Medical Bulletin 04/ October/ 2024

Higher Prevalence of Mental Disorder and Suicidality Among Transgender When Compared to Cisgender Population: JAMA Study

Higher prevalence of mental disorders and suicidal behavior was found in transgender and gender diverse people when compared with the cisgender population in a recent JAMA Network study. The study investigated prevalence and risk of mental disorders, substance use disorders, and suicidal behaviors among transgender and gender diverse (TGD) and cisgender Canadians.

The study used data from the Mental Health and Access to Care Survey (MHACS), which is a nationally representative cross-sectional study administered by Statistics Canada from March to July 2022. A sample size of 9861 was included in the study. When sex at birth and gender identity matched, respondents were classified as cisgender; in the case of a mismatch, respondents were classified as transgender and gender diverse. Past 12-month and lifetime major depressive episode, generalized anxiety disorder, bipolar disorder, social phobia, alcohol use disorder, and substance use disorder, suicidal thoughts, plan, and attempt were assessed as outcomes.

Out of the total sample, 52 were identified as transgender. The study found that in the past 12-month and lifetime major depressive episode, generalized anxiety disorder, bipolar disorder, social phobia, substance use disorder, suicide ideation, suicide plan, and suicide attempts were higher in transgender and gender diverse respondents compared with cisgender respondents.

The risk of all 12-month and past-year mental disorders, substance use disorder, and suicide ideation were higher in transgender and gender diverse respondents compared with cisgender participants. The risk of lifetime suicide plan and attempts was significantly higher in transgender and gender diverse respondents. Alcohol use disorder did not differ between the groups.

This disparity may be explained by minority stress theory, which posits that the experience of prejudice and negative social experiences by members of historically stigmatized groups can have substantial impacts on both physical and mental health, concluded the authors.

Reference: Eccles H, Abramovich A, Patte KA, et al. Mental Disorders and Suicidality in Transgender and Gender-Diverse People. JAMA Netw Open. 2024;7(10):e2436883. doi:10.1001/jamanetworkopen.2024.36883

Obesity and Diabetes May Be Risk Factors for Recurrence of Hepatocellular Carcinoma

A recent study has highlighted that the coexistence of obesity and Diabetes mellitus increased late recurrence and worsened prognosis in patients with Hepatocellular carcinoma undergoing hepatic resection. The findings were published in Liver Cancer.

Hepatocellular carcinoma is known to have a high recurrence rate after cancer removal. Recent advances in antiviral therapy have reduced the number of patients affected, but obesity and diabetes are factors in hepatocellular carcinoma prevalence. However, these factors’ effects on patient survival and cancer recurrence have been unclear.

To gain insights, Dr. Hiroji Shinkawa’s research team at Osaka Metropolitan University’s Graduate School of Medicine analyzed the relationship between diabetes mellitus, obesity, and postoperative outcomes in 1,644 patients with hepatocellular carcinoma who underwent liver resection.

The results revealed that the risk of recurrence after two years postoperatively was approximately 1.5 times higher in the case of comorbid obesity and 1.3 times higher in the case of diabetes mellitus. In addition, the risk of recurrence after five years postoperatively was 3.8 times higher in the case of comorbid obesity and 2 times higher in the case of comorbid diabetes alone.

“This study is expected to contribute to the early detection of cancer recurrence and the design of appropriate treatment strategies,” stated Dr. Shinkawa. “Because the risk of late recurrence is higher in hepatocellular carcinoma with comorbid obesity and diabetes, controlling obesity and diabetes is an important treatment strategy for hepatocellular carcinoma.”

Reference: Hiroji Shinkawa, Masaki Kaibori, Masaki Ueno, Satoshi Yasuda, Hisashi Ikoma, Tsukasa Aihara, Takuya Nakai, Masahiko Kinoshita, Hisashi Kosaka, Shinya Hayami, Yasuko Matsuo, Ryo Morimura, Takayoshi Nakajima, Chihoko Nobori, Takeaki Ishizawa; Impact of Diabetes Mellitus and Obesity Comorbidities on Survival Outcomes after Hepatocellular Carcinoma Resection: A Multicenter Retrospective Study. Liver Cancer 2024; https://doi.org/10.1159/000540858

1 in 14 Patients Faces Harmful Diagnostic Errors in Hospitals: BMJ Quality and Safety

Harmful diagnostic errors may be occurring in as many as 1 in every 14 (7%) hospital patients—at least those receiving general medical care—suggest the findings of a single centre study in the US, published online in the journal BMJ Quality & Safety.

Most (85%) of these errors are likely preventable and underscore the need for new approaches to improving surveillance to avoid these mistakes from happening in the first place, say the researchers.

The researchers developed and validated a structured case review process to enable clinicians to interrogate the electronic health record (EHR) to evaluate the diagnostic process for hospital patients, assess the likelihood of a diagnostic error, and characterise the impact and severity of harm.

They used the process to estimate retrospectively the prevalence of harmful diagnostic errors in a randomly selected sample of 675 hospital patients out of a total of 9147 in receipt of general medical care between July 2019 and September 2021, excluding the height of the COVID-19 pandemic (April-December 2020).

Cases deemed to be at high risk of diagnostic error were categorised as: transfer to intensive care 24 or more hours after admission (130; 100%); death within 90 days of admission either in hospital or after discharge (141; 38.5%); complex clinical issues, but no transfer to intensive care or death within 90 days of admission (298; 7%).

Complex clinical issues included clinical deterioration; treatment by several different medical teams; unexpected events, such as cancelled surgery; unclear or discrepant diagnostic information recorded in the medical notes.

Cases deemed to be at low risk were those fulfilling none of the high risk criteria (106; 2.5%).

Each case was reviewed by two adjudicators trained to judge the likelihood of diagnostic error and identify associated process failures using the Diagnostic Error Evaluation and Research Taxonomy modified for acute care.

Harm was classified as minor, moderate, severe, and fatal, and whether the diagnostic error contributed to the harm and whether it was preventable were also assessed.

Cases with discrepancies or uncertainty about the diagnostic error or its impact were further reviewed by an expert panel.

Among all the cases reviewed, diagnostic errors were found in 160 cases (154 patients). These comprised: intensive care transfer (54); death within 90 days (34); complex clinical issues (52); low risk patients (20).

Harmful diagnostic errors were assessed to have occurred in 84 cases (82 patients), of which 37 (28.5%) occurred among intensive care transfers; 18 (13%) among those who died within 90 days; 23 (8%) among those with complex clinical issues; and 6 (6%) in low risk cases.

Harm severity was characterised as minor in 5 (6%), moderate in 36 (43%), major in 25 (30%) and fatal in 18 (21.5%).

In all, an estimated 85% of harmful diagnostic errors were preventable, with older, White, non-Hispanic, non-privately insured and high-risk patients most at risk.

Weighted to take account of the population, the researchers estimated the proportion of harmful, preventable, and severely harmful diagnostic errors in general medical hospital patients to be just over 7%, 6%, and 1%, respectively.

Process failures were significantly associated with diagnostic errors, particularly uncertainty in initial assessments and complex diagnostic testing and interpretation (4 times the risk), suboptimal subspecialty consultation (3 times the risk), concerns reported by patients (3 times the risk) and history taking (2.5 times the risk).

Forty (48%) diagnostic errors were related to the primary diagnosis at admission or discharge and 44 (52.5%) to a secondary diagnosis. Fifty two (62%) were characterised as delays. Errors associated with major or fatal harm were frequent in the high risk group (55%, 43/78) and rare in the low risk group (0/6).

The most frequent diagnoses associated with diagnostic errors included heart failure, acute kidney failure, sepsis, pneumonia, respiratory failure, altered mental state, abdominal pain and hypoxaemia (low blood oxygen levels).

Careful analysis of the errors and integrating AI tools into the workflow should help to minimise their prevalence, by improving monitoring and triggering timely interventions, suggest the researchers.

Reference: Dalal AK, Plombon S, Konieczny K, et al Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. BMJ Quality & Safety Published Online First: 01 October 2024. doi: 10.1136/bmjqs-2024-017183

Clinical Trial Highlights Synthetic Cannabis “Dronabinol” Alleviates Agitation in Alzheimer’s Patients

In a study led by the Johns Hopkins University School of Medicine and Tufts University School of Medicine, researchers show that a pill form of the drug dronabinol, an FDA-approved synthetic version of marijuana’s main ingredient, THC, reduces agitation in patients with Alzheimer’s by an average of 30%.

The researchers say that compared to current treatments for agitation, such as antipsychotics, dronabinol produced similar calming effects without adverse results such as delirium or seizures.

“These new findings represent eight years of work dedicated to people who have Alzheimer’s as well as their caregivers,” says Paul Rosenberg, M.D., professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine and co-principal investigator for this study. “Agitation is one of the most distressing symptoms of Alzheimer’s dementia, and we are pleased to make positive strides forward in treatment of these patients.”

Although mild agitation can sometimes be moderated by behavioral intervention, in moderate to severe cases, some form of medication is typically required to manage symptoms and provide relief for caregivers.“It is the agitation, not the memory loss, that often drives individuals with dementia to the emergency department and long-term-care facilities,” says Brent Forester, M.D., psychiatrist-in-chief and chairman of the Department of Psychiatry at Tufts Medical Center and co-principal investigator on the study. “Dronabinol has the potential to both reduce health care costs and make an important, positive impact on caregivers’ mental and physical health.”

In the new study, researchers recruited 75 patients with severe Alzheimer’s agitation across five clinical sites, including 35 admitted to The Johns Hopkins Hospital between March 2017 and May 2024. To qualify, patients had to have a formal clinical diagnosis of Alzheimer’s disease and show at least one major symptom of agitation for at least two weeks. Prior to treatment, patients were tested for agitation using the Pittsburgh Agitation Scale (PAS) and the Neuropsychiatric Inventory Agitation/Aggression subscale (NPI-C).

The PAS scores agitation from 0 to 4, with 4 being the most agitated. The NPI-C provides a brief assessment of neuropsychiatric symptoms including delusions, hallucinations, anxiety/depression and other factors. Baseline scores were acquired from caregivers at the onset of the trial.

Participants were then randomly selected to get either 5 milligrams of dronabinol in pill form or a placebo in pill form twice daily for three weeks, and then retested using the PAS and NPI-C.

Results from the dronabinol group show an average PAS starting value of 9.68 and an end value of 7.26 after three weeks, a 30% decrease compared to the scores in the placebo group which did not change. Additionally, dronabinol was well tolerated by patients compared to current treatments for agitation.“Results like this are encouraging. We are thrilled that FDA-approved dronabinol was robustly effective and appeared safe for treatment of agitation,” says Rosenberg. “This adds another tool in our efforts to improve the care of our loved ones with Alzheimer’s disease.”

What Would Happen if Tobacco Smoking is Eliminated? A Lancet Public Health Study Finds

Accelerating the decline in tobacco smoking globally, by decreasing smoking prevalence from current levels to 5% everywhere, could increase life expectancy and prevent millions of premature deaths by 2050, according to a study from the Global Burden of Disease, Injuries and Risk Factors (GBD) Tobacco Forecasting Collaborators published in The Lancet Public Health journal.

“We must not lose momentum in efforts to reduce, and ultimately eliminate, smoking around the world. Our findings highlight that millions of premature deaths could be avoided by bringing an end to smoking,” said senior author, Professor Stein Emil Vollset, of the Institute for Health Metrics and Evaluation (IHME).

Reference: Forecasting the effects of smoking prevalence scenarios on years of life lost and life expectancy from 2022 to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Bryazka, Dana et al. The Lancet Public Health, Volume 9, Issue 10, e729 - e744