Recurrent Aspiration in a Patient With Gastric Band Undergoing Electroconvulsive Therapy.

We report a case of a 33-year-old woman with depression and suicidal ideation, treated successfully with electroconvulsive therapy (ECT) in the past. Since her previous course of ECT, she underwent gastric banding, a bariatric surgical procedure associated with increased risk of gastric regurgitation. Despite increasingly stringent measures to minimize the risk of regurgitation and aspiration during ECT, she had several episodes of regurgitation, the last of which precipitated an acute illness consistent with aspiration pneumonitis. We took additional precautions after each event, until she had no further episodes of regurgitation. We discuss the risk posed by the gastric band, the measures we implemented to minimize that risk, and our recommendations for assessment and management of post-gastric banding patients who present for ECT.

Quality Improvement Framework to Examine Health Care Disparities in Behavioral Emergency Management in the Inpatient Medical Setting: A Consultation-Liaison Psychiatry Health Equity Project.

BACKGROUND: De-escalation of behavioral emergencies in the inpatient medical setting may involve restrictive clinical interventions that directly challenge patient autonomy. OBJECTIVE: We describe a quality improvement framework used to examine associations between patient characteristics and behavioral emergency de-escalation strategies. This project may inform other Consultation-Liaison Psychiatry teams seeking to promote equity in care. METHODS: We examined behavioral emergency response team (BERT) management at an urban, tertiary-care medical center in the United States over a 3-year period. BERT data from an existing dataset were combined with demographic information from the hospital's electronic medical record. Race and ethnic identities were categorized as Black, Hispanic, Asian, White, and unknown. BERT events were coded based on the most restrictive intervention utilized per unique patient. Cross-tabulations and adjusted odds ratios from multivariate logistic regression were used to identify quality improvement targets in this exploratory project. RESULTS: The sample included N = 902 patients and 1532 BERT events. The most frequent intervention reached was verbal de-escalation (n = 419 patients, 46.45%) and the least frequent was 4-point restraints (n = 29 patients, 3.2%). Half of BERT activations for Asian and a third for Hispanic patients required interpreter services. Anxiety and cognitive disorders and 2 BERT interventions, verbal de-escalation, and intramuscular/intravenous/ medications, were significantly associated with race/ethnic category. The most restrictive intervention for BERTs involving Black and Asian patients were verbal de-escalation (60.1%) and intramuscular/intravenous(53.7%), respectively. These proportions were higher compared with other race/ethnic groups. There was a greater percentage of patients from the unknown (6.3%) and Black (5.9%) race/ethnic groups placed in 4-point restraints compared with other groups (3.2%) that did not reach statistical significance. A logistic regression model predicting 4-point restraints indicated that younger age, multiple BERTs, and violent behavior as a reason for BERT activation, but not race/ethnic group, resulted in significantly higher odds. CONCLUSIONS: This project illustrates that a quality improvement framework utilizing existing clinical data can be used to engage in organizational introspection and identify potential areas of bias in BERT management. Our findings suggest opportunities for further exploration, enhanced education, and programmatic improvements regarding BERT intervention; 4-point restraints; interpreter services; and the influence of race on perception of psychopathology.

Exploring the Chemical Profiles and Biological Values of Two Spondias Species (S. dulcis and S. mombin): Valuable Sources of Bioactive Natural Products.

Spondias species have been used in traditional medicine for different human ailments. In this study, the effect of different solvents (ethyl acetate, methanol, and water) and extraction methods (infusion, maceration, and Soxhlet extraction) on the enzyme inhibitory activity against acetylcholinesterase, butyrylcholinesterase, tyrosinase, α-amylase, α-glucosidase, and antioxidant properties of S. mombin and S. dulcis leaves and stem bark were evaluated. Ultra-high-performance liquid chromatography-high resolution mass spectrometry (UHPLC-HRMS) yield in the identification and/or annotation of 98 compounds showing that the main secondary metabolites of the plant are gallic and ellagic acids and their derivatives, ellagitannins, hydroxybenzoic, hydroxycinnamic, acylquinic acids and flavonols, flavanones, and flavanonols. The leaves infusion of both Spondias species showed highest inhibition against acetylcholinesterase (AChE) (10.10 and 10.45 mg galantamine equivalent (GALAE)/g, for S. dulcis and S. mombin, respectively). The ethyl acetate extracts of the stem bark of S. mombin and S. dulcis actively inhibited α-glucosidase. Methanolic extracts of the leaves and stem bark exhibited highest tyrosinase inhibitory action. Antioxidant activity and higher levels of phenolics were observed for the methanolic extracts of Spondias. The results suggested that the Spondias species could be considered as natural phyto-therapeutic agents in medicinal and cosmeceutical applications.

Three-year medication prophylaxis in panic disorder: to continue or discontinue? A naturalistic study.

OBJECTIVE: Little is known about maintenance treatment for panic disorder. The purpose of this naturalistic study is to compare outcomes of remitted panic disorder patients continued on versus those successfully discontinued from maintenance medication. METHODS: After 3 years of sustained remission with medication in a naturalistic setting, 168 patients were continued on, whereas 37 successfully discontinued from medication. Continued and discontinued groups were followed for an additional 4 to 8 years and compared for differences in treatment outcome using chi(2) and Wilcoxon rank sum tests. Times to relapse were analyzed using the Kaplan-Meier product-limit method, and risk factors for relapse were assessed using Cox proportional hazards regression. RESULTS: The discontinued group was healthier at baseline but had a significantly worse outcome compared with the continued group. Panic-free survival probabilities for the continued group at 1, 2, 3, and 4 years were 0.87, 0.81, 0.71, and 0.64, respectively, and were significantly higher than respective probabilities of 0.53, 0.35, 0.29, and 0.15 for the discontinued group. Median survival time in the continued group was significantly longer, at 5.67 years, than in the discontinued group, at 1.17 years. Cognitive behavioral therapy significantly reduced hazard in the discontinued but not in the continued group. Residual symptoms in either group at time of assignment predicted poorer outcome. CONCLUSION: Our small study suggests that relapse of panic disorder in routine clinical practice occurs even after long-standing remission on maintenance medication, and that relapse risk appears to be markedly higher after medication discontinuation. Discontinuation may be more successful in candidates who received cognitive behavioral therapy and have minimal residual symptoms.