Avnish Tripathi

A cohort study of the prevalence and impact of comorbid medical conditions in pediatric bipolar disorder.

OBJECTIVE To identify the association between medical or psychiatric comorbidities, clinical characteristics, or course of illness/recovery in pediatric bipolar disorder (BD). METHOD Data from the South Carolina Medicaid program covering all medical services and medication prescriptions between January 1996 and December 2005 were used to analyze the temporal onset of 12 comorbid medical or psychiatric conditions for 1,841 children and adolescents diagnosed with BD using DSM-IV-TR criteria and for a random sample of 4,500 children not treated for psychiatric disorders. The primary outcome measures were diagnostic codes and regression analyses of patterns of acute and outpatient treatment services for BD over time. RESULTS Ten conditions examined were significantly more prevalent in the BD cohort: obesity, type 2 diabetes mellitus, endocrine disorders, migraine headaches, central nervous system (CNS) disorders/epilepsy, organic brain disorders/mental retardation, cardiovascular disorders, attention-deficit/hyperactivity disorder (ADHD), asthma, and substance abuse (P ≤ .01). For clinical characteristics within the BD cohort, an adolescent-onset diagnosis of BD (age ≥13 years) was significantly associated with the diagnosis of preexisting obesity, hypertension, migraine, mental retardation, endocrine disorders, and substance abuse (P ≤ .05), whereas recurrent depressive episodes were associated with preexisting endocrine disorders and substance abuse. Preexisting ADHD, substance abuse, CNS disorders/epilepsy, cardiovascular disorders, obesity, and asthma were associated with higher overall medical and psychiatric outpatient and acute service use, but none of these comorbid disorders differentially impacted the course of illness or recovery for BD. CONCLUSIONS Neuropsychiatric (ie, ADHD, substance abuse, CNS disorders/epilepsy) and medical (ie, obesity, asthma, cardiovascular disease) disorders temporally precede the diagnosis of early-onset BD in pediatric patients and are associated with discrete facets of illness presentation, but they do not substantially alter the clinical course of the BD over time.

Preexposure prophylaxis for HIV infection: healthcare providers' knowledge, perception, and willingness to adopt future implementation in the southern US.

Background Understanding providers’ perspective on preexposure prophylaxis (PrEP) would facilitate planning for future implementation. Methods A survey of care providers from sexually transmitted disease and family planning clinics in South Carolina and Mississippi was conducted to assess their knowledge, perception, and willingness to adopt PrEP. Multivariable logistic and general linear regression with inverse propensity score treatment weights were used for analyses. Results Survey response rate was 360/480 (75%). Median age was 46.9 years and a majority were women (279 [78%]), non-Hispanic white (277 [78%]), nonphysicians (254 [71%]), and public health care providers (223 [62%]). Knowledge about PrEP was higher among physicians compared with nonphysicians (P = 0.001); nonpublic health care providers compared with public health care providers (P = 0.023), and non-Hispanic whites compared with non-Hispanic blacks (P = 0.034). The majority of the providers were concerned about the safety, efficacy, and cost of PrEP. Providers’ perceptions about PrEP were significantly associated with their sociodemographic and occupational characteristics. The willingness to prescribe PrEP was more likely with higher PrEP knowledge scores (adjusted odds ratio [aOR] 14.94; 95% confidence interval [CI] 3.21–69.61), older age (aOR 1.14; 95% CI 1.01–1.29), and in those who agreed that “PrEP would empower women” (aOR 2.90; 95% CI 1.28–6.61); and was less likely for “other” race/ethnicity versus white (aOR 0.23; 95% CI 0.07–0.76) and in those who agreed that “PrEP, if not effective, could lead to higher HIV transmission” (aOR 0.45; 95% CI 0.27–0.75). Conclusions To improve the acceptance of PrEP among providers, there is a need to develop tailored education/training programs to alleviate their concerns about the safety and efficacy of PrEP.

Incidence of diabetes mellitus in a population-based cohort of HIV-infected and non-HIV-infected persons: the impact of clinical and therapeutic factors over time.

To examine incidence density rate and correlates of incident diabetes mellitus in a cohort of HIV‐infected individuals compared with matched non‐HIV‐infected persons.

Transmitted antiretroviral drug resistance in individuals with newly diagnosed HIV infection: South Carolina 2005-2009.

Objectives: The transmission of drug-resistant human immunodeficiency virus 1 (HIV-1) has important implications for the antiretroviral management of newly diagnosed individuals, increasing the risk of suboptimal treatment outcomes. The study objective was to characterize rates and factors associated with transmitted drug-resistant HIV-1 infection among newly diagnosed South Carolina (SC) residents. Methods: This study utilized surveillance genotypic data from antiretroviral therapy (ART)-naïve individuals newly diagnosed with HIV-1 infection from June 2005 through December 2009. Multivariable negative binomial regression was used to model the association between the presence of major mutations and sociodemographic characteristics. Results: Of the 1,277 study participants, 14.4% (184/1,277) had HIV-1 variants with major antiretroviral drug mutations. Of these individuals, 126 had non-nucleoside reverse transcriptase inhibitor-associated mutations (NNRTI), 54 had nucleos(t)ide reverse transcriptase inhibitor-associated mutations (NRTI), 37 had protease inhibitor-associated mutations (PI). Nineteen (10.3%) individuals had dual class-associated mutations (NNRTI and PI in seven, NNRTI and NRTI in seven, and NRTI and PI in five individuals), and seven (3.8%) individuals had triple drug class-associated mutations (PI, NNRTI, and NRTI). The multivariable negative binomial regression models indicated that age at HIV diagnosis had a significant negative association with total number of mutations (rate ratio [RR] 0.88, 95% confidence interval [CI] 0.80–0.96, P value = 0.005) and total number of reverse transcriptase (RT) mutations (RR 0.88, 95% CI 0.80–0.97, P value = 0.006) present. Conclusion: Prevalence of transmitted drug resistance is consistently high among newly diagnosed HIV-infected individuals in SC. It is important to continue genotypic surveillance to facilitate effective HIV treatment and empiric post-exposure prophylaxis regimens.

Prevalence and treatment of depression in children and adolescents with sickle cell disease: a retrospective cohort study.

OBJECTIVE To describe the prevalence and treatment of comorbid depressive disorders in children and adolescents diagnosed with sickle cell disease. METHOD A retrospective cohort design evaluating South Carolina Medicaid medical and pharmacy claims between January 1, 1996, and December 31, 2006, was employed to identify 2,194 children and adolescents aged 17 years and younger diagnosed with sickle cell disease. Cohorts diagnosed with and without comorbid unipolar depressive disorders (using DSM-IV-TR criteria) were then compared. RESULTS Forty-six percent of the sickle cell disease cohort was diagnosed with a depressive disorder (n = 1,017), either dysthymia (90%) or major depressive disorder (10%). Dysthymia was diagnosed at approximately 9 years of age, whereas major depressive disorder was diagnosed at approximately 14 years of age. Compared with the controls, the sickle cell disease cohort with depression had more acute vaso-occlusive pain and acute chest syndrome visits per year, developed more complications with related organ damage, and incurred significantly higher outpatient, acute (emergency + inpatient), and total sickle cell disease care costs. The depression cohort was primarily treated with selective serotonin reuptake inhibitors (SSRIs; 12%) or serotonin-norepinephrine reuptake inhibitors (SNRIs; 10%) for approximately 9 months. Although alleviating the comorbid depression might positively affect their sickle cell disease pain, over 80% of the patients received no antidepressant medications, and many of the prescribed SSRIs and SNRIs have previously shown no impact on relieving chronic pain. CONCLUSIONS Comorbid depression in sickle cell disease is associated with adverse course and outcomes. These findings underscore the need for earlier and more aggressive treatment of comorbid depression by primary care or psychiatric providers in order to reduce the chronic, severe pain-depression burden on these patients.

Incidence and Costs of Cardiometabolic Conditions in Patients with Schizophrenia Treated with Antipsychotic Medications

To examine the incidence of cardiometabolic conditions and change in care costs for patients with schizophrenia treated with antipsychotic medications, medical and pharmacy claims from the South Carolina Medicaid program were used to compare the incidence rates for five cardiometabolic conditions in 2,231 patients with schizophrenia who were newly prescribed one of seven antipsychotic medications, using a retrospective cohort design spanning three years. Incidence and cumulative prevalence (pre-existing + incident) rates for the five cardiometabolic conditions were: 10%/23.3% for Type II diabetes mellitus, 7%/13.3% for obesity/excessive weight gain, 17%/20.9% for dyslipidemia, 4.5%/7.3% for high blood pressure, and 15.6%/41.8% for hypertension. After being treated with the antipsychotic medications examined, the odds of developing obesity/excessive weight gain, Type II diabetes mellitus, or dyslipidemia were not significantly related to any specific atypical agent compared to haloperidol. Incidence rates for elevated blood pressure and clinically diagnosed hypertension were higher for patients prescribed ziprasidone (Odds Ratio [OR]=2.41, Confidence Intervals [CI]=1.20-4.85; OR=1.83, CI=1.16-2.90, respectively) relative to those prescribed haloperidol. Cost results indicate significant differences over time in medical service and pharmacy costs in the group which developed incident cardiometabolic conditions. Individuals diagnosed with schizophrenia with moderate prevalence and incidence rates for these cardiometabolic conditions demonstrated substantially decreasing medical care costs over the three years examined, perhaps indicating a widening gap in access to needed services for conditions that are known mortality risk factors.

Impact of Clinical and Therapeutic Factors on Incident Cardiovascular and Cerebrovascular Events in a Population‐Based Cohort of HIV‐Infected and Non–HIV‐Infected Adults

Cardiovascular and cerebrovascular (CVD) events/diseases are a common cause of non–acquired immunodeficiency syndrome (AIDS)‐related mortality in the aging human immunodeficiency virus (HIV)‐infected population. The incidence rate and clinical correlates of CVD in people living with HIV/AIDS compared to the general population warrants further investigation.

Prevalence and impact of initial misclassification of pediatric type 1 diabetes mellitus.

Purpose To characterize rates of initial misclassification of type 1 diabetes mellitus as type 2/unspecified diabetes mellitus in a cohort of children/adolescents and to examine the impact of misclassification on the risk of diabetes-related complications. Methods An 11-year dataset (1996–2006) was analyzed. Inclusion criteria included age 17 years and younger, enrollees in South Carolina State Medicaid, and diagnosis of type 2/unspecified or type 1 diabetes mellitus for at least two visits, 15 days apart. Survival analysis was used to assess the association of “misclassification” with the incidence of diabetic ketoacidosis (DKA), and the cumulative incidence of neuropathy, nephropathy, and cardiovascular complications, after controlling for individual risk factors and comorbid conditions. Results A total of 1130 individuals meeting the inclusion criteria were studied for a median of 7 years. Of the 1130 individuals, 669 (59.2%) maintained a diagnosis of type 2/unspecified diabetes mellitus, 205 (18.1%) were consistently diagnosed as type 1 diabetes mellitus, and the remaining 256 individuals (22.7%) were misclassified. Insulin treatment was used in 100% of the type 1 diabetes mellitus group and 73% of the misclassified group. Compared with the type 2 diabetes mellitus group, being misclassified was associated with earlier development of DKA (adjusted hazard ratio [aHR] 5.08, 95% confidence interval [CI] 3.09–8.37), neuropathy (aHR 1.94, CI 1.31–2.88), and nephropathy (aHR 1.72, CI 1.19–2.50), whereas being consistently classified with type 1 diabetes mellitus was associated only with earlier development of DKA (aHR 4.96, CI 2.56–9.61). Conclusions Proper categorization of pediatric diabetes can be challenging, especially with comorbid obesity. Failure to ascertain type 1 diabetes mellitus in a timely manner in a pediatric population may increase the risk of substandard care and diabetes-related complications.

Prevalence, treatment, and outcomes of renal conditions in pediatric sickle cell disease.

Objectives: Vaso-occlusive events in pediatric sickle cell disease (SCD) may cause various renal complications and lead to renal failure. We describe the renal conditions that develop among young patients with SCD and the factors associated with the prevalence of these nephropathies. Materials and Methods: Medicaid medical and pharmacy claims for an 11-year period were used to identify 2194 pediatric patients with SCD (HbSS homozygous). Survival analysis identified the most significant predictors of acute kidney injury and chronic renal failure, using demographics, SCD severity and pain medication, comorbid hypertension, hematuria, and proteinuria as the initial covariates. Results: Prevalence of renal complications in our cohort was found to be relatively low, predominantly hematuria (6.3%) and proteinuria (3.2%). The multivariable analysis indicated that earlier development of acute kidney injury was significantly associated with older age (adjusted hazard ratio [aHR] 1.16, confidence interval [CI] 1.06-1.27), preexisting hypertension (aHR 3.05, CI 1.09-8.60), and preexisting hematuria (aHR 2.87, CI 1.05-7.93). Earlier development of chronic renal failure was significantly associated with older age (aHR 1.20, CI 1.08-1.32), preexisting hematuria (aHR 4.67, CI 1.57-13.94), and preexisting proteinuria (aHR 8.25, CI 2.12-10.38). Conclusions: These prevalence findings are novel in the US SCD pediatric population. The predictors of nephropathies identified in these children confirm clinical expectations. In addition, they suggest not only that pediatric nephrologists should be consulted earlier in the treatment of patients with SCD who are diagnosed as having comorbid hypertension or who develop hematuria or proteinuria during the course of their SCD treatment but also that both hydroxyurea and angiotensin-converting enzyme inhibitor therapies may be better used in these cases.

Delivering laboratory results by text message and e-mail: a survey of factors associated with conceptual acceptability among STD clinic attendees.

OBJECTIVE This study examines factors associated with the acceptability of receiving sexually transmitted disease (STD) laboratory results by text message and e-mail among clinic attendees. SUBJECTS AND METHODS An anonymous self-administered survey was conducted with a convenience sample of STD clinic attendees in South Carolina and Mississippi in 2009-2010. In total, 2,719 individuals with a median age of 26 years (interquartile range, 21-32 years) completed the survey. RESULTS More than 70% had Internet access at home, and 80% reported using text messaging daily. Participants preferred receiving laboratory results by text message compared with e-mail (50.2% versus 42.3%; p<0.001). Acceptability of receiving laboratory results by text message was higher with younger age (adjusted odds ratio [aOR] 1.13; 95% confidence interval [CI] 1.10-1.26), daily use of text messaging (aOR 1.30; 95% CI 1.14-1.49), and reporting cell phone and text message as the preferred choice of regular communication with the clinic (aOR 2.31; 95% CI 1.50-3.58) and was significantly lower in female subjects (aOR 0.89; 95% CI 0.81-0.98) and those with college-level education (aOR 0.88; 95% CI 0.77-0.99). CONCLUSIONS A majority of STD clinic attendees have access to cell phones and Internet. The acceptability of receiving STD laboratory results electronically may facilitate test result delivery to patients and expedite treatment of infected individuals.