Implementation of an Evidence-Based Treatment Protocol and Order Set for Alcohol Withdrawal Syndrome.

BACKGROUND: Alcohol withdrawal syndrome (AWS) is highly prevalent in hospital inpatients. Recent evidence supports use of phenobarbital and gabapentin in certain patients, and screening tools for severe withdrawal risk can be used to guide care. Inpatients with AWS should also be considered for evidence-based treatment for alcohol use disorder (AUD). PURPOSE: The purpose of this quality improvement study was to monitor clinical outcomes and prescribing habits after updating an electronic order set for inpatient AWS management at a large, academic hospital. METHODS: Protocol updates included use of the Prediction of Alcohol Withdrawal Severity Scale, phenobarbital and gabapentin protocols, and linkage to treatment resources. Data were collected for 10 months before and 14 months after implementation. RESULTS: Intensive care unit (ICU) transfer rate decreased by 2.3%, whereas length of stay and readmissions were not significantly different. In patients treated with the order set, ICU transfer and length of stay outcomes were superior. Patients treated through the order set were more likely to receive evidence-based treatment for AWS and AUD. CONCLUSIONS: Electronic order sets can promote evidence-based practice for AWS. The updated protocol will remain in place at the study institution, with future efforts focused on education and ease of use to increase order set utilization.

Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System.

Since 2007, the Medicare Severity Diagnosis Related Groups classification system has favored billing codes for acute encephalopathy over delirium codes in determining hospital reimbursement and several quality-of-care value metrics, despite broad overlap between these sets of diagnostic codes. Toxic and metabolic encephalopathy codes are designated as major complication or comorbidity, whereas causally specified delirium codes are designated as complication or comorbidity and thus associated with a lower reimbursement and lesser impact on value metrics. The authors led a submission to the U.S. Centers for Medicare and Medicaid Services requesting that causally specified delirium be designated major complication or comorbidity alongside toxic and metabolic encephalopathy. Delirium warrants reclassification because it satisfies U.S. Centers for Medicare and Medicaid Services' guiding principles for re-evaluating Medicare Severity Diagnosis Related Group severity levels. Delirium: (1) has a bidirectional relationship with the permanent condition of dementia (major neurocognitive disorder per DSM-5-TR), (2) indexes vulnerability across populations, (3) impacts healthcare systems across levels of care, (4) complicates postoperative recovery, (5) consigns patients to higher levels of care, (6) impedes patient engagement in care, (7) has several recent treatment guidelines, (8) often indicates neuronal/brain injury, and (9) represents a common expression of terminal illness. The proposal's impact was explored using the 2019 National Inpatient Sample, which suggested that increasing delirium's complexity designation would lead to an upcoding of less than 1% of eligible discharges. Parity for delirium is essential to enhancing awareness of delirium's clinical and economic costs. Appreciating delirium's impact would encourage delirium prevention and screening efforts, thereby mitigating its dire outcomes for patients, families, and healthcare systems.

A 10-Year Follow-up Survey of Psychiatry Resident Education in Consultation-Liaison Psychiatry.

BACKGROUND: In 2010, the Academy of Consultation-Liaison (then Academy of Psychosomatic Medicine) surveyed US residency programs to understand training in consultation-liaison (CL) psychiatry, leading to recommendations in 2014. Since then, residency training in CL has evolved in the context of competing training demands, increased prioritization of electives, and reactions to coronavirus 2019. OBJECTIVE: To determine the current state of residency training in CL across the United States, including the structure of core and elective resident rotations in CL, attending physician staffing, presence of fellows and other trainees, didactic curriculum, and impact of coronavirus 2019. METHODS: Members of the Academy of Consultation-Liaison Residency Education Subcommittee designed and piloted an 81-question survey tool that was sent to program directors of 269 US general psychiatry training programs for voluntary completion. RESULTS: One hundred three of 269 programs responded to the survey, yielding a response rate of 38.3%. Responding programs were larger and more likely to have a CL fellowship than nonresponding programs. Of the 103 responding programs, 82.5% have more than the minimally required time on CL, with 46.6% reporting an increase in total CL time in the past decade. Since 2010, 18.4% of responding programs changed the placement of the CL rotation, with 43.7% now adherent to the 2014 Academy of Psychosomatic Medicine recommendation to include core CL training in the second half of residency. Thirty-five percent of responding programs require residents to rotate on more than 1 CL service, and 19.4% have a required outpatient CL component. Faculty full-time equivalent varies widely. Of all services included, 33.8% report that all CL faculty are board-certified in CL psychiatry, whereas 18.7% have no board-certified faculty. Of the 103 responding programs, 36.9% offer a CL fellowship, but 31.1% report no residency graduates pursuing CL fellowships in the past 5 years. Of the included programs, 77.7% have a formal CL curriculum for residents, with 34.0% reporting a separate didactic series during the CL rotation. CONCLUSIONS: Among the responding programs, the amount of time spent on core CL rotations has increased in the past decade, but programs have also shifted CL training earlier in the course of residency. Residency programs are increasingly challenged to provide an optimal CL experience, and updated guidance from Academy of Consultation-Liaison may be appreciated.

Association Between COVID-19 and Delirium Development in the General Medical Units at an Academic Medical Center.

INTRODUCTION: Evidence suggests that inpatients who develop delirium experience worse outcomes. Although there is reason to believe that COVID-positive patients may be at a higher risk for developing delirium, little is known about the association between COVID-19 and delirium among hospitalized patients outside the intensive care unit (ICU). This study aimed to examine (1) the independent association between COVID-19 infection and the development of delirium among all non-ICU patients and (2) the risk factors associated with developing delirium among patients admitted with COVID-19, with a special focus on presenting symptoms. METHODS: Using electronic health record (EHR) data of adults admitted to any general medical unit at a large academic medical center from July 2020 through February 2021, we used a cross-sectional multivariable logistic regression to estimate the associations, while adjusting for patients' sociodemographic, clinical characteristics, delirium-free length of stay, as well as time fixed effects. RESULTS: Multivariable regression estimates applied to 20 509 patients hospitalized during the study period indicate that COVID-19-positive patients had 72% higher relative risk (odds ratio 1.72; 95% CI, 1.31 - 2.26; P < 0.001) of developing delirium than the COVID-19-negative patients. However, among the subset of patients admitted with COVID-19, having any COVID-19-specific symptoms was not associated with elevated odds of developing delirium compared to those who were asymptomatic, after controlling for potential confounders. CONCLUSIONS: COVID-19 positivity was associated with higher odds of developing delirium among patients during their non-ICU hospitalization. These findings may be helpful in targeting the use of delirium prevention strategies among non-ICU patients.

Body image disturbance and associated eating disorder and body dysmorphic disorder pathology in gay and heterosexual men: A systematic analyses of cognitive, affective, behavioral und perceptual aspects.

OBJECTIVE: This study contributes to the quantitatively large, yet narrow in scope research on body image in gay men by assessing whether gay and heterosexual men systematically differ on various dimensions of body image disturbance and associated pathology, i.e., eating disorder and body dysmorphic disorder symptoms. Moreover, we examined the influence of general everyday discrimination experiences and involvement with the gay community on body image. METHOD: N = 216 men (n = 112 gay men, n = 104 heterosexual men) participated in an online survey measuring the discrepancy between self-rated current and ideal body fat/ muscularity; drive for leanness, muscularity, and thinness; body satisfaction; body-related avoidance and checking; appearance fixing; overall body image disturbance; eating disorder and body dysmorphic disorder pathology; general everyday discrimination experiences; and involvement with the gay community. RESULTS: Gay men showed a greater discrepancy between self-rated current and ideal body fat; higher drive for thinness, body-related avoidance, appearance fixing, overall body image disturbance, eating disorder and body dysmorphic disorder pathology; and lower body appreciation than heterosexual men (all p ≤ .05). Contrary to expectation, everyday discrimination experiences were more strongly associated with body image disturbance and eating disorder/ body dysmorphic disorder pathology in heterosexual men than in gay men (all p ≤ .05). Gay community involvement was not associated with any body image disturbance-, ED-, or BDD aspect in gay men (all p ≥ .20). DISCUSSION: The results suggest greater body image disturbance in gay men than in heterosexual men regarding cognitions, emotions, behaviors, and perception as well as higher eating disorder and body dysmorphic disorder pathology. The results also suggest the dilemma of a thin, yet muscular body ideal in gay men. Surprisingly, discrimination experiences and involvement with the gay community did not explain differences in body image disturbance. Gay men may have become resilient to discrimination over time, and body ideals might differ across gay sub-communities.

Management of SIADH-related hyponatremia due to psychotropic medications - An expert consensus from the Association of Medicine and Psychiatry.

OBJECTIVE: Hyponatremia is the most common electrolyte imbalance encountered in clinical practice and is associated with negative healthcare outcomes and cost. SIADH is thought to account for one third of all hyponatremia cases and is typically an insidious process. Psychotropic medications are commonly implicated in the etiology of drug induced SIADH. There is limited guidance for clinicians on management of psychotropic-induced SIADH. METHODS: After an extensive review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus recommendations for management of psychotropic-induced SIADH. A risk score was proposed based on risk factors for SIADH to guide clinical decision-making. RESULTS: SSRIs, SNRIs, antipsychotics, carbamazepine, and oxcarbazepine have moderate to high level of evidence demonstrating their association with SIADH. Evaluation for an avoidance of medications that cause hyponatremia is particularly important. Substitution with medication that is less likely to cause SIADH should be considered when appropriate. We propose an algorithmic approach to monitoring hyponatremia with SIADH and corresponding treatment depending on symptom severity. CONCLUSIONS: The proposed algorithm can help clinicians in determining whether psychotropic medication should be stopped, reduced or substituted where SIADH is suspected with recommendations for sodium (Na+) monitoring. These recommendations preserve a role for clinical judgment in the management of hyponatremia with consideration of the risks and benefits, which may be particularly relevant for complex patients that present with medical and psychiatric comorbidities. Further studies are needed to determine whether baseline and serial Na+ monitoring reduces morbidity and mortality.

mHealth for schizophrenia spectrum disorders management: A systematic review.

BACKGROUND: Various types of computational technologies can be used to access, store and wirelessly share private and sensitive user-related information. The 'big data' provided by these technologies may enable researchers and clinicians to better identify behavioral patterns and to provide a more personalized approach to care. The information collected, however, can be misused or potentially abused, and therefore could be detrimental to the very people who provided their medical data with the hope of improving care. This article focuses on the use of emerging mobile technologies that allow the collection of data about patients experiencing schizophrenia spectrum and related disorders. Schizophrenia has been recognized by the Sustainable Development Goals of the United Nations for its burden on our health care system and society [1]. Our analysis provides an overview of the range of available mobile technologies for people with schizophrenia and related conditions along with the technology's reported capabilities and limitations, and efficacy of mHealth interventions based on the data from articles. Thus, the focus of this review is first and foremost to update the scope of existing technologies as previous systematic reviews such as the ones by Alvarez-Jimenez et al. and by Firth and Torous are outdated [2, 3]. Although we also examine the ethical issues arising from the use of these technologies, for an in-depth analysis of the ethical implications of mobile Health technologies (mHealth), we refer the readers to our follow-up article. In terms of the ubiquitous availability of technology on the internet, our article summarizes significant information for mental health specialists and apprises the reader about the existence of these technologies. OBJECTIVES: In terms of the ubiquitous availability of technology on the internet, our article summarizes significant information for mental health specialists and apprises the reader about the existence of these technologies.

QTc monitoring in adults with medical and psychiatric comorbidities: Expert consensus from the Association of Medicine and Psychiatry.

OBJECTIVE: Several psychiatric medications have the potential to prolong the QTc interval and subsequently increase the risk for ventricular arrhythmias such as torsades de pointes (TdP). There is limited guidance for clinicians to balance the risks and benefits of treatments. METHODS: After a review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus guidelines for ECG monitoring of the QTc interval for patients with medical and psychiatric comorbidities who are prescribed medications with the potential to prolong the QTc interval. A risk score was developed based on risk factors for QTc prolongation to guide clinical decision-making. RESULTS: A baseline ECG may not be necessary for individuals at low risk for arrythmia. Those individuals with a risk score of two or more should have an ECG prior to the start of a potentially QTc-prolonging medication or be started on a lower risk agent. Antipsychotics are not equivalent in causing QTc prolongation. A consensus-based algorithm is presented for the management of those identified at high (QTc >500 msec), intermediate (males with QTc 450-499 msec or females with QTc > 470-499 msec), or low risk. CONCLUSIONS: The proposed algorithm can help clinicians in determining whether ECG monitoring should be considered for a given patient. These guidelines preserve a role for clinical judgment in selection of treatments that balance the risks and benefits, which may be particularly relevant for complex patients with medical and psychiatric comorbidities. Additional studies are needed to determine whether baseline and serial ECG monitoring reduces mortality.

A novel approach to avoid capping and/or lamination by application of external lower punch vibration.

Capping as well as lamination are two common problems, which affect the resulting product quality of the tablet. Usually, capping and lamination occur during or after tablet manufacturing, and may therefore influence follow-up processes such as the coating. In this context, there is an urgent need for approaches to overcome the occurrences of capping and lamination. In the present study, a novel lower punch vibration technique was used to decrease the capping or lamination tendency of different powder formulations. Different microcrystalline cellulose types, as well as an API (acetaminophen), were selected as model powders. The powders were investigated regarding their powder flow, density, particle morphology, and surface area. Moreover, the manufactured tablets were characterized regarding their tablet weight, tensile strength, and capping or lamination indices. It was shown that the capping or lamination tendency was strongly affected by the physical powder properties, the formulation composition, and the adjusted turret speed. In addition, the application of externally applied lower punch vibration led to a pronounced decrease of the capping or lamination tendency and improved mechanical stability of the manufactured tablets.

Improving the Validity of Nurse-Based Delirium Screening: A Head-to-Head Comparison of Nursing Delirium-Screening Scale and Short Confusion Assessment Method.

BACKGROUND: As part of a multicomponent delirium prevention protocol the Confusion Assessment Method (Short-CAM) was introduced to nursing as the standard delirium screening instrument on the general medical units. Despite significant educational efforts, quality monitoring revealed poor sensitivity with the use of Short-CAM. OBJECTIVES: To compare the validity of the Nursing Delirium Screening Scale (Nu-DESC) and Short-CAM on general medical units and to explore the impact of delirium education on the successful implementation of delirium screening tools. METHODS: In this quality improvement project, both Nu-DESC and Short-CAM were scored by nurses on 2 general medical units, per standard practice. Two blinded physician-raters determined delirium diagnosis in 192 patients on these units on 8 separate days, utilizing the Diagnostic and Statistical Manual of Mental Disorders-5 criteria as the reference standard. Sensitivity and specificity of both scales were calculated. RESULTS: Thirty-five of 192 patients (18.2%) were suffering from delirium on the day of assessment. The Short-CAM scored positive for 3 (1.6%) patients and the Nu-DESC for 50 (26.0%) patients on the same day as the physician-raters assessment. Sensitivity and specificity were respectively calculated at 8.6% and 100% for the Short-CAM and 77.1% and 85.4% for the Nu-DESC. There was no statistical difference in sensitivity and specificity of the Nu-DESC on the units regardless of the level of preimplementation delirium education. CONCLUSIONS: The Nu-DESC was shown to be an easy-to-deploy delirium-screening tool on general medical units with improved sensitivity when compared to the Short-CAM.

Predictive factors of daily opioid use and quality of life in adults with sickle cell disease.

OBJECTIVES: In adults with sickle cell disease (SCD), pain often necessitates opioid use. Few studies have examined the relationship between opioid use and health-related quality of life (HRQOL) in adults with SCD. We tested the hypothesis that higher doses of opioids are associated with worse HRQOL. METHODS: A cross-sectional cohort study was performed in adults with SCD who completed standardized and validated HRQOL questionnaires: Patient Health Questionnaire-15 (PHQ-15), Patient Health Questionnaire-9 (PHQ-9), Medical Outcome Study 36 Item Short Form (SF-36), and Generalized Anxiety Disorder questionnaire (GAD-7). Daily outpatient opioid dose was converted into morphine milligram equivalents (MME) and categorized as < 90 mg/day or ≥ 90 mg/day. Subject's questionnaire scores were compared by opioid dose. RESULTS: Ninety-nine adults completed questionnaires. The majority had HbSS and median age was 30 years. The median MME was 80 mg/day. When the association between HRQOL and opioid dose was compared, those prescribed ≥ 90 MME had significantly lower SF-36 subscale scores in 7 of 8 domains, and significantly higher severity scores in the PHQ-15, GAD-7, and the PHQ-9 in comparison those prescribed < 90 MME. Using a multivariable regression tree analysis, in addition to the presence of chronic pain, mental health, physical health, and somatic burden were key predictors of ≥ 90 MME opioid use. CONCLUSION: Higher daily opioid dose is associated with chronic pain. Among those with chronic pain, opioid dose ≥ 90 MME is associated with worse HRQOL.

Central Neuromodulators for Treating Functional GI Disorders: A Primer.

Patients with functional GI disorders (FGIDs) are commonplace in the gastroenterologist's practice. A number of these patients may be refractory to peripherally acting agents, yet respond to central neuromodulators. There are benefits and potential adverse effects to using TCAs, SSRIs, SNRIs, atypical antipsychotics, and miscellaneous central neuromodulators in these patients. These agents can benefit mood, pain, diarrhea, constipation, nausea, sleep, and depression. The mechanisms by which they work, the differences between classes and individual agents, and the various adverse effects are outlined. Dosing, augmentation strategies, and treatment scenarios specifically for painful FGIDs, FD with PDS, and chronic nausea and vomiting syndrome are outlined.

A photoswitchable rotaxane operating in monolayers on solid support.

A novel photoswitchable rotaxane was synthesised and its switching behaviour in solution was analysed with NMR and UV-Vis. A monolayer of rotaxanes was deposited on glass surfaces and the on-surface photoswitching was investigated. Angle-resolved NEXAFS spectra revealed a preferential orientation that reversibly changes upon switching.

Photocontrolled On-Surface Pseudorotaxane Formation with Well-Ordered Macrocycle Multilayers.

The photoinduced pseudorotaxane formation between a photoresponsive axle and a tetralactam macrocycle was investigated in solution and on glass surfaces with immobilized multilayers of macrocycles. In the course of this reaction, a novel photoswitchable binding station with azobenzene as the photoswitchable unit and diketopiperazine as the binding station was synthesized and studied by NMR and UV/Vis spectroscopy. Glass surfaces have been functionalized with pyridine-terminated SAMs and subsequently with multilayers of macrocycles through layer-by-layer self assembly. A preferred orientation of the macrocycles could be confirmed by NEXAFS spectroscopy. The photocontrolled deposition of the axle into the surface-bound macrocycle-multilayers was monitored by UV/Vis spectroscopy and led to an increase of the molecular order, as indicated by more substantial linear dichroism effects in angle-resolved NEXAFS spectra.

Pharmacologic and nonpharmacologic approaches to the prevention and management of delirium.

Delirium is a syndrome of neuropsychiatric signs and symptoms that can accompany virtually any serious medical condition. Delirium is characterized by a disturbance of attention and awareness, as well as variety of other aspects of cognition that develops over a short period of time in response to another medical condition. It is an independent risk factor for increased morbidity and mortality and is associated with increased lengths of stay and costs of care. Despite this, it frequently goes unrecognized, and debate continues about the best prevention and treatment strategies. This article will review the current best practices for the prevention and treatment of delirium and how collaborative care can aid in improving outcomes and minimizing adverse events for patients suffering from delirium.

Dementia: A complex disease with multiple etiologies and multiple treatments.

As the population of the United States ages, the rates of dementia are also likely to increase. Clinicians will, therefore, likely be asked to evaluate and treat an escalating number of patients experiencing a decline in multiple domains of cognitive function, which is the hallmark of neurocognitive disorders. It is also probable that clinicians will be confronted with management dilemmas related to the myriad of psychological and behavioral problems that often occur as a consequence of the neurocognitive impairment. In fact, these behavioral and psychological issues might be the initial symptoms that lead the patient to present to the clinician. Dementia has multiple potential etiologies, and a careful diagnostic assessment is imperative to best characterize the specific type of dementia impacting the patient. This is important, as knowing the type of dementia helps the clinician choose the most effective treatment. Potential treatments should be interdisciplinary in scope, patient/family-centered, and may include both nonpharmacologic and pharmacologic treatments.