Rae Spiwak

Predictors of persistent nicotine dependence among adults in the United States

BACKGROUND Evidence suggests that nicotine dependence is the key barrier to successful smoking cessation. No previous study has documented predictors of persistent nicotine dependence among adults in the community. The goal of this study is to prospectively identify predictors of continued nicotine dependence over a 3-year period among adults. METHODS Data were drawn from Waves I and II of the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a nationally representative sample of 34,653 adults in the United States. Logistic regression analyses were used to estimate the odds of persistent nicotine dependence at Wave 2 given the presence of various sociodemographic and psychiatric predictors at Wave 1. RESULTS Mood, anxiety, personality and illicit substance use disorders were associated with significantly increased risk of persistent nicotine dependence. The strength of these relationships was attenuated slightly after adjusting for demographic differences, but remained statistically significant. Persistent nicotine dependence was more common among unmarried, younger females with lower income levels and lower educational attainment. CONCLUSIONS To our knowledge, this study is the first to prospectively identify predictors of persistent nicotine dependence among adults. Our results suggest that the incorporation of mental health treatment into alternative smoking cessation approaches may help to increase the effectiveness of these programs and that a greater focus of these services on vulnerable segments of the population is needed in order to reduce continued disparities in smoking in the general population.

Predicting suicide attempts with the SAD PERSONS scale: a longitudinal analysis.

OBJECTIVE The SAD PERSONS scale is a widely used risk assessment tool for suicidal behavior despite a paucity of supporting data. The objective of this study was to examine the ability of the scale in predicting suicide attempts. METHOD Participants consisted of consecutive referrals (N=4,019) over 2 years (January 1, 2009 to December 31, 2010) to psychiatric services in the emergency departments of the 2 largest tertiary care hospitals in the province of Manitoba, Canada. SAD PERSONS and Modified SAD PERSONS (MSPS) scale scores were recorded for individuals at their index and all subsequent presentations. The 2 main outcome measures in the study included current suicide attempts (at index presentation) and future suicide attempts (within the next 6 months). The ability of the scales to predict suicide attempts was evaluated with logistic regression, sensitivity and specificity analyses, and receiver operating characteristic curves. RESULTS 566 people presented with suicide attempts (14.1% of the sample). Both SAD PERSONS and MSPS showed poor predictive ability for future suicide attempts. Compared to low risk scores, high risk baseline scores had low sensitivity (19.6% and 40.0%, respectively) and low positive predictive value (5.3% and 7.4%, respectively). SAD PERSONS did not predict suicide attempts better than chance (area under the curve =0.572; 95% confidence interval [CI], 0.51-0.64; P value nonsignificant). Stepwise regression identified 5 original scale items that accounted for the greatest proportion of future suicide attempt variance. High risk scores using this model had high sensitivity (93.5%) and were associated with a 5-fold higher likelihood of future suicide attempt presentation (odds ratio =5.58; 95% CI, 2.24-13.86; P<.001). CONCLUSION In their current form, SAD PERSONS and MSPS do not accurately predict future suicide attempts.

Separated Women's Risk for Violence

Abstract It is well known that women are at an increased risk for violence during separation. Existing research does not provide an understanding of why separated women are more at risk. The following study helps to fill this gap through an empirical examination of indicators derived from potential explanations for the relationship between separation and violence. Using Statistics Canadas 1999 General Social Survey (GSS), the study employs both descriptive and multivariate statistical analyses to examine the following variables: continuation of previous violence; immigrant status; youth; power; jealousy; and Aboriginal status. These risk factors accounted for over half of the variance in separation violence. This was largely due to the impact of age and Aboriginal status. The findings also showed that women without a previous history of violence were not protected from experiencing separation violence. The article concludes with a discussion of the findings.

The SAD PERSONS Scale for Suicide Risk Assessment: A Systematic Review

The SAD PERSONS scale (SPS) is widely used for suicide risk assessment in clinical and educational settings. The study objective was to systematically review the SPS performance in clinical situations. A systematic search of electronic databases was conducted. Relevant descriptive, quality, and outcome data were reviewed. In the search, 149 studies were identified and 9 met inclusion criteria. Included studies were highly variable across outcome measures, populations, and assessment methods. Only 3 studies examined SPS performance in predicting suicide outcomes; none showed the scale accurately predicted suicidal behavior. Available literature is of limited quality and quantity. Insufficient evidence exists to support SPS use in assessment or prediction of suicidal behavior. Well-designed studies that address the observed limitations are required.

Co-morbidity of bipolar disorder and borderline personality disorder: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVES Clinical studies suggest a high co-morbidity rate of borderline personality disorder (BPD) with bipolar disorder (BD). This study examines the prevalence and correlates of BPD in BD (I and II) in a longitudinal population-based survey. METHODS Data came from waves 1 and 2 (wave 2: N=34,653, 70.2% cumulative response rate; age ≥ 20 years) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Lay interviewers conducted in person interviews using the Alcohol Use Disorders and Associated Disabilities Interview (AUDADIS-IV), a reliable diagnostic tool of psychiatric disorders based on DSM-IV criteria. Subjects with BD I (n=812), BD I/BPD (n=360), BD II (n=327) and BD II/BPD (n=101) were examined in terms of sociodemographics, mood, anxiety, substance use and personality disorder co-morbidities and history of childhood traumatic experiences. RESULTS Lifetime prevalence of BPD was 29.0% in BD I and 24.0% in BD II. Significant differences were observed between co-morbid BD I/II and BPD versus BD I/II without BPD in terms of number of depressive episodes and age of onset, co-morbidity, and childhood trauma. BPD was strongly and positively associated with incident BD I (AOR=16.9; 95% CI: 13.88-20.55) and BD II (AOR=9.5; 95% CI: 6.44-13.97). CONCLUSIONS BD with BPD has a more severe presentation of illness than BD alone. The results suggest that BPD is highly predictive of a future diagnosis of BD. Childhood traumatic experiences may have a role in understanding this relationship.

Phenylephrine tumescence in split-thickness skin graft donor sites in surgery for burn injury- a concentration finding study.

The purpose of this study is to determine the lowest concentration of subcutaneous phenylephrine (neosynephrine) required for effective vasoconstriction in skin graft donor sites. Surgery for burn injury is associated with blood loss. Tourniquet use and tumescence with epinephrine have decreased blood loss. However, absorption of epinephrine has been reported with systemic effects. Phenylephrine, an &agr;1-adrenergic receptor agonist, has vasoconstrictive properties similar to epinephrines without other &agr;-adrenergic or &bgr;-adrenergic activity. The aim of this study is to determine the lowest effective concentration of phenylephrine that will provide vasoconstriction in split-thickness graft donor sites. By using intensive care unit equivalency tables, the authors estimated a concentration of phenylephrine on the basis of current epinephrine tumescence. This concentration was titrated up or down according to an algorithm established a priori, determining the minimum concentration that achieved vasoconstriction in three consecutive patients. The primary outcome was local vasoconstriction. Secondary outcomes measured were pre-, intra-, and postoperative mean arterial pressure, systolic pressure and heart rate, graft take, and donor site healing. The subjects were six otherwise healthy adult patients (five men and one woman) with a mean age of 36 years. The average TBSA was 737.5 cm2. Vasoconstriction was achieved at 5 &mgr;g/ml. No significant alterations in hemodynamic measures were observed. The optimal concentration of phenylephrine for prevention of bleeding in donor sites appears to be 5 &mgr;g/ml. Participants will be able to identify the effects of phenylephrine and epinephrine tumescence. They will also identify the concentration at which phenylephrine will be effective in donor sites.

The Relationship Between Physical Intimate Partner Violence and Sexually Transmitted Infection Among Women in India and the United States

To investigate the association between physical intimate partner violence (IPV) and sexually transmitted infection (STI) in two national samples. Data came from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (n = 34,653) and the National Family Health Survey-3 (n = 124 385). Ever-married women between the ages of 20 and 49 were asked if they had experienced physical violence by their partner in the past year. Outcomes were presence of doctor confirmed HIV and self-reported STI. Age at first intercourse was examined as a mediator of the relationship between IPV and STI. Logistic regression examined associations between IPV, age at first intercourse and STI. Compared to individuals with no physical IPV, risk for STI was higher for individuals who experienced past year IPV living in the United States and India, however once controlling for age at first intercourse, age, education, household wealth/income and past year sexual violence, the relationship between IPV, and STI was significant in the American sample [(AOR) = 1.65, 95% (CI) = 1.21-2.26], however not for individuals living in India [(AOR) = 1.75, 95% (CI) = 0.84-3.65]. Individuals with exposure to physical IPV are at increased odds for STI. Age at first intercourse although a marker of risk, may not be an accurate marker of risky sexual behavior in both samples.

Predictors of Future Suicide Attempts Among Individuals Referred to Psychiatric Services in the Emergency Department: A Longitudinal Study.

Abstract This study examined which factors predict future suicide attempts (SAs) among people referred to psychiatric services in the emergency department (ED). It included consecutive adult (age >18 years) presentations (N = 6919) over a 3-year period to the two tertiary care hospitals in Manitoba, Canada. Medical professionals assessed each individual on 19 candidate risk factors. Stepwise logistic regression and receiver operating characteristic curves examined the association between the baseline variables and future SAs within the next 6 months. A total of 104 individuals re-presented to the ED with future SAs. Of the 19 baseline variables, only two independently accounted for the variance in future attempts. High-risk scores using this two-item model were associated with elevated odds of future SA (odds ratio, 3.22; 95% confidence interval, 1.62–6.42; p < 0.01), but this was tempered by a low positive predictive value. Further evaluation is required to determine if this two-item tool could help identify people requiring more comprehensive risk assessment referred to psychiatry in the ED.

Creation of a standardized burn course for Low Income Countries: Meeting local needs

INTRODUCTION Standardized courses for the care of the burn patient have historically been developed in High Income Countries (HIC). These courses do not necessarily reflect the challenges and needs of Low Income Countries (LIC) and some components may not be relevant there (i.e. use of ventilators in a country that has no or very limited number of ventilators). We are developing a Burn Management Course for East Africa. This course was created and trialed in a LIC and subsequently a formal manual and course curriculum created. Recently the first iteration of the course was undertaken in a major regional burn centre in East Africa. We present participant feedback on the course content, and potential future directions for course development. OBJECTIVE (1) To evaluate the ability of a standardized burn course for LIC to meet the needs of the participants. (2) To explore characteristics of burn care and needs related to delivery of burn care in LIC. METHODS 21 students participated in a multidisciplinary burn management course. They were asked to complete an anonymous questionnaire at the end of the course. RESULTS There were 11 nurses, 6 doctors, a physiotherapist, occupational therapist, and a dietician. 15 worked in either the adult or pediatric burn units, the other six worked in emergency, ICU or the operating room. The majority of respondents (56%) had less than 3 years of experience working with burn patients. Overall agreement that the course met their objectives was rated as 4.6 out of 5. As well the students agreement that they had a better understanding of burn injury was rated as 4.8/5. 55.6% indicated that scalds were the most commonly seen injury followed by 27.8% responding that flames were the most common. Some responses to the question of top difficulties facing the caregivers were similar to HIC: staffing shortages, bed shortages, and finding useable donor site in large burns. Other responses highlighted the challenges these care givers face: poverty stricken patients, not enough appropriate food available, and deficiencies in infection control practices. CONCLUSION It is possible to create a course that translates knowledge from a HIC setting to meet the needs of the end-user in a LIC setting.

Childhood exposure to caregiver suicidal behavior and risk for adult suicide attempts : findings from a national survey

The objective of this study was to investigate the association between exposure to caregiver suicidality and subsequent adult suicide attempt (SA). Data came from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (n = 34,653). Respondents were asked if they had a caregiver attempt or complete suicide during childhood. Logistic regression examined associations between SA and caregiver suicidality. Compared to individuals with no suicidality, risk for lifetime SA was higher for individuals that were exposed to a SA (15.6%, [OR] = 5.86, 95% [CI] = 4.57–7.51) and for those who experienced a death by suicide (6.1%, [OR] = 2.08, CI = 1.32–3.26]. Associations remained significant after controlling for demographics, Axis I and II disorders and childhood adversity. Individuals with exposure to suicidality are at increased odds for SA.