Quality of Life in Recurrent Pericarditis.

Recurrent pericarditis (RP) poses a significant burden on individuals' quality of life. The psychosocial impact of RP is not well understood. It cannot be overlooked, as it can impact the psychosocial well-being of the patients due to the chronicity of the symptoms and multiple flare-ups. Addressing the multifaceted challenges posed by RP requires a comprehensive approach that not only focuses on symptom control but also emphasizes patient education, psychological support, and shared decision-making to optimize both physical and emotional well-being. Therefore, we aim to share our perspective on the effect of RP on the quality of life of the patients.

Universal suicide screening in emergency departments across a large healthcare system.

BACKGROUND: Suicidal ideation is a common complaint in Emergency Departments (EDs) across the United States (US) and is an important preventable cause of death. Consequently, current Joint Commission guidelines require screening high-risk patients and those with behavioral health needs for suicide. Accordingly, we implemented universal suicide screening for all patients presenting to EDs in our healthcare system and sought to describe the characteristics of the identified "high-risk" patients. We also sought to determine whether universal suicide screening was feasible and what its impact was on ED length of stay (LOS). METHODS: All ED encounters in the healthcare system were assessed. Data were collected from February 1, 2020, through June 30, 2022. All patients aged 18 and over were screened using the Columbia Suicide Severity Rating Scale (C-SSRS) and categorized as no risk, low risk, moderate risk, and high risk. Encounters were then grouped into 'high risk" and "not high risk," defined as no, low, and moderate risk patients. Data collected included gender, discharge disposition, LOS, and insurance status. RESULTS: A total of 1,058,735 patient encounter records were analyzed. The "high risk" group (n = 11,359; 10.7%) was found to have a higher proportion of male patients (50.9 vs 43.7%) and government payors (71.6 vs. 67.1%) and a higher ED LOS [medians 380 min vs. 198 min] than the not high-risk group (p ≤0.001). Those with suicidal ideation comprised 0.73-1.58% of ED encounters in a given month. A secondary analysis of 2,255,616 ED encounter records from January 2019 - June 30, 2022, revealed that 40,854 (1.81%) encounters required 1:1 observation. The proportion of 1:1 observations in 2019, the year before implementation, was 1.91%. Using a non-inferiority margin of 25%, we found that the proportion of 1:1 patients in 2020, the year following implementation, was non-inferior to (no worse than) the previous year at 2.09% and decreased from 2021 to 2022 (1.69% and 1.57% respectively). CONCLUSION: Implementing universal suicide screening in all EDs within a healthcare system is feasible. The percentage of patients who screened high risk was under 5% of the overall ED population. While the median LOS was longer for "high-risk" patients than for the general ED population, it was not excessively so. Adequate staffing to properly maintain the safety of these patients is paramount.

General Hospital Agitation Management: Leadership Theory and Health Care Team Best Practices Using TeamSTEPPS.

BACKGROUND: Acute agitation management is an emergency clinical intervention, often presenting acute danger to patients and medical staff. Unlike many other emergency clinical interventions, acute agitation management lacks a substantial evidence base regarding leadership and teamwork best practices. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) framework is a comprehensive strategy for improving health care outcomes in acute clinical situations. OBJECTIVE: Practical application of TeamSTEPPS frameworks in team-based acute agitation management in the medical setting. METHODS: A literature review was performed from January 1990 to March 2021 for verbal de-escalation in acute agitation management, leadership and teamwork in psychiatry and medicine, and TeamSTEPPS. RESULTS: No literature was found that applied TeamSTEPPS for acute agitation management in the general medical unit context although limited application has been trialed in the inpatient psychiatric context. The verbal de-escalation literature describes applicable content including conflict management approaches, communication strategies, security presence management, modeling therapeutic behavior, and debriefing strategies. Several articles were found regarding a rapid response team model for acute agitation management and describing handoff tools in psychiatric care contexts. Translation of the TeamSTEPPS approach provided many additional approaches for operation of a rapid response team in acute agitation management. CONCLUSIONS: The leadership and teamwork best practices in TeamSTEPPS provide a clear and actionable framework for team-based acute agitation management as an emergency clinical intervention.

Neuropsychiatric assessment and management of the ICU survivor.

Any survivor among the millions of patients admitted to the intensive care unit (ICU) for critical illness each year is susceptible to persistent health problems that continue after discharge and may lead to post-intensive care syndrome (PICS), defined as new or worsening dysfunction from physical impairment, cognitive impairment, or emotional impairment, or a combination. Considering the increased rates of ICU survival and the growing elderly population more likely to utilize ICU resources, critical care practitioners have broadened their focus on outcomes and care of ICU survivors to include the acute post-ICU survival period as well as months and even years after ICU discharge. This review focuses on the neuropsychiatric aspects of PICS in ICU survivors including diagnostic, screening, and treatment recommendations. It also highlights the value of post-ICU clinics and the unique role of the consultation psychiatrist in the care of this patient population.

Evaluation of the Patient Health Questionnaire-2 as a Screening Tool for Depression during the Acute Stroke Admission.

BACKGROUND: The ideal time to screen for poststroke depression remains uncertain. We evaluated the 2-item Patient Health Questionnaire (PHQ-2) as a screening tool for depression during the acute stroke admission by determining the prevalence of positive depression screen during admission and by calculating the level of agreement between positive screens during admission and follow-up. METHODS: This was a retrospective cohort of adult stroke survivors discharged January to December 2013 with principal discharge diagnosis of acute ischemic stroke or intracerebral hemorrhage. Depression screening was systematically performed during the hospital admission using the PHQ-2. The 9-item Patient Health Questionnaire (PHQ-9), which includes the PHQ-2, was completed by patients at outpatient follow-up. RESULTS: The study cohort consisted of 337 patients with mean age of 66.3 years. Median time from admission to PHQ-2 was 3 days (interquartile range 1-4 days). The screen was positive for depression in 4.7% (95% confidence interval 2.7%-7.6%) of patients. Of the 150 patients with PHQ-9 data at outpatient follow up, 19.3% screened positive for depression. In both the inpatient setting and at outpatient follow-up, the prevalence of a positive depression screen was similar between patients with and without a history of depression or antidepressant use. CONCLUSIONS: Systematic screening for depression using PHQ-2 during hospitalization for acute stroke identified few patients. Most patients with depressive symptoms were identified only at the time of outpatient follow-up. Further study is needed to evaluate the usefulness of other depression screens for stroke patients in the acute hospital setting and the optimal timing for depression screening after stroke.

What the Psychiatrist Needs to Know About Ventricular Assist Devices: A Comprehensive Review.

BACKGROUND: The number of patients with end-stage heart failure using mechanical circulatory support has dramatically increased over the past decade. Left ventricular assist devices, the most common type of mechanical circulatory support, can be used as a bridge to transplant, destination therapy, and as a bridge to recovery. As this patient population continues to grow, consultation-liaison psychiatrists will become increasingly involved in their care. A thorough biopsychosocial assessment is required to ensure adequate recognition and management of medical, psychiatric, social, and ethical challenges posed by this population. METHODS: We performed a literature review to identify key issues relevant to the practice of consultation-liaison psychiatrists. RESULTS: General functioning of left ventricular assist devices, device types, system components, life with a left ventricular assist device, preoperative evaluation, treatment of psychiatric comorbidities, and end-of-life decision-making are discussed. CONCLUSIONS: Consultation-liaison psychiatrists need to be familiar with the high prevalence of psychopathology in patients implanted with left ventricular assist devices. A detailed biopsychosocial formulation is required to adequately identify and, if possible, resolve a myriad of medical, psychiatric, social, and ethical challenges presented by this population. Future efforts should accurately identify and report specific psychiatric disorders and adverse events within this cohort.

A prospective study of anxiety in ICD patients with a pilot randomized controlled trial of cognitive behavioral therapy for patients with moderate to severe anxiety.

PURPOSE: Stress and anxiety are potential consequences from arrhythmias and implantable cardioverter defibrillator (ICD) shocks that can contribute to substantial morbidity. We assessed anxiety associated with an ICD and whether cognitive behavioral therapy (CBT) reduces anxiety. METHODS: The study consisted of two parts: part 1 (N = 690) was a prospective cross-sectional observational study of consecutive ICD patients. Patients completed the Beck Anxiety Inventory (BAI), Generalized Anxiety Disorder Scale (GAD-7), Florida Shock Anxiety Scale (FSAS), and Florida Patient Acceptance Survey (FPAS) psychometric tests. Part 2 (N = 29) was a pilot randomized controlled trial of CBT (three sessions in 3 months) vs. usual care (UC) in patients with BAI ≥ 19 from part 1. RESULTS: The median BAI and GAD-7 scores were 5 and 2, respectively. By BAI scores, 64.5 % had minimal and 3.9 % had severe anxiety. By GAD-7 scores, 73.0 % had low probability of anxiety and 2.9 % had high anxiety. Higher anxiety levels were associated with recent (p = 0.017) and total number of shocks (p = 0.002). Any shock was associated with fear about shocks (FSAS, p < 0.001) and reduced patient ICD acceptance (FPAS, p = 0.019). In the pilot trial of CBT, median BAI scores decreased from 24.5 to 11 at 1 year (p = 0.031) in the CBT group and GAD-7 scores from 12.5 to 7 (p = 0.063); no significant changes in anxiety scores were observed in the UC group. CONCLUSIONS: Severe anxiety was present in a small proportion of ICD patients, but higher anxiety was associated with recent and total number of shocks. The small pilot study suggested that a simple program of CBT might lower moderate-high anxiety with lasting effects to 1 year and supports the need for a larger trial to validate these results. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00851071. URL: http://clinicaltrials.gov/ct2/show/NCT00851071?term=anxiety+in+icd+patients+cleveland+clinic&rank=1.

Electroconvulsive therapy: what the internist needs to know.

Although electroconvulsive therapy (ECT) is widely used to treat a number of psychiatric disorders, many physicians are still unfamiliar with the procedure, its indications, and its contraindications. This article is an internist's guide to ECT, with particular focus on how commonly prescribed medications and medical conditions affect ECT.

A malignant neuroleptic spectrum: review of diagnostic criteria and treatment implications in three case reports.

Prompt identification of cases of Neuroleptic Malignant Syndrome (NMS) pose a diagnostic and treatment challenge. Three hospital cases of neuroleptic toxicity were reviewed and compared across five published diagnostic criteria sets for NMS. Of these criteria sets, only Levenson's criteria led to the detection of NMS in two out of our three patients. This criteria set supports a NMS spectrum concept, allowing earlier diagnosis and intervention. Lorazepam was used as initial treatment, which provided significant improvement. Use of Levenson's criteria for early diagnosis of NMS and lorazepam for its treatment may be useful tools for the early management of NMS.