Journal Article Annotations
2021, 1st Quarter

Infectious Diseases

Annotations by Aum Pathare, MD
March, 2021

Risky sexual behavior and its associated factors among patients with severe mental disorder in University of Gondar Comprehensive Specialized Hospital, 2018
Effect of initiation of medications for opioid use disorder on hospitalization outcomes for endocarditis and osteomyelitis in a large private hospital system in the United States, 2014–18

PUBLICATION #1 — Infectious Diseases

Risky sexual behavior and its associated factors among patients with severe mental disorder in University of Gondar Comprehensive Specialized Hospital, 2018

Daniel Ayelegne Gebeyehu, Missaye Mulatie

Abstract: BMC Psychiatry. 2021 Jan 21;21(1):51. doi: 10.1186/s12888-021-03054-z.

Background:
People with severe mental disorders are more likely to engage in high-risk sexual behaviors. As a result of these high-risk behaviors, they might contract sexually transmitted infections and become pregnant unintentionally. Despite the high burden of this problem, very little is known about the association between mental disorders and high-risk sexual behaviors; for this reason, the current study aimed at determining the association between these two behaviors in patients with mental disorders attending an outpatient clinic at the University of Gondar Comprehensive Specialized Hospital, Psychiatric Clinic.

Methods:
A total of 223 study participants were recruited via a stratified sampling followed by a systematic sampling technique. An institutional-based cross-sectional study was conducted from April to May 2018. Data were collected using a pretested interviewer-based questionnaire. A four-item questionnaire was adopted from a behavioral surveillance survey and different literature sources. A multivariable logistic regression model was fitted to assess the strength in addition to the direction of the association between risky sexual behavior and independent variables. An interpretation was made based on the adjusted odds ratio and p-value at a 95% confidence interval (CI).

Result:
Nearly half of the study participants (49.8, 95% CI; 43.9-56.5%) presented risky sexual behavior. The study found that male gender (2.98; adjusted odds ration [AOR] = 2.98; 95% CI; 1.49-5.95), no ability to read and write (3.99; AOR = 3.99; 95% CI: 1.53-10.4), history of hospitalization (3.95; AOR = 3.95; 95% CI: 1.87-8.32), perceived internal stigma (2.45, AOR = 2.45; 95% CI: 1.18-5.11), and poor social support (3.07, AOR = 3.07; 95% CI: 1.29-7.30) were significant predictors of risky sexual behaviors among patients with severe mental disorder.

Conclusion:
Risky sexual behavior among patients with a severe mental disorders was high (49.8%). Special attention should be given to male patients, incorporating people with severe mental disorders into the adult education programs, continuous health education regarding risky sexual behavior and utilization of condoms, building self-esteem, and engaging others to provide good social support systems are strongly recommended to alleviate this type of behavior in this population.

Keywords:
Ethiopia; Gondar; Risky sexual behavior; Severe mental disorder.

Annotation

The finding:
Nearly half of outpatients at the study site who had been diagnosed with schizophrenia, bipolar disorder, or major depressive disorder reported risky sexual behaviour (RSB), which could be one or more of four issues—unprotected sex, multiple (2 or more) sexual partners, alcohol or drug driven sexual intercourse, or exchanging money for sex. This population was predominantly orthodox, seen at the University of Gondar Comprehensive Specialized Hospital in Ethiopia, and between 18-34 years of age. The risk in men was three-fold that of women, with a slightly higher risk being conferred by illiteracy, psychiatric hospitalization, and lack of social supports. Patients with self-stigmatization were also at increased risk, and bipolar disorder contributed to more risk than major depressive disorder.

Strength and weaknesses:
This study examined stigma and its role in risky sexual behavior, which is an often-ignored aspect in such endeavours. The investigators selected patients with an understanding of their insight, which increased the reliability of information collected. General limitations relate to social desirability and recall biases, and challenges in survey construction. Drug/alcohol use was not clearly identified or quantified in the survey, and it was restricted to outpatients who may have better judgement and ability to participate in the study. The definition of RSB could (one out of four questions answered affirmatively) could fail to identify other risks.

Relevance:
Unsafe sex and consequent sexually transmitted infections are global problems. Patients with mental illnesses have been found to be at increased risk for STIs. This study highlights the degree of increase in risk as well as how this issue cuts across the domains of mood and psychotic disorders. Screening for unsafe sex practices becomes even more relevant when taking the role of stigma, correlated with a doubling of risk by this study, into account. C-L and other psychiatrists should be mindful of taking a sexual history in patients with mental illness. Not only is this population more vulnerable to STIs, but psychiatrists’ skillset at navigating complex medical and psychological issues position us to direct patients to appropriate treatment and reduce disparities in access to care.

Type of study:
Cross-sectional study

PUBLICATION #2 — Infectious Diseases

Effect of initiation of medications for opioid use disorder on hospitalization outcomes for endocarditis and osteomyelitis in a large private hospital system in the United States, 2014–18

Young Jo, Rebecca Nosal , Angela Vittori, Leopold Cordova, Christian Vandever, Clara Alvarez, Tyler S Bartholomew, Hansel E Tookes

Abstract: Addiction. 2021 Jan 4. doi: 10.1111/add.15393. Online ahead of print.

Background and aims:
Opioid use disorder (OUD) has led to not only increases in overdose deaths, but also increases in endocarditis and osteomyelitis secondary to injection drug use (IDU). We studied the association between initiation of medications for opioid use disorder (MOUD) and treatment outcomes for people with infectious sequelae of IDU and OUD.

Design and setting:
This is a retrospective cohort study reviewing encounters at 143 HCA Healthcare hospitals across 21 states of the United States from 2014 to 2018.

Participants:
Adults aged 18-65 with the ICD diagnosis code for OUD and endocarditis or osteomyelitis (n = 1407).

Measurements:
Main exposure was the initiation of MOUD, defined as either methadone or buprenorphine at any dosage started during hospitalization. Primary outcomes were defined as patient-directed discharge (PDD), 30-day re-admission and days of intravenous antibiotic treatment. Covariates included biological sex, age, ethnicity, other co-occurring substance use disorders, and insurance status.

Findings:
MOUD was initiated among 269 (19.1%) patients during hospitalization. Initiation of MOUD was not associated with decreased odds of PDD. Initiation of MOUD did not impact 30-day re-admission. Patients who received MOUD, on average, had 5.7 additional days of gold-standard intravenous antibiotic treatment compared with those who did not [β = 5.678, 95% confidence interval (CI) = 3.563, 7.794), P < 0.05].

Conclusion:
For people with opioid use disorder hospitalized with endocarditis or osteomyelitis, initiation of methadone or buprenorphine appears to be associated with improved receipt of gold-standard therapy, as quantified by increased days on intravenous antibiotic treatment.

Keywords:
buprenorphine; gold-standard antibiotic therapy; infective endocarditis; infective osteomyelitis; injection drug use; methadone; opioid agonist therapy; opioid use disorder.

Annotation

The finding:
Despite being admitted with endocarditis or osteomyelitis in the setting of opioid use disorder (OUD), fewer than 20 % of patients were initiated on medications for OUD treatment such as methadone and Suboxone. Even among patients who were treated with medications, 30-day readmission rates were not lowered nor was there a decreased risk of discharge against medical advice. Patients receiving OUD treatment had about 30 % longer treatment with IV antibiotics than average, but this success must be interpreted in the light that the overall duration of treatment remained about two weeks short of goal.

Strength and weaknesses:
This study examines missed opportunities for treatment of OUD in patients admitted with severe infections related to substance use. One of the major limitations of this study is the lack of clarity whether the patients given buprenorphine or methadone were being transitioned to maintenance treatment versus being managed for symptoms of withdrawal. Only first hospitalizations were noted, and the possibility of clustering within hospitals remained. Patient’s treatment decisions and other medical reasons for foregoing treatment could not be accounted for in this model.

Relevance:
Medications remain underutilized for treatment of opioid use disorders, even in the context of serious illnesses that occur as a consequence of IV drug use. Physician discomfort, lack of access to expert care, and patient resistance have been factors preventing adequate usage of these agents in the past. The adverse outcomes include increased number of discharges against medical advice and increased 30-day readmission rates. C-L psychiatrists are crucial partner in increasing patient engagement through focusing on early and adequate MAT and helping hospital systems retain patients longer for IV antibiotic treatment. While the total number of days with IV antibiotic treatment remains suboptimal, interventions for OUD may still result in a better timeline for transition to oral agents.

Type of study (EBM guide):
Cohort study