Another Option for Aggression and Self-Injury, Alternative Benzodiazepines for Catatonia in Profound Autism.

Introduction: Individuals with profound autism often present for inpatient care due to aggression. Diagnostic and treatment options are limited. Agitated catatonia is a treatable comorbidity in autism, which should be considered in cases of aggression. Preliminary data report high clinical response rates of catatonia in autism when treated with electroconvulsive therapy (ECT), with poor response to lorazepam. However, access to ECT is often limited, especially in pediatric populations. Methods: We conducted a retrospective chart review to identify cases of hyperactive catatonia with partial response to lorazepam in profoundly autistic children presenting to the pediatric medical hospital. Five cases were identified, all of whom were followed by the child and adolescent psychiatry consult-liaison service during admission and treated without the use of ECT. Data from the medical record were obtained after institutional review board (IRB) approval including the following: (1) treatment course, (2) Bush-Francis Catatonia Rating Scale (BFCRS) scores, and (3) Kanner Catatonia Rating Scale (KCRS) severity scores. The Clinical Global Impressions-Improvement (CGI-I) Scale was applied retrospectively to each case. Results: All five patients demonstrated clinically significant improvements. The average CGI-I score was 1.2. The average percentage reduction in the BFCRS and KCRS severity scores was 63% and 59%, respectively. Two of five patients were first stabilized with infusions midazolam and dexmedetomidine due to the symptom severity and then transitioned to long-acting oral benzodiazepines. Overall, four of five patients were stabilized with oral clonazepam and one of five with oral diazepam. Notably, four of five patients experienced an acute worsening of aggression, self-injury, and other catatonic symptoms with escalating dosages of antipsychotic treatment, which occurred before inpatient admission. All patients experienced resolution of physical aggression toward self and/or others, experienced improvement in their communicative abilities, and were able to return home or enter residential level of care upon discharge. Conclusions: Given the limited availability of ECT and the unclear utility of lorazepam for hyperactive catatonia in autism, the use of long-acting benzodiazepines and/or midazolam infusion may offer a safe and readily available treatment alternative.

Lifestyle Counseling for Medication Adherence in Glaucoma.

BACKGROUND: Medication adherence in glaucoma patients remains sub-par despite proven benefits of regular administration. The objective was to analyze medication adherence before and after lifestyle counseling in patients with ocular hypertension (OHT) or primary open-angle glaucoma (POAG) (mild, moderate, severe). METHODS: Prospective cohort study from May to July 2018 at a single academic center. From 391 consecutive records, 247 were excluded based on exclusion criteria with 28 patients not meeting inclusion criteria resulting in the final sample of 116 patients (33 had OHT, 83 had POAG - 28 mild, 39 moderate, 16 severe). Scripted lifestyle counseling focusing on diet, exercise, vitamin intake, stress management, and medication adherence was administered by a team of trained medical students. Primary outcome measure was self-reported medication adherence, defined as not missing an eye drop administration in the past month. A 2-3 week follow-up with scripted telephone survey assessing medication adherence, diet, and exercise was collected. RESULTS: At baseline, in 116 patients, 59.5% were adherent to their medication with a breakdown of 42.4% OHT, 64.3% mild, 66.7% moderate, and 68.7% severe and an increasing trend in medication adherence was found across increasing disease severity (p=0.055). Of the 76 (65.5%) patients reached for follow-up, 17 (22.4%) became adherent following lifestyle counseling (p=0.02) increasing overall adherence to 78.9% from 62.5%. CONCLUSION: In our study, comprehensive lifestyle counseling succeeded in increasing medication adherence in patients with OHT and POAG.

Frequency of atrial arrhythmias after atrial flutter ablation and the effect of presenting rhythm on the day of ablation.

Radiofrequency catheter ablation of the cavotricuspid isthmus is a proven therapy for typical atrial flutter (AFl); however, in some patients, new atrial arrhythmias (AA) may occur after AFl ablation. This study explored the difference in the occurrence of spontaneous AA after AFl ablation as a function of the patient's presenting rhythm on the day of the AFl ablation. A retrospective study of consecutive patients who underwent AFl ablation at Baylor University Medical Center at Dallas was performed. A total of 188 subjects were included; 50% (94) presented in AFl (Group AFl) on the day of the ablation procedure and 94 presented in sinus rhythm (SR; Group SR). Group AFl patients were older (P < 0.001), more likely to have diabetes (P = 0.03), and more likely to have undergone previous heart surgery (P = 0.03). The median size of the left atrium was 4 cm (range 2.8-6.8) in Group AFl compared with 3.8 cm (range 2.6-5.6) in Group SR (P = 0.009). Atrial fibrillation was induced during the ablation procedure in 7.5% and 21.3% of patients in Groups AFl and SR, respectively (P = 0.007). Overall, 29 of 188 (15.4%) patients developed new AA within 1 year of the procedure, 13.8% in Group AFl vs 17.0% in Group SR (P = 0.57). In conclusion, patients presenting for AFl ablation in SR were younger and healthier but had more atrial fibrillation induced during their ablation procedure, with a trend toward more postablation AA due to additional arrhythmia substrate.