Complications and Outcomes of Endovascular Embolization for Intractable Epistaxis: A Systematic Review and Meta-analysis

OBJECTIVES

Endovascular embolization has emerged as an effective treatment for intractable epistaxis. This systematic review and meta-analysis aimed to calculate the rates of success, rebleeds, and complications and to identify the etiologies and complications of patients who undergo endovascular embolization.

METHODS

This systematic review and meta-analysis was conducted per the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles were extracted from Scopus, PubMed, Web of Science, and Cochrane Central and were filtered by a systematic review process using Rayyan software. A random-effects model was used to quantify the rates success, rebleeds, and complications.

RESULTS

Forty-two studies were included, totaling 1660 patients. The pooled success rate was 89% (95% confidence interval [CI] 86%-92%) and the pooled rebleed rate was 19% (95% CI 16%-22%). The pooled minor complication rate was 18% (95% CI 11%-27%). The most common major complication was soft tissue necrosis followed by stroke. The most common minor complication was facial pain. No minor complications were reported to be permanent. Of the patients who failed initial embolization, 42% underwent repeat embolization and 34% underwent surgical arterial ligation.

CONCLUSIONS

Endovascular embolization is an effective treatment for intractable epistaxis. The decision to perform embolization should be carefully weighed given the rare but significant major complications.

The Appalachia Mind Health Initiative (AMHI): a pragmatic randomized clinical trial of adjunctive internet-based cognitive behavior therapy for treating major depressive disorder among primary care patients

BACKGROUND

Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems.

METHODS

Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE.

DISCUSSION

The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.

Designing mental health promotion campaigns: segmenting U.S. Veteran audiences to address public stigma

BACKGROUND

Public stigma is a significant deterrent to mental health service use for U.S. veterans. Media campaigns are often used to dispel stigmatizing beliefs and actions. Segmentation is an evidence-based practice for their effective use; however, little data has been published on veteran segments to target with anti-stigma messages.

AIMS

This article aims to identify and describe initial typologies of stigmatizing attitudes within a group of U.S. military veterans.

METHODS

Telephone-based cross-sectional surveys were conducted with a national random sample of veterans from 2014 to 2016 (N = 2142). Stigma outcomes were measured using a brief, validated instrument used in population-based surveys of public perceptions toward people with mental illness. Cluster analysis was conducted to identify specific groupings along multiple dimensions.

RESULTS

A final four-cluster solution was identified among veterans with distinct patterns of attitudes toward mental illness and include: 1) the undecided, 2) the influencer, 3) the ambivalent, and 4) the potential ally. Several strategies were also identified for designing anti-stigma messaging toward these segments.

CONCLUSIONS

This research demonstrates veterans can be segmented by attitudes to target with anti-stigma campaign messages.

Early First Deployment and Risk of Suicide Attempt Among First-term Enlisted Soldiers in the U.S. Army

OBJECTIVE

We examined early first deployment and subsequent suicide attempt among U.S. Army soldiers.

METHOD

Using 2004-2009 administrative data and person-month records of first-term, Regular Army, enlisted soldiers with one deployment (89.2% male), we identified 1,704 soldiers with a documented suicide attempt during or after first deployment and an equal-probability control sample (n = 25,861 person-months).

RESULTS

Logistic regression analyses indicated soldiers deployed within the first 12 months of service were more likely than later deployers to attempt suicide (OR = 1.7 [95% CI = 1.5-1.8]). Adjusting for sociodemographic characteristics, service-related characteristics, and previous mental health diagnosis slightly attenuated this association (OR = 1.6 [95% CI = 1.5-1.8]). Results were not modified by gender, deployment status, military occupation, or mental health diagnosis. The population-attributable risk proportion for deploying within the first 12 months of service was 17.8%. Linear spline models indicated similar risk patterns over time for early and later deployers, peaking at month 9 during deployment and month 5 postdeployment; however, monthly suicide attempt rates were consistently higher for early deployers.

CONCLUSIONS

Enlisted soldiers deployed within the first 12 months of service have elevated risk of suicide attempt during and after first deployment. Improved understanding of why early deployment increases risk can inform the development of policies and intervention programs.

Factors Associated With Suicide Ideation in US Army Soldiers During Deployment in Afghanistan

IMPORTANCE

Understanding suicide ideation (SI) during combat deployment can inform prevention and treatment during and after deployment.

OBJECTIVE

To examine associations of sociodemographic characteristics, lifetime and past-year stressors, and mental disorders with 30-day SI among a representative sample of US Army soldiers deployed in Afghanistan.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study, soldiers deployed to Afghanistan completed self-administered questionnaires in July 2012. The sample was weighted to represent all 87 032 soldiers serving in Afghanistan. Prevalence of lifetime, past-year, and 30-day SI and mental disorders was determined. Logistic regression analyses examined risk factors associated with SI. Data analyses for this study were conducted between August 2018 and August 2019.

MAIN OUTCOMES AND MEASURES

Suicide ideation, lifetime and 12-month stressors, and mental disorders were assessed with questionnaires. Administrative records identified sociodemographic characteristics and suicide attempts.

RESULTS

A total of 3957 soldiers (3473 [weighted 87.5%] male; 2135 [weighted 52.6%] aged ≤29 years) completed self-administered questionnaires during their deployment in Afghanistan. Lifetime, past-year, and 30-day SI prevalence estimates were 11.7%, 3.0%, and 1.9%, respectively. Among soldiers with SI, 44.2% had major depressive disorder (MDD) and 19.3% had posttraumatic stress disorder in the past 30-day period. A series of analyses of the 23 grouped variables potentially associated with SI resulted in a final model of sex; race/ethnicity; lifetime noncombat trauma; past 12-month relationship problems, legal problems, and death or illness of a friend or family member; and MDD. In this final multivariable model, white race/ethnicity (odds ratio [OR], 3.1 [95% CI, 1.8-5.1]), lifetime noncombat trauma (OR, 2.1 [95% CI, 1.1-4.0]), and MDD (past 30 days: OR, 31.8 [95% CI, 15.0-67.7]; before past 30 days: OR, 4.9 [95% CI, 2.5-9.6]) were associated with SI. Among the 85 soldiers with past 30-day SI, from survey administration through 12 months after returning from deployment, 6% (5 participants) had a documented suicide attempt vs 0.14% (6 participants) of the 3872 soldiers without SI.

CONCLUSIONS AND RELEVANCE

This study suggests that major depressive disorder and noncombat trauma are important factors in identifying SI risk during combat deployment.

A randomized controlled trial of public messaging to promote safe firearm storage among U.S. military veterans

BACKGROUND

The objectives of this study were to determine whether short-term exposure to firearm safety messaging significantly improved (1) firearm storage practices, and (2) attitudes of safe firearm storage behaviors among U.S. veterans, a group at elevated risk for firearm suicide.

DESIGN

A three-arm, parallel-group RCT was conducted online in the U.S. nationwide from December 2015 to January 2016.

SETTING

A national random sample of U.S. veterans (N = 358) was recruited from the GfK KnowledgePanel, a probability-based internet panel representative of U.S. adults. All study activities were administered online over a three-week study period.

INTERVENTION

Participants were randomized and exposed three times (once per week) to either (a) firearm safety message only (n = 115); (b) firearm safety and mental health promotion messages (n = 133); or (c) active control group exposed to mental health promotion message only (n = 110). Each message was less than two minutes long.

MEASURES

Assessments were completed at baseline (pre-randomization) and at end-of-trial. Changes in awareness of risk for injuries, attitudes/beliefs related to safe storage practices, behavioral intentions, and storage practices were measured using self-reported surveys. Linear mixed effect models with weighted generalized estimating equations were used to test for exposure effects. Analyses were conducted February 2018.

RESULTS

Analyses restricted to those with baseline firearm access (n = 195) identified no significant changes for intentions or safe storage practices across exposure groups. At baseline, participants' attitudes and beliefs were generally supportive of safe firearm storage. The Firearm Safety message yielded small increases in agreement with the concept that secure storage is "important during emotional or stressful times" (0.36; 95% CI = 0.08, 0.64). Other significant changes in awareness and beliefs were found, but across all study conditions.

CONCLUSION

Results reinforce the critical need for considerable research and testing prior to the widespread implementation of public messages to increase the likelihood for desired exposure effects.

Risk factors and timing of suicide attempts among US Army Reserve Component soldiers during deployment to the Afghanistan and Iraq wars: Results from the Army Study to Assess Risk and Resilience in Servicemembers

Objective: During the wars in Afghanistan and Iraq, suicidal behaviors increased among U.S. Army soldiers. Although Reserve Component (RC) soldiers (National Guard and Army Reserve) comprise approximately one third of those deployed in support of the wars, few studies have examined suicidal behaviors among these "citizen-soldiers". The objective of this study is to examine suicide attempt risk factors and timing among RC enlisted soldiers. Methods: This longitudinal, retrospective cohort study used individual-level person-month records from Army and Department of Defense administrative data systems to examine socio-demographic, service-related, and mental health predictors of medically documented suicide attempts among enlisted RC soldiers during deployment from 2004-2009. Data were analyzed using discrete-time survival models. Results: A total of 230 enlisted RC soldiers attempted suicide. Overall, the in-theater suicide attempt rate among RC soldiers was 81/100,000 person-years. Risk was highest in the fifth month of deployment (13.8 per 100,000 person-months). Suicide attempts were more likely among soldiers who were women (adjusted odds ratio, aOR = 2.5 [95% CI: 1.8-3.5]), less than high school educated (aOR = 1.8 [95% CI: 1.3-2.5]), in their first 2 years of service (aOR = 2.0 [95% CI: 1.2-3.4]), were currently married (aOR = 2.0 [95% CI: 1.5-2.7]), and had received a mental health diagnosis in the previous month (aOR = 24.7 [95% CI: 17.4-35.0]). Conclusions: Being female, early in service and currently married are associated with increased odds of suicide attempt in RC soldiers. Risk of suicide attempt was greatest at mid deployment. These predictors and the timing of suicide attempt for RC soldiers in-theater are largely consistent with those of deployed Active Component (Regular) soldiers. Results also reinforce and replicate the findings among Active Component soldiers related to the importance of a recent mental health diagnosis and the mid-deployment as a period of enhanced risk.

Opioid-Related Outcomes in West Virginia, 2008-2016

OBJECTIVES

To examine opioid-related outcomes by using hospitalization and mortality data as an indicator of the current opioid crisis in West Virginia.

METHODS

We used data from the West Virginia University Medicine health care system to examine the trend in opioid overdoses and percentage of patients with a repeat overdose from 2008 to 2016. We obtained the opioid overdose death rate for the state from Centers for Disease Control and Prevention WONDER (Wide-ranging ONline Data for Epidemiologic Research) mortality data for 2008 to 2016.

RESULTS

The hospitalization rate for opioid overdoses increased (13%) on average each year in a similar fashion to the opioid overdose death rate for the state (12%) between 2008 and 2016. During the same time, the percentage of patients with a repeat opioid overdose increased annually by 13% on average.

CONCLUSIONS

There continues to be a surge of opioid overdoses in West Virginia. These findings suggest a need to amplify comprehensive prevention and treatment efforts throughout the state. Public health initiatives to reduce the morbidity and mortality associated with overdoses should consider how the changes in potency may be influencing these outcomes.

The Use of Theory-Based Formative Research to Design Suicide Prevention Messaging for U.S. Veterans in Midlife

BACKGROUND

Communication campaigns offer a viable mechanism to promote suicide prevention and reinforce mental health for U.S. veterans in midlife, a group with a high suicide burden. However, little empirical investigation of this type of messaging has been conducted, with formative campaign research conspicuously missing from the limited literature.

AIMS

Using the theory of planned behavior as a guide, formative research was conducted to inform the design of suicide prevention messaging by (a) describing and measuring several theoretical constructs among our audience and (b) modeling associations between constructs and intentions to seek help for suicidal behaviors and mental health more broadly.

METHODS

Telephone-based cross-sectional surveys were collected between 2014 and 2016 from a nationally representative sample of veterans with analyses restricted to those aged between 44 and 65 years ( n = 809). Multiple logistic regression was used to identify significant factors associated with intentions to seek help for either suicidal behaviors or mental health.

RESULTS

Perceived behavioral control was one of the largest predictors of intentions to seek help for both suicidal behaviors and mental health concerns. Descriptive norms were also significantly associated with suicide-related intentions. Data further suggest several types of attitudes (i.e., discordant beliefs, stereotypes) to consider when designing messages for this group.

DISCUSSION

This study represents one of the first efforts to document and describe theoretical constructs and their influence on intentions among veterans in midlife to contribute to the development of evidence-based messaging for veterans informed by a conceptual framework.

CONCLUSION

Findings have important implications as the use of communication strategies for suicide prevention grows increasingly popular.

Activation of translation initiation factor eIF2B by insulin requires phosphatidyl inositol 3-kinase

Eukaryotic initiation factor eIF2B mediates a key regulatory step in peptide-chain initiation and is acutely activated by insulin, although, it is not clear how. Inhibitors of phosphatidylinositide 3-kinase blocked activation of eIF2B, although rapamycin, which inhibits the p70 S6 kinase pathway, did not. Furthermore, a dominant negative mutant of PI 3-kinase also prevented activation of eIF2B, while a Sos-mutant, which blocks MAP kinase activation, did not. The data demonstrate that a pathway distinct from MAP and p70 S6 kinases regulates eIF2B. Glycogen synthase kinase-3 (GSK-3) phosphorylates and inactivates eIF2B. In all cases, eIF2B and GSK-3 were regulated reciprocally. Dominant negative PI 3-kinase abolished the insulin-induced inhibition of GSK-3. These data strongly support the hypothesis that insulin activates eIF2B through a signalling pathway involving PI 3-kinase and inhibition of GSK-3.