Single-center experience with early liver transplantation for acute alcohol-related hepatitis-Limitations of the SALT score and directions for future study.

Alcohol-related liver disease (ALD) is the leading indication for liver transplantation worldwide. Since Mathurin et al. described their experience in providing early liver transplantation for patients with ALD in 2011, other centers have followed suit with generally favorable survival outcomes. This patient population poses a unique clinical challenge given the expedited nature of the evaluation and the lack of any significant sobriety period prior to transplantation. The SALT (Sustained Alcohol Use Post-Liver Transplant) score is a standardized psychometric tool increasingly used to help stratify the risk of relapse and guide listing decisions for these challenging clinical situations. In 2018, our center introduced a protocol for early liver transplantation for acute alcohol-related hepatitis (AAH). In this article, we offer a retrospective review of 26 patients transplanted between May 2018 and May 2021, including at least 1-year follow-up, and compare outcomes to initial SALT scores; we further identify additional factors that may impact post-transplant success. As transplant committees continue to weigh the ethical dilemma of denying lifesaving treatment against the obligation to remain stewards of a limited resource, we aim to contribute to a more nuanced understanding of risk regarding early transplantation for ALD.

Phenobarbital for Acute Alcohol Withdrawal Management in Surgical Trauma Patients-A Retrospective Comparison Study.

BACKGROUND: Alcohol withdrawal syndrome (AWS) in surgical trauma patients is associated with significant morbidity and mortality. Benzodiazepines, commonly used for withdrawal management, pose unique challenges in this population given the high prevalence of head trauma and delirium. Phenobarbital is an antiepileptic drug that offers a viable alternative to benzodiazepines for AWS treatment. METHODS: This is a retrospective chart review of patients with active alcohol use disorder who presented to a level 1 trauma center over a 4-year period and required medication-assisted management for AWS. The primary outcome variable examined was the development of AWS and associated complications. Additional outcomes measured included hospital length of stay, mortality, and medication-related adverse events. RESULTS: Of the 85 patients in the study sample, 52 received a fixed-dose benzodiazepine-based protocol and 33 received phenobarbital-based protocol. In the benzodiazepine-based protocol group, 25 patients (48.2%) developed AWD and 38 (73.1%) developed uncomplicated AWS, as compared to 0 patients in the phenobarbital-based protocol (P = 0.0001). There were 10 (19.2%) patients with medication adverse side effects in the benzodiazepine-based protocol group versus 0 patients in the phenobarbital-based protocol group. There were no statically significant differences between the 2 groups as pertains to rates of other AWS-related complications, patient mortality, or length of stay. CONCLUSION: The use of a phenobarbital-based protocol in trauma patients with underlying active alcohol use disorder resulted in a statistically significant decrease in the incidence of AWD and uncomplicated AWS secondary to AWS when compared to patients treated with a fixed-dose benzodiazepine-based protocol.

Neurocovid: Pharmacological Recommendations for Delirium Associated With COVID-19.

BACKGROUND: The pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the biggest health threats of our generation. A significant portion of patients are presenting with delirium and neuropsychiatric sequelae of the disease. Unique examination findings and responses to treatment have been identified. OBJECTIVE: In this article, we seek to provide pharmacologic and treatment recommendations specific to delirium in patients with COVID-19. METHODS: We performed a literature search reviewing the neuropsychiatric complications and treatments in prior coronavirus epidemics including Middle Eastern respiratory syndrome and severe acute respiratory syndrome coronaviruses, as well as the emerging literature regarding COVID-19. We also convened a work group of consultation-liaison psychiatrists actively managing patients with COVID-19 in our hospital. Finally, we synthesized these findings to provide preliminary pharmacologic recommendations for treating delirium in these patients. RESULTS: Delirium is frequently found in patients who test positive for COVID-19, even in the absence of respiratory symptoms. There appears to be a higher rate of agitation, myoclonus, abulia, and alogia. No data are currently available on the treatment of delirium in patients with COVID-19. Extrapolating from general delirium treatment, Middle Eastern respiratory syndrome/severe acute respiratory syndrome case reports, and our experience, preliminary recommendations for pharmacologic management have been assembled. CONCLUSIONS: COVID-19 is associated with neuropsychiatric symptoms. Low-potency neuroleptics and alpha-2 adrenergic agents may be especially useful in this setting. Further research into the pathophysiology of COVID-19 will be key in developing more targeted treatment guidelines.

Use of Phenobarbital in Alcohol Withdrawal Management - A Retrospective Comparison Study of Phenobarbital and Benzodiazepines for Acute Alcohol Withdrawal Management in General Medical Patients.

BACKGROUND: Benzodiazepine-based protocols offer a standard of care for management of alcohol withdrawal, though they may not be safe or appropriate for all patients. Phenobarbital, a long-acting barbiturate, presents an alternative to conventional benzodiazepine treatment, though existing research offers only modest guidance to the safety and effectiveness of phenobarbital in managing alcohol withdrawal syndrome (AWS) in general hospital settings. METHODS: To compare clinical effectiveness of phenobarbital versus benzodiazepines in managing symptoms of alcohol withdrawal, we conducted a retrospective chart review of 562 patients admitted over a 2-year period to a general hospital and treated for AWS. The development of AWS-related complications (seizures, alcoholic hallucinosis, and alcohol withdrawal delirium) post-treatment initiation was the primary outcome examined in both treatment groups. Additional outcomes measured included hospital length of stay, intensive care unit (ICU) admission rates/length of stay, medication-related adverse events, and discharge against medical advice. RESULTS: Despite being significantly more likely to have a history of prior complications related to AWS (including seizures and delirium), patients initiated on phenobarbital (n = 143) had overall similar primary and secondary treatment outcomes to those in the benzodiazepine treatment protocol (n = 419). Additionally, a subset of patients (n = 16) initially treated with benzodiazepines displayed signs of treatment nonresponse, including significantly higher rates of AWS-related delirium and ICU admission rates, but were well-managed following transition to the phenobarbital protocol. CONCLUSION: The data from this retrospective chart review lend further support to effectiveness and safety of phenobarbital for the treatment and management of AWS. Further randomized controlled trials are warranted.

Intentional Self-inflicted Burn Injuries: Review of the Literature.

BACKGROUND: Intentional self-inflicted burn injuries are a rare occurrence in the United States, but they represent a considerable portion of all burn injuries in the developing world. Compared to nonintentional burns, patients with intentional self-inflicted burns have increased rates of higher total body surface area involvement and associated complications, including overall mortality. METHODS: We present 2 representative cases and review the available literature on the topic of self-inflicted burns. We review epidemiologic, social, and cultural factors of importance, and also provide an overview of most common psychiatric pathologies encountered in patients with self-inflicted burns. RESULTS: The patient demographics and motivation for intentional self-inflicted burn injuries differ considerably across the world. Although self-immolation is commonly associated with women experiencing domestic stress in the developing world, most cases of self-immolation in higher-income countries are males. Psychiatric pathologies, including primary mood and thought disorders and substance use, play a significant component in latter cases, while most patients in the developing world lack any premorbid psychiatric diagnosis, or carry diagnosis of adjustment disorder. CONCLUSIONS: Nonlethal self-burns present a distinct subset of intentional self-burn injuries, often occurring in the context of significant personality pathology, or with potential secondary gain.

Readings on psychosomatic medicine: survey of resources for trainees.

BACKGROUND: As systems of care become more complex and comorbid medical and psychiatric illness becomes more evident, it is essential to prepare psychiatric trainees for practice in more integrated models of care. OBJECTIVE: We sought to identify readings available for residency training in consultation-liaison (C-L) psychiatry/psychosomatic medicine with the intent to help educators and trainees identify appropriate and essential learning resources within the field. METHODS: We reviewed readings available to the residents (including commonly used textbooks in C-L psychiatry and C-L training programs' required reading lists) and identified areas of consensus regarding the topics germane to the care of patients with comorbid medical and psychiatric illness (namely depression, dementia, and delirium) and the education of trainees. RESULTS: There was considerable variation in the references cited by well-regarded textbooks and by reading lists created for trainees in C-L psychiatry. In the 4 textbooks reviewed, there were 83 shared citations on delirium (including 10 citations that were common to all 4 textbooks and 17 citations shared by 3 textbooks). Markedly less overlap was noted in the chapters on depression (only 2 references cited in all of the textbooks with relevant content) and dementia (only 7 shared references). CONCLUSION: Given the paucity of overlap of citations in commonly used textbooks, we recommend that practical topical reviews or textbook chapters be used as core (required) or recommended readings for residents on C-L psychiatry rotations, supplemented by a small number of studies or case series that illustrate key teaching points on each essential topic.

The impact of implementing the single provider model of emergency medicine in a paediatric hospital: a retrospective cohort analysis.

STUDY OBJECTIVE: The Meyer Pediatric Hospital in Florence, Italy recently implemented the single provider model of emergency medicine. Prior to these changes, patients were triaged to a paediatric surgeon or paediatrician based on the complaint. The authors assess the outcomes of patients evaluated by surgeons prior to this change and compare them with those of patients seen by emergency physicians. METHODS: A retrospective, cohort study was performed reviewing patients seen in the emergency department between 2005 and 2008 for the three most common surgical complaints encountered before the systems change: head trauma, testicular pain and abdominal pain. Outcomes include misdiagnoses, consultation rates, dispositions, imaging, interventions and surgeries. RESULTS: A total of 2415 patient visits were included. Emergency physicians saw more patients (1388 vs 1027) and obtained more consultations (25.6% vs 8.1%) than surgeons. Patients triaged directly to surgeons were more likely to be admitted to the hospital (10.3% vs 7.6%), undergo urgent interventions (9.5% vs 6.7%), undergo surgery (8.0% vs 4.8%), have more radiographic images to evaluate head trauma (12.1% vs 5.3%), be misdiagnosed (1.0% vs 0.3%) and have more plain films for abdominal pain (3.1% vs 1.3%). There is an overall trend towards fewer missed diagnoses by emergency physicians (0.3% vs 0.9%), but this difference is only statistically significant in the abdominal pain subset analysis (p=0.032, combined data p=0.052). CONCLUSIONS: The single provider model of emergency medicine where emergency physicians manage all patients presenting to the emergency department appears to be a safe and efficient model of emergency medical care.

Evaluating the association between COVID-19 and psychiatric presentations, suicidal ideation in an emergency department.

OBJECTIVE: To estimate the association between COVID-19 and Emergency Department (ED) psychiatric presentations, including suicidal ideation. METHODS: Using an interrupted time series design, we analyzed psychiatric presentations using electronic health record data in an academic medical center ED between 2018 and 2020. We used regression models to assess the association between the onset of the COVID-19 outbreak and certain psychiatric presentations. The period February 26-March 6, 2020 was used to define patterns in psychiatric presentations before and after the coronavirus outbreak. RESULTS: We found a 36.2% decrease (unadjusted) in ED psychiatric consults following the coronavirus outbreak, as compared to the previous year. After accounting for underlying trends, our results estimate significant differential change associated with suicidal ideation and substance use disorder (SUD) presentations following the outbreak. Specifically, we noted a significant differential increase in presentations with suicidal ideation six weeks after the outbreak (36.4 percentage points change; 95% CI: 5.3, 67.6). For presentations with SUD, we found a differential increase in the COVID-19 time series relative to the comparison time series at all post-outbreak time points and this differential increase was significant three weeks (32.8 percentage points; 95% CI: 4.0, 61.6) following the outbreak. Our results estimate no differential changes significant at the P value < 0.05 level associated with affective disorder or psychotic disorder presentations in the COVID-19 time series relative to the comparator time series. CONCLUSIONS: The COVID-19 outbreak in Boston was associated with significant differential increases in ED presentations with suicidal ideation and SUD.

Trends in suicidal ideation in an emergency department during COVID-19.

OBJECTIVE: This study aims to detail changes in presentations at a United States Emergency Department for suicidality before and after the outbreak of COVID-19. METHODS: A retrospective chart review was conducted of all adult patients who presented to an ED with suicidality and underwent psychiatric consultation during the study period. The cohorts consisted of patients who presented between December 2018 - May 2019 and December 2019 - May 2020. Information was collected on demographics, characteristics of suicidality, reasons for suicidality and disposition. The first wave from March - May 2020 was examined, using a difference-in-differences design to control for factors other than COVID-19 that may have influenced the outcomes' trend. RESULTS: Immediately following the pandemic outbreak there was a statistically significant increase in the proportion of undomiciled patients represented in visits for suicidality (40.7% vs. 57.4%; p-value <0.001). In addition, the proportion of patient visits attributed to social (18.0% vs. 29.2%; p-value 0.003) and structural (14.2% vs. 26.4%; p value <0.001) reasons for suicidality increased. Conversely, the proportion of visits due to psychiatric symptoms (70.5% vs 50.0%; p-value <0.001) decreased. Furthermore, patient visits were more likely to result in a medical admission (2.1% vs. 8.3%; p-value 0.002) and less likely to result in a psychiatric admission (68.4% vs 48.6%; p-value <0.001) during the initial phase of the pandemic. CONCLUSIONS: COVID-19 was associated with increased ED presentations for suicidality among undomiciled patients, as well as greater likelihood of social and structural reasons driving suicidality among all visits.

Perioperative Buprenorphine Continuous Maintenance and Administration Simultaneous With Full Opioid Agonist: Patient Priority at the Interface Between Medical Disciplines.

Buprenorphine is a partial-agonist opioid that is prescribed as a medication-assisted treatment (MAT) for opioid use disorder (OUD). Buprenorphine is also a potent analgesic with high opioid-receptor affinity and binding coefficient; when buprenorphine is administered simultaneously with a µ-opioid receptor full agonist ("full agonist opioid" [FAO]), the combination can yield unexpected outcomes depending on dosing and timing. Buprenorphine is sometimes perceived as a powerful competitive opioid blocker that will hamper pharmacologic management that necessitates the use of FAO. When patients receiving buprenorphine-MAT (BUP-MAT) formulations have presented for operative procedures, there has been clinical variance in approach to their BUP-MAT management. Recognizing the risk management challenge from both analgesia and BUP-MAT perspectives, we convened a multidisciplinary group of clinicians who treat BUP-MAT patients and completed a literature review with the goal of generating a guideline for appropriate management of these patients presenting for a broad spectrum of surgical procedures. Our conclusion is that continuous simultaneous administration of buprenorphine products with FAO is safe when accounting for dose and timing, including surgeries that historically produce moderate to severe pain, and may further provide an analgesic advantage, lessen FAO burden, and reduce relapse risk to this group.