OABD (GAF = 64), though only OABD had significantly higher function than YABD (GAF = 59)., Conclusions: OOABD have unique features, suggesting that (1) OOABD individuals may be easier to manage psychiatrically, but require more attention to comorbid physical conditions; (2) OOABD is a survivor cohort associated with resilience despite high medical burden, warranting both qualitative and quantitative methods to better understand how to advance clinical care and ways to age successfully with BD., (© 2024 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

In developing countries like Uganda, people with dementia are cared for by non-medically trained family members with minimal support from the formal healthcare system. The quality of care in this setting is largely unknown but significantly affects the well-being of those with dementia. A tool designed to measure the quality of informal care for old frail adults with or without dementia was translated into Luganda. A committee of experts reviewed and finalized the translation, which was pilot-tested and then used to measure the quality of dementia self-care. We consecutively enrolled 105 caregivers of elderly people with dementia; the median age was 35 years (Interquartile Range 26-47 years), and 67% were females, taking care of a grandparent (44%) or a parent (34%). We used confirmatory factor analysis to assess for structural validity and computed correlation coefficients and Cronbach's alpha to assess for discriminant validity and internal reliability, respectively. The three-factor model applied to the 20 items, adequately fit the data (Comparative Fit Index = 0.88, Tucker-Lewis Index = 0.87, Root Mean Square Error of Approximation = 0.08; 90% Confidence Interval (0.06-0.09), Standardized Root Mean Square Residual = 0.089). There was good discriminant validity, and correlation coefficients between dimensions/scales and the Dementia Knowledge Assessment Scale scores were low. There was good internal reliability with all items Cronbach's alpha ranging from 0.69 to 0.89. Our findings demonstrated that this culturally adapted, shorter measurement tool is valid and reliable. The tool can be used by researchers, health workers, and agencies to assess the quality of self-care for elderly people with dementia in Uganda., Competing Interests: Conflict of interest The authors declare no conflict of interest.

Background: While the indication for Anterior Cervical Discectomy and Fusion (ACDF) may influence the expected postoperative course, there is limited data comparing how length of stay (LOS) and disposition for patients with myelopathy differ from those with radiculopathy. This study aimed to compare LOS and discharge disposition, in patients undergoing ACDF for cervical radiculopathy versus those for myelopathy., Methods: A retrospective review of all adult ACDF cases between 2013 and 2019 was conducted analyzing sex, age, race, comorbidities, level of surgery, myelopathy measures when applicable, complications, dysphagia, hospital LOS, and discharge disposition., Results: A total of 157 patients were included in the study with 73 patients undergoing an ACDF for radiculopathy and 84 for myelopathy. Univariate analysis determined older age (p < 0.01), male sex (p = 0.03), presence of CKD (p < 0.01) or COPD (p = 0.01), surgery at C3/4 level (p = 0.01), and indication (p < 0.01) as predictors for a discharge to either acute rehabilitation or a skilled nursing facility rather than to home. Multivariate logistic regression demonstrated age and indication as the only independent predictors of disposition, with home disposition being more likely with decreased age (OR 0.92, 95 % CI 0.86-0.98) and radiculopathy as the diagnosis (OR 6.72, 95 % CI 1.22- 37.02)., Conclusions: Myelopathic patients, as compared to those with radiculopathy at presentation, had significantly longer LOS, increased dysphagia, and were more often discharged to a facility. Understanding these two distinct populations as separate entities will streamline the pre and post-surgical care as the current DRG codes and ICD 10 PCS do not differentiate the expected post-operative course in patients undergoing ACDF for myelopathy versus radiculopathy., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Bipolar disorder type 1 (BD-1) is a serious episodic mental illness whose severity can be impacted by social determinants of health (SDOH). To date the relationship of social and economic factors with health care utilization has not been formally analyzed using real-world data., Objective: To describe patient characteristics and assess the influence of SDOH on hospitalizations and costs in patients with BD-1 insured with commercial and managed Medicaid health plans., Methods: This retrospective observational study used data from the Medical Outcomes Research for Effectiveness and Economics (MORE 2 ) Registry to identify patients aged 18 years and older with evidence of BD-1 between July 1, 2016, and December 31, 2018. SDOH were linked to patients at the "near neighborhood" level (based on ZIP9 area). Multivariable models assessed the relationship between patient characteristics and hospitalizations (incidence rate ratios [95% CI]) and costs (cost ratios [95% CI])., Results: Of 243,286 patients with BD-1, 62,148 were covered by commercial insurance and 181,138 by Medicaid. Mean ages [±SD] were similar (commercial 39.8 [±14.8]; Medicaid 40.1 [±13.6]), with more female patients in both cohorts (commercial 59.8%; Medicaid 65.4%). All-cause hospitalization rates were 21.6% for commercial and 35.1% for Medicaid patients; emergency department visits were 39.7% and 64.3%, respectively. All-cause costs were $15,379 [±$27,929] for commercial and $21,474 [±$37,600] for Medicaid. Older age was a significant predictor of fewer hospitalizations compared with those aged younger than 30 years, particularly ages 40-49 for both commercial (0.60 [0.57-0.64]) and Medicaid (0.82 [0.80-0.85]). Increasing age was associated with significantly higher costs, especially age 65 and older (commercial 1.37 [1.31-1.44]); (Medicaid 1.43 [1.38-1.49]). Initial treatment with antipsychotics plus antianxiety medications was a significant predictor of higher hospitalizations (commercial 2.12 [1.98-2.27]; Medicaid 1.62 [1.57-1.68]) and higher costs (commercial 1.86 [1.80-1.92]); Medicaid 1.80 [1.76-1.84]). Household income was inversely associated with hospitalizations for Medicaid (<$30,000 [1.16 (1.12-1.19)]; $30,000-$39,999 [1.11 (1.07-1.15)]; $40,000-$49,999 [1.08 (1.05-1.12)]; $50,000-$74,999 [1.06 (1.02-1.09)]). Not speaking English well or at all was associated with 90% higher hospitalizations for commercial patients (1.93 [1.36-2.76]) but 40% fewer hospitalizations for Medicaid patients (0.59 [0.53-0.67]). Low English language proficiency was associated with significantly higher costs for commercial patients (2.22 [1.86-2.64]) but lower costs for Medicaid patients (0.57 [0.53-0.61])., Conclusions: Medicaid patients with BD-1 had high SDOH burden, hospitalizations, and costs. The association of lower English proficiency with fewer hospitalizations and lower costs in Medicaid patients suggests a potential disparity in access to care. These findings highlight the importance of addressing social risk factors to advance health equity in treatment of mental illness.

Objective: The current literature on employment in older adults with bipolar disorder (OABD) is limited. Using the Global Aging and Geriatric Experiments in Bipolar Disorder Database (GAGE-BD), we examined the relationship of occupational status in OABD to other demographic and clinical characteristics., Methods: Seven hundred and thirty-eight participants from 11 international samples with data on educational level and occupational status were included. Employment status was dichotomized as employed versus unemployed. Generalized linear mixed models with random intercepts for the study cohort were used to examine the relationship between baseline characteristics and employment. Predictors in the models included baseline demographics, education, psychiatric symptom severity, psychiatric comorbidity, somatic comorbidity, and prior psychiatric hospitalizations., Results: In the sample, 23.6% (n = 174) were employed, while 76.4% were unemployed (n = 564). In multivariable logistic regression models, less education, older age, a history of both anxiety and substance/alcohol use disorders, more prior psychiatric hospitalizations, and higher levels of BD depression severity were associated with greater odds of unemployment. In the subsample of individuals less than 65 years of age, findings were similar. No significant association between manic symptoms, gender, age of onset, or employment status was observed., Conclusion: Results suggest an association between educational level, age, psychiatric severity and comorbidity in relation to employment in OABD. Implications include the need for management of psychiatric symptoms and comorbidity across the lifespan, as well as improving educational access for people with BD and skills training or other support for those with work-life breaks to re-enter employment and optimize the overall outcome., (© 2023 The Authors. Bipolar Disorders published by John Wiley & Sons Ltd.)

Purpose: One-capsule, once-daily valbenazine is approved for tardive dyskinesia and under evaluation for chorea associated with Huntington's disease, conditions in which patients often experience dysphagia. In vitro studies were conducted to assess the suitability of crushing the contents of valbenazine capsules (40 and 80 mg) for mixing with soft foods or liquids or administration via a gastrostomy tube (G-tube)., Methods: In study 1, the dissolution of whole valbenazine capsules and crushed capsule contents were measured serially for 1 hour. In study 2, valbenazine recovery was evaluated after crushed contents were mixed with soft foods, buffer solutions (pH range, 1.2-6.8), and fed-state simulated gastric fluid. In study 3, valbenazine recovery was evaluated after crushed contents were dispersed in water and delivered via a G-tube. In studies 2 and 3, acceptable valbenazine recovery was 90% to 110%., Findings: Study 1 indicated rapid and complete drug release for whole valbenazine capsules and crushed capsule contents, with similar release at 10 minutes (whole, 94%-99%; crushed, 98%-100%) and 60 minutes (whole, 101%-103%; crushed, 101%-102%). Study 2 found acceptable valbenazine recovery within 2 hours of adding crushed capsule contents to tested foods, buffers, or fed-state simulated gastric fluid (recovery, 92%-102%). Study 3 found acceptable valbenazine recovery when crushed contents were added to cold or hot water and delivered via G-tube, with a water cup rinse to capture residual contents (recovery, 91%-97%)., Implications: These studies indicate the potential viability of valbenazine formulation(s) that can be added to soft foods or liquids or delivered via G-tube. Such formulations will be important for individuals who require treatment with a vesicular monoamine transporter 2 inhibitor but cannot swallow whole pills., Competing Interests: Declaration of Competing Interest The three studies included in this report were supported by Neurocrine Biosciences, Inc. MS has received the following: research grants within past 3 years from International Society for Bipolar Disorders (ISBD), National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Patient-Centered Outcomes Research Institute (PCORI), Merck, Otsuka, Alkermes; consultant fees in the past 1 year from Alkermes, Otsuka, Janssen, Lundbeck, Teva, Neurelis; royalties in the past 1 year from Springer Press, Johns Hopkins University Press, Oxford Press, UpToDate; and compensation in the past 1 year for CME preparation/participation in CME activities: American Physician's Institute (CMEtoGo), Psychopharmacology Institute, American Epilepsy Society, Clinical Care Options, American Academy of Child and Adolescent Psychiatry, Neurocrine. AP has received consulting fees from Neurocrine Biosciences, Inc. All remaining authors are full-time employees of Neurocrine Biosciences, Inc., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

The study set out to perform a systematic literature review of evidence-based interventions that target the reduction of secondary stroke risk in Africa. The review analyzed longitudinal intervention studies conducted in Sub-Saharan Africa, focusing on adult participants who had suffered a prior stroke. It encompassed publications and peer-reviewed papers sourced from reputable databases, including PubMed, Ovid, Cochrane, and Web of Science. Three randomized clinical trial (RCT) studies were included with sample sizes ranging from 16 to 400 participants, mean age ranged between 50 and 66 years, with 64.5% male participants. All studies applied multidisciplinary team interventions of enhanced patient follow-up involving care givers, nurse educators, physicians, and social workers. Interventions ranged from comprehensive patient education, tracking of medication adherence and enforcing healthy lifestyle behaviors (regular exercise, regular BP checks, and dietary changes). We found a decrease in Systolic Blood Pressure over time in 2 of 3 treatment groups, an improvement in medical adherence in all treatment groups, and a decrease in cholesterol levels in 1 treatment group. Evidence-based interventions involving multidisciplinary teams and comprehensive patient education were found to demonstrate promising results in reducing secondary stroke risk in Africa, leading to significant improvements in medical adherence and reductions in systolic blood pressure in the majority of treatment groups. However, more research is required to confirm the influence of these interventions on cholesterol levels and to establish their lasting advantages in preventing strokes among African communities., Competing Interests: Shirley Moore and Martha Sajatovic report grants from NIH, during the conduct of the study; Martha Sajatovic reports grants from Otsuka, Alkermes, International Society for Bipolar Disorders (ISBD), National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Patient-Centered Outcomes Research Institute (PCORI), and personal fees from Alkermes, Otsuka, Janssen, Lundbeck, Teva, Neurelis, Springer Press, Johns Hopkins University Press, Oxford Press, UpToDate, outside the submitted work; The authors report no other conflicts of interest in this work., (© 2023 Kaddumukasa et al.)

Background: By 2030, over 50% of individuals living with bipolar disorder (BD) are expected to be aged ≥50 years. However, older age bipolar disorder (OABD) remains understudied. There are limited large-scale prospectively collected data organized in key dimensions capable of addressing several fundamental questions about BD affecting this subgroup of patients., Methods: We developed initial recommendations for the essential dimensions for OABD data collection, based on (1) a systematic review of measures used in OABD studies, (2) a Delphi consensus of international OABD experts, (3) experience with harmonizing OABD data in the Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE-BD, n ≥ 4500 participants), and (4) critical feedback from 34 global experts in geriatric mental health., Results: We identified 15 key dimensions and variables within each that are relevant for the investigation of OABD: (1) demographics, (2) core symptoms of depression and (3) mania, (4) cognition screening and subjective cognitive function, (5) elements for BD diagnosis, (6) descriptors of course of illness, (7) treatment, (8) suicidality, (9) current medication, (10) psychiatric comorbidity, (11) psychotic symptoms, (12) general medical comorbidities, (13) functioning, (14) family history, and (15) other. We also recommend particular instruments for capturing some of the dimensions and variables., Conclusion: The essential data dimensions we present should be of use to guide future international data collection in OABD and clinical practice. In the longer term, we aim to establish a prospective consortium using this core set of dimensions and associated variables to answer research questions relevant to OABD., (© 2023 John Wiley & Sons Ltd. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: Studies examining end-of-life (EOL) care in older cancer patients are scarce, and prior studies have not accounted for gradients of cognitive impairment (COG-I). We examine EOL care patterns across COG-I gradients, hypothesizing that greater COG-I severity is associated with lower odds of receiving aggressive EOL care., Methods: Using data from the linked Surveillance Epidemiology and End Results (SEER) -Medicare -Minimum Data Set (MDS) 3.0, we identified patients with nursing facility stays (NFS) and who died with metastatic cancer from 2013 to 2017. Markers of aggressive EOL care were: cancer-directed treatment, intensive care unit admission, >1 emergency department visit, or >1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to evaluate the independent association between COG-I severity and receipt of aggressive EOL care., Results: Of the 40,833 patients in our study population, 49.2% were cognitively intact; 24.4% had mild COG-I; 19.7% had moderate COG-I; and 6.7% had severe COG-I. The percent of patients who received aggressive EOL care was 62.6% and 74.2% among those who were cognitively intact and those with severe COG-I, respectively. Compared with cognitively intact patients, those with severe COG-I had 86% higher odds of receiving any type of aggressive EOL care (adjusted odds ratio (aOR): 1.86 (95% confidence interval: 1.70-2.04)), which were primarily associated with higher odds of in-hospital death. The odds of in-hospital death associated with severe COG-I were higher among those with short- than with long-term stays (aOR:2.58 (2.35-2.84) and aOR:1.40 (1.17-1.67), respectively)., Conclusions: Contrary to our hypothesis, aggressive EOL care in older metastatic cancer patients with NFS was highest among those suffering severe COG-I. These findings can inform the development of interventions to help reduce aggressive EOL care in this patient population., (© 2023 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Stroke outcomes among young adults in Uganda are unclear. This study therefore determined the clinical characteristics and 30-day outcome among young adults with an acute stroke. In a prospective observational cohort study, 61 young adults with confirmed stroke were followed up for 30 days. Socio-demographic and clinical characteristics were collected using a study questionnaire. Kaplan-Meier curves, and modified Poisson regression were performed for factors associated with the 30-day mortality outcome. A third of the screened stroke survivors, (61/195) were young adults aged between 18 and 50 years. About two-thirds were male. More than half were diagnosed with ischaemic strokes while 42.6% had a haemorrhagic stroke. Nearly half (29/61) were known hypertensives, 43% (26/61) had a history of alcohol consumption with 95% classified as dependent on CAGE assessment. Ten percent had a prior smoking history while 29% of the female gender had a prior history of oral contraception use. Twenty-three percent (14/61) of the young stroke patients died within 30 days of stroke onset (95% CI: 0.01, 0. 901). A history of smoking (adjusted prevalence ratio: aPR;5. 094, 95% CI: 3.712, 6. 990) and stroke severity National Institutes of Health Stroke score (NIHSS) >16; Prevalence ratio (PR) -3. 301, 95%CI: 1. 395, 7. 808) and not drinking alcohol (aPR (adjusted prevalence ratio) -7. 247, 95% CI: 4. 491, 11.696) were associated with 30- day mortality. A third of all stroke survivors were young adults. About 23. 3% died within 30 days of stroke onset. Stroke severity and a history of smoking were associated with mortality. Identifying high risk patients and early outpatient follow up may help reduce the 30-day mortality in our settings., Competing Interests: The authors have declared that no competing interests exist, (Copyright: © 2023 Nampogo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Despite advancements in acute stroke care, acute stroke patients present late for care resulting in high mortality and poor functional outcomes. This study determined the prevalence of pre-hospital delay and associated factors among adult acute stroke patients in Uganda., Methods: In a hospital based, cross-sectional study, one hundred and forty-three study participants with confirmed acute stroke presenting to the emergency units of Mulago and Kiruddu national referral hospitals were enrolled. Using an interviewer-administered questionnaire, details on sociodemographics, onset of stroke, arrival at the tertiary facility, health system and clinical factors were collected. Descriptive statistics and modified Poisson regression analyses were performed to determine factors associated with prehospital delay., Results: Among the 143 study participants, nearly two-thirds (79/146) had ischemic stroke while a third (59/143) had haemorrhagic stroke. The mean age was 59 years (SD 16) and 51.7% of acute stroke patients were males. Ninety one percent (130/143) presented to the emergency unit after 3 hours. The majority (124/143) reported visiting lower-level facilities prior to referral to the tertiary facility. Staying outside Kampala district (PR: 1.28 (1.22-1.34), p < 0.001), and using hired or government ambulance for transport to tertiary facility (PR: 1.17 (1.13-1.20), p < 0.001) were associated with pre-hospital delay., Conclusions: Prevalence of pre-hospital delay among acute stroke patients presenting to public tertiary hospitals in Uganda is very high. The causes of pre hospital delay should be further explored qualitatively. Efforts to reduce prehospital delay should include improving pre-hospital transport systems for stroke patients., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Studies show that fibrinogen concentrations <2 g/L in patients with traumatic brain injury (TBI) is associated with increased mortality. However, little is known regarding fibrinogen levels and TBI severity as well as mortality in sub-Saharan Africa despite shouldering a high burden of TBI. We therefore set out to determine whether fibrinogen levels are associated with TBI severity and outcome. To determine the sensitivity and specificity of fibrinogen levels and the association with severity and mortality among TBI patients at Mulago Hospital. We prospectively enrolled 213 patients with TBI aged between 13 and 60 years of age and presenting within 24 hours of injury. Patients with preexisting coagulopathy, concurrent use of anticoagulant or antiplatelet agents, preexisting hepatic insufficiency, diabetes mellitus and who were pregnant were excluded. Fibrinogen levels were determined using the Clauss fibrinogen assay. Logistic regression analyses were conducted to identify the association between fibrinogen level and 7-day outcomes. Majority of the patients were male (88.7%) and nearly half were aged 30 or less (48.8%). Fibrinogen levels <2 g/L were observed in 35.1% of the study participants. The average time spent in the study was 3.7 ± 2.4 days. The sensitivity and specificity using fibrinogen <2 g/L was 56.5% and 72.9% respectively. Fibrinogen levels predict TBI severity with an AUC = 0.656 (95% CI 0.58-0.73: P = .000) Fibrinogen levels <2 g/L (hypofibrinogenemia) were independently associated with severe TBI. (Adjusted odds ratio 2.87 CI, 1.34-6.14: P = .007). Levels above 4.5 g/L were also independently associated with injury severity (adjusted odds ratio 2.89, CI 1.12-7.48: P < .05) Fibrinogen levels more than 4.5 g/L were independently associated with mortality (OR 4.5, CI; 1.47-13.61, P < .05). The fibrinogen level is a useful tool in predicting severity including mortality of TBI. Fibrinogen levels may be used as an additional tool to screen TBI patients for injury severity especially among patients with Glasgow coma scale scores of <14., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Greater blood pressure variability has detrimental effects on clinical outcome after a stroke; its effects are controversial and have not been evaluated in Sub-Saharan Africa (SSA)., Methods: We conducted a prospective study of patients with CT head confirmed ischemic and hemorrhagic strokes admitted to a tertiary hospital within 7 days of onset of unilateral neurological deficits. Blood pressure variability indices, standard deviation (SD) and coefficient of variation (CV) of systolic and diastolic blood pressure between day 0 and day 7, were calculated with a subsequent modified Rankin Scale (mRS) score on day 14 post-stroke. Linear regression was performed to determine the exponential coefficients of mortality at 14 days post- stroke., Results: Out of 120 patients, 51.7% were female, 52.5% had ischemic stroke and the overall median age was 65 (IQR 54-80) years. Twenty (16.7%) patients died within a median survival time of 7 days, while 32 (26.7%) died by day 14 post-stroke. Patients with hemorrhagic stroke had an overall SDSBP of 16.44 mmHg while those with ischemic stroke had an overall SDSBP of 14.05 mmHg. In patients with ischemic stroke, SDSBP had adjusted coefficients of 1, p  = 0.004 with C·I: 1.01-1.04 and NIHSS had adjusted coefficients of 1, p  = 0.019 with C·I: 1.00-1.03 while in patients with hemorrhagic stroke, SDSBP had adjusted coefficients of 1, p  = 0.045 with C·I: 1.00-1.04 and NIHSS had adjusted coefficients of 1, p  ≤0.001 with C·I: 1.01-1.03., Conclusion: Exponential increase in Blood Pressure Variability (BPV) and stroke severity scale were independently associated with early mortality among all stroke patients in our study. We recommend future studies to evaluate whether controlling BPV among patients with stroke in Sub-Saharan Africa can reduce mortality., Competing Interests: The authors declare that they have no competing interests., (© 2023 The Authors. Published by Elsevier B.V.)

Objectives: Persistent functional impairment is common in bipolar disorder (BD) and is influenced by a number of demographic, clinical, and cognitive features. The goal of this project was to estimate and compare the influence of key factors on community function in multiple cohorts of well-characterized samples of individuals with BD., Methods: Thirteen cohorts from 7 countries included n = 5882 individuals with BD across multiple sites. The statistical approach consisted of a systematic uniform application of analyses across sites. Each site performed a logistic regression analysis with empirically derived "higher versus lower function" as the dependent variable and selected clinical and demographic variables as predictors., Results: We found high rates of functional impairment, ranging from 41 to 75%. Lower community functioning was associated with depressive symptoms in 10 of 12 of the cohorts that included this variable in the analysis. Lower levels of education, a greater number of prior mood episodes, the presence of a comorbid substance use disorder, and a greater total number of psychotropic medications were also associated with low functioning., Conclusions: The bipolar clinical research community is poised to work together to characterize the multi-dimensional contributors to impairment and address the barriers that impede patients' complete recovery. We must also identify the core features which enable many to thrive and live successfully with BD. A large-scale, worldwide, prospective longitudinal study focused squarely on BD and its heterogeneous presentations will serve as a platform for discovery and promote major advances toward optimizing outcomes for every individual with this illness.Reprinted from Bipolar Disord 2022; 24:709-719 , with permission from John Wiley and Sons. Copyright © 2022., (Copyright © 2023 by the American Psychiatric Association.)

Background: The onset of type 2 diabetes (T2D) is increasingly common in adolescents and young adults (AYAs). Improving self-management skills and the mental health of this population is important, but understudied., Methods: The goal of this research was to develop a mind-body intervention which could serve as an adjunctive therapy to support AYAs with T2D (INTEND intervention). Toward that end, we used an iterative process, including use of focus groups, advisory board, and cognitive semi-structured interviews with patients, parents of patient and clinical providers, to understand the gaps in the current information provided to AYAs with T2D. Based on the data gathered from the focus groups and interviews, we enhanced an existing self-management intervention for adults with T2D to include an additional mind body intervention for AYAs with T2D. The INTEND intervention will be piloted in a group of AYAs with T2D., Results: This report describes the methodology and design of the InterveNTion for Early oNset type 2 Diabetes (INTEND) study. The details of this single arm pre-post pilot feasibility trial are described., Discussion: If successful, the INTEND approach has the potential to advance care for vulnerable youth with T2D., Competing Interests: Declaration of Competing Interest The authors express no conflicts of interest for the writing this article., (Copyright © 2023. Published by Elsevier Inc.)

The term older-age bipolar disorder (OABD) refers to patients with bipolar disorder who are ages 50 and older. Research findings suggest important differences, including the attenuation of manic symptoms with age and the occurrence of multiple somatic comorbid conditions. Although the pharmacological treatment of OABD is fairly similar, adverse effects, somatic comorbidity, and drug-drug interactions are more common. Lithium is effective in treating OABD and may have the potential to be neuroprotective. Anticonvulsants and second-generation antipsychotics have a growing evidence supporting their use in treating OABD. Behavioral intervention can be a helpful adjunct to pharmacological treatment. Clinicians and health care systems need to be prepared to provide care and services to individuals with bipolar disorder throughout the life span. Although older adults have typically been excluded from bipolar disorder RCTs, emerging efforts organized by global advocates and harnessing teams of clinicians and scientists have the potential to advance care., Competing Interests: Dr. Sajatovic has received research funding from the International Society for Bipolar Disorders, the National Institutes of Health, the Centers for Disease Control and Prevention, and the Patient-Centered Outcomes Research Institute. Dr. Sajatovic has also been a consultant to Alkermes, Otsuka, Janssen, Lundbeck, Teva, and Neurelis and has received publication royalties from Springer Press, Johns Hopkins University Press, Oxford Press, and UpToDate. Dr. Sajatovic has received compensation for preparation of and/or participation in continuing medical education activities from the American Physician Institute (CMEtoGO), the Psychopharmacology Institute, the American Epilepsy Society, Clinical Care Options, the American Academy of Child and Adolescent Psychiatry, and Neurocrine. Dr. Sekhon has received postdoctoral fellowship awards from the Canadian Institutes of Health Research, and AGE-WELL. The other authors report no financial relationships with commercial interests., (Copyright © 2023 by the American Psychiatric Association.)