Right Heart and Wrong Rhythm: Atrial Flutter in Dextrocardia.

Atrial flutter is characterized by rapid atrial activity, causing an abnormal heart rhythm. Recognition and prompt management are of utmost importance since this cardiac arrhythmia could increase the risk of thromboembolic stroke and atrial fibrillation, which may lead to disability and death. Risk factors include myocardial infarction, surgery, medication, and structural heart abnormalities. One distinctive structural abnormality is dextrocardia. Herein, we present a case of a 47-year-old male who initially complains of difficulty in ambulation. Further workup showed atrial flutter with rapid ventricular response on electrocardiogram (ECG) and dextrocardia on imaging. This case tackles the possible association between dextrocardia and arrhythmias, which was an atrial flutter, its management, and treatment outcomes.

A Sixty-Nine-Year-Old Female With Serratia marcescens Infection.

Serratia marcescens is a bacterial pathogen that tends to cause opportunistic infections, mainly in immune-compromised patients. In this case, we present a 69-year-old female who presented to the emergency department (ED) at Mount Sinai Hospital in Chicago on February 11th, 2022, after a mechanical fall. She had a medical history of metastatic lung cancer treated with chemotherapy, hypertension, pulmonary embolism, polysubstance abuse, and chronic obstructive pulmonary disease (COPD). The patient was found to be positive for systemic inflammatory response syndrome (SIRS). The patient was then started on broad-spectrum antibiotics, including vancomycin and cefepime. Blood cultures were ordered and came back positive for Serratia marcescens. This patient had multiple factors for immune suppression, including metastatic lung cancer, chemotherapy, and polysubstance abuse. The infectious disease department was consulted for the blood culture results, and ceftriaxone was recommended. Later on, levofloxacin was recommended. Blood cultures were negative two days after being positive. Afterward, the patient was kept for monitoring until discharge. Serratia marcescens is found in several reservoirs in nature. Therefore, preventing contact with this pathogen in immune-compromised patients can be difficult. It is important to have a degree of clinical suspicion for opportunistic pathogens like Serratia marcescens whenever a patient with factors for immune compromise presents for any condition.

Cross-diagnostic evaluation of minor physical anomalies in psychiatric disorders.

BACKGROUND: Minor physical anomalies (MPA) are markers of impaired neurodevelopment during the prenatal stage. Assessing MPA across psychiatric disorders may help understand their shared nature. In addition, MPA in family members would indicate a shared liability and endophenotype potential. We examined familial aggregation of MPA and their role as transdiagnostic and disorder-specific markers of 5 major psychiatric/neuropsychiatric conditions (schizophrenia, bipolar disorder, substance dependence, obsessive-compulsive disorder, and Alzheimer's dementia). METHODS: Modified Waldrop's MPA scale was applied on 1321 individuals from 439 transdiagnostic multiplex families and 125 healthy population controls (HC). Stage of fetal development (morphogenetic/phenogenetic)- and anatomical location (craniofacial/peripheral)-based sub-scores were calculated. Familiality and endophenotypic potential of MPA were analyzed with serial negative binomial mixed-effect regression. Cross-diagnostic differences and the effect of family history density (FHD) of each diagnosis on MPA were assessed. Mixed-effects Cox models estimated the influence of MPA on age-at-onset of illness (AAO). RESULTS: MPA were found to be heritable in families with psychiatric disorders, with a familiality of 0.52. MPA were higher in psychotic disorders after controlling for effects of sex and intrafamilial correlation. Morphogenetic variant MPA was noted to be lower in dementia in comparison to HC. FHD of schizophrenia and bipolar disorder predicted higher, and that of dementia and substance dependence predicted lower MPA. MPA brought forward the AAO [HR:1.07 (1.03-1.11)], and this was more apparent in psychotic disorders. CONCLUSION: MPA are transmissible in families, are specifically related to the risk of developing psychoses, and predict an earlier age at onset. Neurodevelopmentally informed classification of MPA has the potential to enhance the etiopathogenic and translational understanding of psychiatric disorders.

Are There Familial Patterns of Symptom Dimensions in Obsessive-Compulsive Disorder?

Background: Obsessive-compulsive disorder (OCD) is a heterogeneous illness, and emerging evidence suggests that different symptom dimensions may have distinct underlying neurobiological mechanisms. We aimed to look for familial patterns in the occurrence of these symptom dimensions in a sample of families with at least two individuals affected with OCD. Methods: Data from 153 families (total number of individuals diagnosed with DSM-5 OCD = 330) recruited as part of the Accelerator Program for Discovery in Brain Disorders using Stem Cells (ADBS) was used for the current analysis. Multidimensional Item Response Theory (IRT) was used to extract dimensional scores from the Yale-Brown Obsessive-Compulsive Scale (YBOCS) checklist data. Using linear mixed-effects regression models, intra-class correlation coefficients (ICC), for each symptom dimension, and within each relationship type were estimated. Results: IRT yielded a four-factor solution with Factor 1 (Sexual/Religious/Aggressive), Factor 2 (Doubts/Checking), Factor 3 (Symmetry/Arranging), and Factor 4 (Contamination/Washing). All except for Factor 1 were found to have significant ICCs, highest for Factor 3 (0.41) followed by Factor 4 (0.29) and then Factor 2 (0.27). Sex-concordant dyads were found to have higher ICC values than discordant ones, for all the symptom dimensions. No major differences in the ICC values between parent-offspring and sib-pairs were seen. Conclusions: Our findings indicate that there is a high concordance of OCD symptom dimensions within multiplex families. Symptom dimensions of OCD might thus have significant heritability. In view of this, future genetic and neurobiological studies in OCD should include symptom dimensions as a key parameter in their analyses.

Psychiatric symptoms and syndromes transcending diagnostic boundaries in Indian multiplex families: The cohort of ADBS study.

Syndromes of schizophrenia, bipolar disorder, obsessive-compulsive disorder, substance use disorders and Alzheimer's dementia are highly heritable. About 10-20% of subjects have another affected first degree relative (FDR), and thus represent a 'greater' genetic susceptibility. We screened 3583 families to identify 481 families with multiple affected members, assessed 1406 individuals in person, and collected information systematically about other relatives. Within the selected families, a third of all FDRs were affected with serious mental illness. Although similar diagnoses aggregated within families, 62% of the families also had members with other syndromes. Moreover, 15% of affected individuals met criteria for co-occurrence of two or more syndromes, across their lifetime. Using dimensional assessments, we detected a range of symptom clusters in both affected and unaffected individuals, and across diagnostic categories. Our findings suggest that in multiplex families, there is considerable heterogeneity of clinical syndromes, as well as sub-threshold symptoms. These families would help provide an opportunity for further research using both genetic analyses and biomarkers.

Estimating the familial risk of psychiatric illnesses: A review of family history scores.

A history of psychiatric illnesses in family members of those diagnosed to have an illness has been of significant interest both in research and in clinical practice. Almost all of the major psychiatric illnesses have a familial component to them, perhaps influenced by genetics and a shared environment or their combination. Systematic attempts have been made to quantify these familial risks, as obtained from family history (FH) of psychiatric illnesses. The methods range from a simple dichotomous or count scores to those quantifying as weighted risks such as the Family history density (FHD) measures. This article reviews the available literature on such FH methods and discusses their advantages and limitations. Validation studies have shown that FHD measures may be preferred over dichotomous measures as indicators of familial risk. However, the FHD method has certain limitations, like mostly relying on categorical diagnosis and ignoring other familial risk factors. By critically analysing various existing density measures based on 'ideal characteristics', we suggest a modified version of FHD that would benefit psychiatric research.

Approach to Informed Consent in Telepsychiatric Service: Indian Perspective.

Consent is an essential and important medico-legal prerequisite for a patient's treatment. This necessitates the service provider to participate in the informed consent process and discuss the risk-benefit of the proposed treatment, the best available treatment, engage in shared decision-making process, opportunity to convey their view and thereby limit chances of legal liability for all parties. The clinician should have ample knowledge and skill pertaining to the informed consent process and also have adequate understanding of medical ethics and law. This article provides an overview on informed consent pertaining to telepsychiatric services in India.

Setting Up and Providing Telepsychiatry Services in India.

The exponential growth of technology in the past few decades has benefitted the healthcare sector. Telemedicine is a newer advancement which is making healthcare affordable and more accessible to the needy in recent times. This article discusses how to set up telepsychiatry services, the procedure of telepsychiatry consultation, how to record and maintain the electronic health records, the potential challenges, ethical and legal aspects concerning telepsychiatry while ensuring the good practice guidelines, medical ethics, patient rights, and the minimum requirements as established by the Information Technology Act and the telemedicine practice guidelines (TPG) 2020 issued by the Indian Medical Council.

Consent in current psychiatric practice and research: An Indian perspective.

Consent is a process that allows for free expression of an informed choice, by a competent individual. The consent is considered as one of the important components of health-care delivery and biomedical research today. Informed consent involves clinical, ethical, and legal dimensions and is believed to uphold an individual's autonomy and the right to choose. It is very important in Indian mental health care as the Mental Healthcare Act (MHCA) 2017 mandates informed consent in admission, treatment, discharge planning, and research intervention/procedures. In 2017, the Indian Council of Medical Research laid down the National Ethical Guidelines for BioMedical and Health Research involving Human Participant for research protocols, which the MHCA advocates. This article gives an overview on the evaluation of consent in clinical practice and also highlights the approach and challenge in psychiatric practice in India.

Approach to and practical challenges in certification in Psychiatry.

Psychiatrists and mental health professionals (MHPs) are often requested to provide a certificate in connection with admission, treatment, fitness, competence, administration, legal proceedings, or welfare measures and benefits for persons with mental illness. The role of Psychiatrist and MHPs in providing a certificate is an integral part of clinical practice and more so with the implementation of the Mental Healthcare Act, 2017 (MHCA 2017). While issuing a certificate, keeping patient information confidential is a challenging task for a professional as the patient care in psychiatry involves multiple stakeholders (Central and State Mental Health Authorities, Mental Health Review Board, MHPs including psychiatrist, and caregivers). There is limited training at undergraduate or postgraduate level in documentary practices and certification. This article tries to address some of the issues related to certification, professional and legal accountability, and attempts to remove some of the ambiguities associated with the certification process in psychiatry.