Faculty Bibliography

BACKGROUND AND OBJECTIVES: We examined the association between the conjoint developmental trajectories of body mass index (BMI) and marijuana use from age 24 to age 32 and short sleep duration. METHODS: The participants included 158 African American male, 267 African American female, 166 Puerto Rican male, and 225 Puerto Rican female young adults (N = 816). Using Mplus, we obtained the conjoint trajectories of BMI and marijuana use. Logistic regression analyses examined the association between the conjoint trajectories and short sleep duration. RESULTS: Five conjoint trajectory groups were extracted: normal BMI and no or low marijuana use, obese and no or low marijuana use, morbidly obese and some marijuana use, normal BMI and high marijuana use, and obese and high marijuana use. Those in the obese and no or low marijuana use group, the morbidly obese and some marijuana use group, and the obese and high marijuana use group were more likely to report shorter sleep duration than those with normal BMI and no or low marijuana use group. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: This study highlights the significance of examining joint trajectories over several developmental stages. In treating short sleep duration, we propose focusing on treating obesity, and also treating marijuana use if applicable. (Am J Addict 2014;23:176-183).

Abstract Objectives: There is debate about whether marijuana (cannabis) use is more dangerous than alcohol use. Although difficult to make objective comparisons, research is needed to compare relative dangers in order to help inform preventive efforts and policy. Methods: Data were analyzed from a nationally representative sample of high school seniors in the Monitoring the Future study (2007-2011; Weighted n = 7437; modal age: 18) who reported lifetime use of alcohol or marijuana. Students were asked to indicate whether they experienced various adverse psychosocial outcomes resulting from use of each substance. We examined which outcomes were more prevalent for each substance. Results: Compared to alcohol use, marijuana use was more commonly reported to compromise relationships with teachers or supervisors, result in less energy or interest, and result in lower school or job performance. Compared to marijuana use, alcohol was more commonly reported to compromise relationships with friends and significant others; it was also reported to lead to more regret (particularly among females), and driving unsafely. Marijuana users were more likely to report no adverse outcomes. Females and white students were more likely to report various adverse outcomes and higher frequency use of each substance also increased occurrences of reported adverse outcomes. Conclusions: Marijuana and alcohol are associated with unique adverse psychosocial outcomes. Outcomes differ by sex and race/ethnicity, and perception or experience of outcomes may also be related to legal status and associated stigma. Public health interventions may be more effective by focusing on harm reduction strategies for these drug-specific outcomes.

OBJECTIVE: We sought to examine the relationship of family history of headache and family history of psychiatric disorders on self-reported health care utilization tendencies for migraine treatment. BACKGROUND: Familial aggregation of both migraine and depression has been well established in the literature. Family history of headache and psychiatric disorders could influence health care utilization tendencies for migraine. METHODS: This is a secondary analysis of patients with severe migraine (n = 225) who answered questions about their family history, previous headache treatment history, disability (Headache Disability Inventory), and psychiatric symptoms (Beck Depression Inventory and Beck Anxiety Inventory). Using regression, we examined the relationship between family history of headache, depression, and anxiety and reported headache-related health care utilization. RESULTS: Participants reported family histories of headache (67.6%), anxiety (15.6%), and depression (29.3%). Participants reported seeing a physician for headache an average of 3.1 (standard deviation = 3.8) times in the past 2 years. In a 2-year period, 27.6% of participants reported seeing a general practitioner and 18.5% of participants reported seeing a neurologist. Twenty-eight percent of participants went to urgent care for headaches at least once in the last 2 years. Thirty-nine percent of participants reported using non-pharmacologic treatment for headache in the prior 2 years, with the highest rates of chiropractic manipulation (27.1%) and massage (18.2%), and fewest rates of biofeedback (0.4%), relaxation training (4.4%), psychotherapy (1.8%), physical therapy (4.9%), or acupuncture (1.8%). Family history of anxiety was associated with trying non-pharmacologic treatments for headache, but no other self-reported health care utilization variable. However, neither family history of headache nor family history of depression was associated with self-reported health care utilization tendencies. Headache Disability Inventory was associated with self-reported non-pharmacologic treatments for headache. CONCLUSIONS: Family history of anxiety, but not depression, was associated with utilizing non-pharmacologic treatments for headache. Also, disability was associated with utilizing non-pharmacologic treatments for headache. However, participants reported low rates of utilization for non-pharmacologic treatments with grade-A evidence.

Patients presenting with tinnitus commonly have neuropsychiatric symptoms with which physicians need to be familiar. We provide an overview of tinnitus, including its types and pathophysiology. We discuss how recent methods such as transcranial magnetic stimulation, positron emission tomography, MRI, magnetoencephalography and quantitative EEG improve our understanding of the pathophysiology of tinnitus and connect tinnitus to the neuropsychiatric symptoms. We then explain why treatment of the tinnitus patient falls within the purview of neuropsychiatry. Psychiatric problems such as depression, anxiety and personality disorders are discussed. We also discuss how stress, headache, cognitive processing speed and sleep disturbance are associated with tinnitus. Finally, we provide a brief overview of treatment options and discuss the efficacy of various medications, including benzodiazepines, antidepressants, antipsychotics and mood-stabilising agents, and various non-pharmacological treatment options, such as cognitive behavioural therapy, habituation therapy and acupuncture. We also discuss how brain stimulation therapies are being developed for the treatment of tinnitus. In conclusion, a review of the literature demonstrates the varied neuropsychiatric manifestations of tinnitus. Imaging studies help to explain the mechanism of the association. However, more research is needed to elucidate the neurocircuitry underlying the association.

Head pain is the fifth most common reason for emergency department (ED) visits. It is second only to focal weakness as the most common reason for neurological consultation in the ED. This manuscript reviews how patients with migraine, the most common primary headache disorder for which patients seek medical treatment, are managed in the ED. We discuss existing guidelines for head imaging in patients with migraine, recommended pharmacologic treatments, and current treatment trends. We also review studies evaluating the discharge care of migraine patients in the ED. With the goal of standardizing, streamlining, and optimizing ED-based migraine care, we offer ideas for future research to improve the evaluation, treatment, and discharge care of patients who present to an ED with acute migraine.

OBJECTIVE: To examine how psychiatric comorbidities in migraineurs in the emergency department (ED) affect healthcare utilization and treatment tendencies. METHOD: This is a cross-sectional analysis of 2872 patients who visited our ED over a 10-year period and were given a principal diagnosis of migraine. RESULTS: Compared to migraineurs without a psychiatric comorbidity, migraineurs with a psychiatric comorbidity had about three times more ED visits, six times more inpatient hospital stays and four times more outpatient visits. Migraineurs with psychiatric comorbidities received narcotics in the ED more often than migraineurs without psychiatric comorbidities (P<0.0001). In addition, migraineurs with psychiatric disorders were more likely to have a computed tomography scan of the head [Risk Ratio (RR) 1.42 (95% confidence interval (CI)=1.28-1.56, P<0.001)] or a magnetic resonance image of the brain [RR 1.53 (95% CI=1.33-1.76, P<0.001)] than patients without a psychiatric disorder when visiting our hospital center. CONCLUSIONS: Migraineurs with psychiatric comorbidity who visit the ED have different healthcare utilization tendencies than migraineurs without psychiatric comorbidity who visit the ED. This is seen in the frequency of ED visits, outpatient visits and inpatient stays, in the medications administered to them and in the radiology tests they undergo.

BACKGROUND: Schizophrenia is a disorder of brain connectivity and altered neurodevelopmental processes. Cross-sectional case-control studies in different age groups have suggested that deficits in cortical thickness in childhood-onset schizophrenia may normalize over time, suggesting a disorder-related difference in cortical growth trajectories. METHODS: We acquired magnetic resonance imaging scans repeated over several years for each subject, in a sample of 106 patients with childhood-onset schizophrenia and 102 age-matched healthy volunteers. Using semiparametric regression, we modeled the effect of schizophrenia on the growth curve of cortical thickness in ~80,000 locations across the cortex, in the age range 8 to 30 years. In addition, we derived normative developmental modules composed of cortical regions with similar maturational trajectories for cortical thickness in typical brain development. RESULTS: We found abnormal nonlinear growth processes in prefrontal and temporal areas that have previously been implicated in schizophrenia, distinguishing for the first time between cortical areas with age-constant deficits in cortical thickness and areas whose maturational trajectories are altered in schizophrenia. In addition, we showed that when the brain is divided into five normative developmental modules, the areas with abnormal cortical growth overlap significantly only with the cingulo-fronto-temporal module. CONCLUSIONS: These findings suggest that abnormal cortical development in schizophrenia may be modularized or constrained by the normal community structure of developmental modules of the human brain connectome.

OBJECTIVES: Emergency physician threshold to test for acute coronary syndrome (ACS) is directly related to ACS diagnosis rate and inversely related to ACS missed diagnosis rate. Feedback to emergency physicians of information on their prior patients whose ACS diagnosis was not identified may improve physician diagnostic performance. METHODS: A critical pathway for evaluation of patients for ACS was modified to include feedback to physicians on their cases who had a return visit and did not have their ACS diagnosis identified at their prior emergency department visit. Feedback included case-specific details, discussion of the case at the monthly Morbidity and Mortality conference, and a yearly a report to each physician comparing their performance to their peers (ACS evaluation rate, ACS diagnosis rate, and ACS missed diagnosis rate). Cases were identified, and physician-specific performance was calculated from a computerized encounter database at 2 community teaching hospitals. RESULTS: During the study period, 29 emergency physicians evaluated 295,758 patients and identified 6472 ACS cases. During the study, the yearly ACS evaluation rate for individual physician ranged from 19% to 70% (average 40.3%; 95% confidence interval [CI], 39.5%-41.1%), the yearly ACS diagnosis rate for individual physician ranged from 1.1% to 4.2% (average 1.7%; 95% CI, 1.65%-1.75%), and the yearly missed ACS diagnosis rate for individual physician ranged from 0% to 17% (average 2.8%; 95% CI, 2.3%-3.3%). Individual physician ACS evaluation rate was directly related to physician ACS diagnosis rate (r 0.76, P = 0.00012) and was inversely related to that physician missed ACS rate (r 0.45, P = 0.001). During the study, implementation of the critical pathway increased the ACS evaluation rate from 30% to 48% and decreased the ACS missed diagnosis rate from 1.5% to 0.3%. CONCLUSIONS: Emergency physicians with lower threshold for ACS evaluation more frequently diagnose patients with ACS and less frequently miss the diagnosis of ACS. Feedback to emergency physicians of information on their patient's return visits and their own diagnostic performance may improve outcome for patients with ACS.

Management of uncomplicated type B aortic dissection is traditionally medical with aggressive blood pressure management. However, a significant cohort of these medically managed patients develop the need for late intervention, contributing to long-term morbidity and mortality. While medical therapy remains best for most, evidence continues to mount supporting early intervention in subgroups of patients with certain anatomic characteristics and comorbidities

OBJECTIVES: To determine whether greater burden of geriatric conditions would have contrasting effects on quality of care (QOC) than nongeriatric, general medical conditions. DESIGN: Cross-sectional observation over 1 year of ambulatory care. SETTING: The Assessing Care of Vulnerable Elders-2 study. PARTICIPANTS: Older adults prospectively screened for falls, incontinence, and dementia (N = 644). MEASUREMENTS: Participant-level QOC in absolute percentage points calculated using 65 ambulatory care care-process quality indicators (QIs) for 13 general medical and geriatric conditions (#QIs provided/#QIs eligible). Secondary outcomes were geriatric QOC (a subset of 38 geriatric care QIs) and medical QOC (the 27 remaining nongeriatric QIs). Exposure variables were number of six medical conditions (medical comorbidity) and six geriatric conditions (geriatric comorbidity), controlling for age, sex, number of primary care visits, and site. RESULTS: Medical and geriatric comorbidity were unrelated to each other (correlation coefficient = 0.04, P = .27) yet had opposite effects on QOC. Each additional medical condition was associated with a 3.2-percentage point (95% confidence interval (CI) = 2.3-4.2 percentage point) increment in QOC, and each additional geriatric condition was associated with 4.9-percentage point (95% CI = 3.5-6.5 percentage point) decrement in QOC. Participants with greater geriatric comorbidity received poorer medical and geriatric QOC. CONCLUSION: Greater burden of geriatric conditions, or geriatric multimorbidity, is associated with poorer QOC. Geriatric multimorbidity should be targeted for better care using a comprehensive approach.