Quality prescribing in early psychosis: key pharmacotherapy principles.

OBJECTIVE: To present a practical, easy-to-implement clinical framework designed to support evidence-based quality prescribing for people with early psychosis. METHOD: Identification and explanation of key principles relating to evidence-based pharmacotherapy for people with early psychosis. These were derived from the literature, practice guidelines and clinical experience. RESULTS: Key principles include (1) medication choice informed by adverse effects; (2) metabolic monitoring at baseline and at regular intervals; (3) comprehensive and regular medication risk-benefit assessment and psychoeducation; (4) early consideration of long-acting injectable formulations (preferably driven by informed patient choice); (5) identification and treatment of comorbid mood disorders and (6) early consideration of clozapine when treatment refractory criteria are met. CONCLUSIONS: Current prescribing practices do not align with the well-established evidence for quality pharmacotherapy in early psychosis. Adopting evidence-based prescribing practices for people with early psychosis will improve outcomes.

Reflecting on our practice: an evaluation of Balint groups for medical students in psychiatry.

OBJECTIVE: This paper qualitatively evaluates a one-year trial of Balint clinical reflection groups for medical students in psychiatry at a large Australian tertiary referral hospital. The trial considered whether clinical reflection groups following the Balint process would be perceived as useful and relevant to the learning needs of the student participants. METHOD: A grounded theory approach was undertaken. This included survey data, thematic analysis of written feedback, and facilitator reflection on the process. Facilitators adapted the group process in response to participants' needs. These modifications included: increased education regarding the Balint process; the introduction of co-presenters; and the inclusion of a didactic summary following each session. RESULTS: The evaluation suggested that fidelity of the Balint group experience was achieved and that student attitudes were neutral to mildly positive regarding the educational experience. CONCLUSIONS: Balint groups are potentially useful to medical students in the Australian context. We suggest that Balint groups may be more useful when applied in less alienating learning environments, such as during general practice rotations. Emphasis is placed on the need to maintain a dynamic approach by adapting the group and the educational processes as the work unfolds.

Sexual and Reproductive Health in Adolescents and Young Adults With Psychotic Disorders: A Scoping Review.

BACKGROUND AND HYPOTHESIS: The sexual and reproductive health (SRH) of young people with psychosis has been largely overlooked. We hypothesised that there are key deficiencies in the existing literature on the SRH of adolescents and young adults with psychotic disorders. STUDY DESIGN: We conducted a systematic scoping review using Pubmed, Web of Science, Embase, PsycINFO, and CINAHL. We included empirical studies and case reports focused on SRH issues in young people (aged 14-24 years) with psychotic disorders. A qualitative synthesis was completed. Joanna Briggs Institute Critical Appraisal Tools were utilized to assess study quality. STUDY RESULTS: Seventeen empirical studies and 52 case reports met inclusion criteria. Most focused on sexual dysfunction which was identified as common among this cohort and associated with both psychotic disorders and antipsychotics. The study population was more likely to engage in sexual risk-taking behavior and was at higher risk of sexually transmissible infections than those without psychosis. SRH topics of clinical relevance in older patients with psychosis such as pregnancy, abortion, sexual violence, coercion, sexual identity, and gender were poorly addressed in this younger group. We found empirical studies generally lacked identification and controlling of confounders whilst case reports provided limited description of mental health and SRH outcomes following clinical intervention. CONCLUSION: Research and clinical practice addressing sexual and reproductive health is needed for young people living with psychosis. To address research gaps future studies should focus on women's health, sexual violence, gender, and sexuality in young people with psychosis.

Prothrombin Time and Activated Partial Thromboplastin Time Testing: A Comparative Effectiveness Study in a Million-Patient Sample.

BACKGROUND: A substantial fraction of all American healthcare expenditures are potentially wasted, and practices that are not evidence-based could contribute to such waste. We sought to characterize whether Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT) tests of preoperative patients are used in a way unsupported by evidence and potentially wasteful. METHODS AND FINDINGS: We evaluated prospectively-collected patient data from 19 major teaching hospitals and 8 hospital-affiliated surgical centers in 7 states (Delaware, Florida, Maryland, Massachusetts, New Jersey, New York, Pennsylvania) and the District of Columbia. A total of 1,053,472 consecutive patients represented every patient admitted for elective surgery from 2009 to 2012 at all 27 settings. A subset of 682,049 patients (64.7%) had one or both tests done and history and physical (H&P) records available for analysis. Unnecessary tests for bleeding risk were defined as: PT tests done on patients with no history of abnormal bleeding, warfarin therapy, vitamin K-dependent clotting factor deficiency, or liver disease; or aPTT tests done on patients with no history of heparin treatment, hemophilia, lupus anticoagulant antibodies, or von Willebrand disease. We assessed the proportion of patients who received PT or aPTT tests who lacked evidence-based reasons for testing. CONCLUSIONS: This study sought to bring the availability of big data together with applied comparative effectiveness research. Among preoperative patients, 26.2% received PT tests, and 94.3% of tests were unnecessary, given the absence of findings on H&P. Similarly, 23.3% of preoperative patients received aPTT tests, of which 99.9% were unnecessary. Among patients with no H&P findings suggestive of bleeding risk, 6.6% of PT tests and 7.1% of aPTT tests were either a false positive or a true positive (i.e. indicative of a previously-undiagnosed potential bleeding risk). Both PT and aPTT, designed as diagnostic tests, are apparently used as screening tests. Use of unnecessary screening tests raises concerns for the costs of such testing and the consequences of false positive results.

Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review.

UNLABELLED: In this systematic review we focused on postoperative recovery and complications using four different anesthetic techniques. The database MEDLINE was searched via PubMed (1966 to June 2002) using the search words "anesthesia" and with ambulatory surgical procedures limited to randomized controlled trials in adults (>19 yr), in the English language, and in humans. A second search strategy was used combining two of the words "propofol," "isoflurane," "sevoflurane," or "desflurane". Screening and data extraction produced 58 articles that were included in the final meta-analysis. No differences were found between propofol and isoflurane in early recovery. However, early recovery was faster with desflurane compared with propofol and isoflurane and with sevoflurane compared with isoflurane. A minor difference was found in home readiness between sevoflurane and isoflurane (5 min) but not among the other anesthetics. Nausea, vomiting, headache, and postdischarge nausea and vomiting incidence were in favor of propofol compared with isoflurane (P < 0.05). A larger number of patients in the inhaled anesthesia groups required antiemetics compared with the propofol group. We conclude that the differences in early recovery times among the different anesthetics were small and in favor of the inhaled anesthetics. The incidence of side effects, specifically postoperative nausea and vomiting, was less frequent with propofol. IMPLICATIONS: A systematic analysis of the literature comparing postoperative recovery after propofol, isoflurane, desflurane, and sevoflurane-based anesthesia in adults demonstrated that early recovery was faster in the desflurane and sevoflurane groups. The incidence of nausea and vomiting were less frequent with propofol.