The Correlation of Pain, Psychological Aspects, and Sleep in Fibromyalgia: A Cross-Sectional Analysis.

Background: This pilot study measures pain perception, somatosensory amplification and its relationship to health anxiety in patients with fibromyalgia (FM) and patients with FM and obstructive sleep apnea (OSA); this study also examines the effects of OSA on pain perception in patients with FM. Methods: In this pilot study, patients diagnosed with FM or FM and OSA, completed three self-reported questionnaires: Short-Form McGill Pain Questionnaire (SF-MPQ), Somatosensory Amplification Scale (SSAS), and Illness Behavior Questionnaire (IBQ). Sleep study results were analyzed. Scores were summarized using medians and interquartile ranges and are compared using Wilcoxon rank sum tests. Results: Overall FM (n = 25), female n=23 male n=3 mean age, 57.48 years. OSA n=17 (68%) and 8 (32%) were not. The SF-MPQ Sensory sub-scale scores and the SF-MPQ overall scores differed significantly between patients with and without OSA. The SF-MPQ Sensory sub-scale scores were significantly lower for patients with OSA (p=0.03), as were SF-MPQ overall scores (p=0.04). SSAS overall scores and IBQ overall scores did not differ significantly by OSA diagnosis. Correlations of the different dimensions of IBQ with SSAS and mean number of diagnoses in FM and FM+OSA, mean number of diagnoses in problem list of SSAS ≤30 was 29.5, mean number of diagnoses in SSAS ≥30 was 34.9. Discussion: Developing a better understanding of the effects of OSA on pain perception in patients with FM is needed for improved health status. More research is needed to see if higher pain perception and SSAS score lead to increased health care utilization and to evaluate the relationship between untreated disordered sleeping and pain perception in patients with FM. Conclusion: Our findings highlight the need for more research to evaluate the relationship between treated and untreated disordered sleeping, pain perception, somatization and illness behavior in the health status of individuals with FM.

Agitated and depressed with a traumatic brain injury.

Mr. N, age 46, has a history of alcohol use disorder, insomnia, anxiety, and depression. He is brought to the ED with a TBI after repeatedly beating his head into a table. How can you help him?

Avoidant restrictive food intake disorder emerging during COVID-19 pandemic resulting in superior mesenteric artery syndrome.

The COVID-19 pandemic has significantly increased the prevalence of psychiatric disorders within pediatric populations. However, only a limited number of studies have sought to understand the correlation between the pandemic and increased incidence of eating disorders. This case study highlights the hospital course of an 18-year-old female who presented with restrictive eating patterns and intensive exercise regimen, self-attributed to the COVID-19 pandemic, leading to superior mesenteric artery syndrome. In understanding the patient's avoidant restrictive food intake disorder (ARFID), this case study seeks to inform readers of this newer DSM-V diagnosis with the intent of educating pediatric providers of the severity and long-term impact of this disease. Moreover, the case study highlights the importance of gaining a more holistic view of psychiatric disorders emerging as a result of the COVID-19 pandemic.

Experience Of Resident Presentations In Consultation-Liaison Psychiatry Grand Rounds: Increase Value For Clinical Education.

BACKGROUND: Grand rounds is a formal meeting at which physicians and trainees discuss excellence in medical care. Residents should participate in scholarly activity per Accreditation Council for Graduate Medical Education (ACGME). Consultation-Liaison (CL) psychiatry focuses on caring for patients presenting with psychiatric complications in general hospital. Post-residency subspecialty CL fellowship training plays a big role in creating future leaders in CL. Our program decided to conduct annual CL grand rounds fully allotted to discuss complex CL psychiatry cases in medical setting. METHODS: We conducted a retrospective review of resident's interest in pursuing CL fellowship. We compared the number of residents pursuing CL fellowship after the CL grand rounds to the previous years starting 2005 when CL was recognized as an ACGME approved subspecialty. We also compared our program residents pursuing CL psychiatry fellowship to national trend obtained from National Residency Matching Program (NRMP). RESULTS: From 2013 to 2018, CL grand rounds n=8, Number of residents graduated from 2013 to 2018 n=26. Number of residents pursued CL fellowship from 2013 to 2018 n=3 (11.5%) compared to no residents pursuing CL fellowship before 2013. Fisher's exact test to compare and examine the data from the residents pursuing CL fellowship after implementation of the CL grand rounds is 0.0668 (p value < 0.10). When combining all the available NRMP match results for CL from 2015 to 2019, a total of 531 positions were offered and 359 positions were filled (fill rate of 67.6%). In our program, after we implemented the annual CL grand rounds, 11.5% of the residents from 2013 to 2018 pursued CL fellowship, which is higher than the likely national average of 5.7%. CONCLUSION: Our residency program grand rounds educational module appears to nurture and sustain interest in CL subspecialty compared to previous years. Prospective studies are required.

Obstructive sleep apnea co-morbidity in patients with fibromyalgia: a single-center retrospective analysis and literature review.

Background: Fibromyalgia (FM) is a chronic medical condition characterized by widespread pain, sleep disturbance, and cognitive dysfunction. Sleep disorders are thought to play a prominent role in the etiology and symptomatic management of FM, specifically obstructive sleep apnea (OSA). In order to provide collaborative care, we need a better understanding of any overlapping presentation of FM and OSA. We conducted a site-wide review of patients from 2012-2016 to identify FM patients diagnosed with OSA. Methods: Charts were reviewed in patients aged 18 and above from 2012-2016 using ICD codes from a clinical data repository. Intersection of patients with a diagnosis of FM and OSA in clinics of psychiatry, sleep, rheumatology, and other outpatient clinics was compared. Polysomnography order patterns for FM patients were investigated. Results: Co-morbidity was highest in the sleep clinic (85.8%) compared to psychiatry (42.0%), rheumatology (18.7%), and other outpatient clinics (3.6%) (p<0.001). In the rheumatology and other outpatient clinics, 93.5% and 96% of patients respectively, had no polysomnography ordered. Pairwise comparison of co-morbidity in clinics: sleep vs psychiatry, sleep vs rheumatology, sleep vs other clinics, psychiatry vs rheumatology, psychiatry vs other clinics, and rheumatology vs other clinics were statistically significant after applying a Sidak adjustment to the p-values (all p<0.001). Conclusion: Our analysis suggests that there could be a correlation between FM and OSA, and referral to sleep studies is recommended in the management of patients with FM. The varying prevalence of FM patients with co-morbid OSA in sleep clinics when compared to other outpatient clinics suggests a discrepancy in the identification of FM patients with OSA. When properly screened, OSA co-morbidity has the potential to be higher in other outpatient clinics.

Postseizure aphasia in Wernicke's encephalopathy: a case report and review of literature.

This case discusses the course of a woman with a history of epilepsy, alcohol use disorder, herpes simplex virus (HSV) encephalitis, and Wernicke encephalopathy (WE) who presented with altered mental status following approximately 48 hours of vomiting. After experiencing a tonic-clonic seizure in the emergency department, she developed a fluent aphasia. Aphasias are ordinarily attributed to structural changes in the brain parenchyma, often from stroke, neoplasm, or infection. When the magnetic resonance imaging of brain failed to show changes that could explain her fluent aphasia, the neurology team consulted psychiatry to workup psychogenic aphasia. During an admission 9 months earlier, she had been diagnosed with HSV encephalitis and possible WE. There was a high degree of suspicion for recurrent HSV infection, intermittent focal seizure activity, postictal psychosis, pseudobulbar affect, or a vascular cause of her fluent aphasia. After 3 days of treatment with levetiracetam, high-dose intravenous thiamine, and aripiprazole, the patient's fluent aphasia reversed. The authors conclude that the patient's reversible fluent aphasia was not psychiatric in etiology but likely caused by her seizures, the result of subtherapeutic phenytoin levels; her electroencephalogram showed focal seizure activity in the temporal lobes, possibly affecting her language centers. Language-related neurological conditions, or aphasias, can mimic psychiatric conditions such as conversion disorder or psychosis. In patients with substance use disorders, the line between psychiatric and neurological conditions becomes even more difficult to distinguish. The paper also discusses how unique aspects of her medications - levetiracetam conferring neuron membrane fluidity; aripiprazole, a drug shown to halt brain atrophy in mouse models; and parenteral thiamine to address her deficiency and WE - have aided in the reversal of the fluent aphasia. Levetiracetam should be considered in WE and the rare occurrence of aphasia after seizures.

Review of mini-clinical evaluation exercise (mini-CEX) in a psychiatry clerkship.

BACKGROUND: Direct observation of medical students with actual patients is important for the assessment of clinical skills including interviewing and counseling skills. This article describes medical students' experience of mini-clinical evaluation exercise (mini-CEX) during their clerkship in consultation psychiatry. MATERIALS AND METHODS: In our center during inpatient consultation psychiatry clerkship, all rotating students are expected to complete one mini-CEX assessment as part of their clinical training. We conducted retrospective analysis of mini-CEX ratings completed from 2013 to 2016. All evaluations took place at inpatient medical setting in patients admitted with medical conditions and psychiatric comorbidities. RESULTS: A total of 113 evaluations were reviewed. The time examiner observed the interaction of a student with the patient was 14.24 minutes (mean), and the time spent in providing feedback to the student was 9.71 minutes. Complexity of problem was rated as low in 0.88% (n=1), moderate in 50.44% (n=57), and high in 48.67% (n=55). Highest ratings were for professionalism, similar to previous reports. Total score calculated by examiner showed no difference by the complexity of the patient; however, we observed a trend in higher counseling score for the high complexity group. CONCLUSION: Mini-CEX assessment during busy clerkship is feasible with good outcomes. Direct observation of medical trainees with actual patients is important for the assessment of performance-based clinical skills. Hospital psychiatry rotation covering various medical and surgical units offers a great opportunity for exposure in patient communication.

Vascular endothelial growth factor: Potential predictor of treatment response in major depression.

OBJECTIVES: The aim of the study was to evaluate baseline plasma VEGF levels as a potential predictor of response to antidepressant pharmacotherapy. The study also sought to determine whether baseline plasma VEGF would be useful in predicting treatment outcome when two pharmacodynamically diverse agents with established antidepressant efficacy, escitalopram and quetiapine, were administered monotherapeutically to MDD patients. METHODS: Two groups of qualifying MDD subjects were enrolled. One group was treated with escitalopram and the other with quetiapine. Plasma concentrations of VEGF were measured using Randox Technologies at baseline, and at weeks 8 and 12 of treatment. RESULTS: We stratified the MDD patients into those who remitted and those who failed to respond. Mean baseline VEGF for the remitters and non-responders was 9.61 and 5.40 pg/ml, respectively (P < 0.0005). Using optimal data analysis a cut score of 7.49 pg/ml for baseline plasma VEGF distinguished remitters from non-responders with a 63% overall accuracy. The remission rate was comparable for both drugs (73 and 81% for quetiapine and escitalopram, respectively). VEGF levels did not significantly change following antidepressant treatment with either escitalopram or quetiapine when measured at 8 and 12 weeks; this result held true for both remitters and non-responders. CONCLUSIONS: Our results suggest that VEGF may predict response to antidepressant treatment and may ultimately prove to be a potential biomarker that can be measured with a routine blood draw at the point of service.

Does escitalopram reduce neurotoxicity in major depression?

A pro-inflammatory state and a dysregulation in the tryptophan/kynurenine pathway have been documented in depression. This study examined whether treatment with the SSRI, escitalopram (ESC), could suppress inflammation and favorably shift metabolites of the kynurenine pathway in patients with major depressive disorder (MDD) within the utilized treatment period. Twenty seven healthy control subjects were included for comparison. Thirty patients were enrolled after completing baseline assessments. They received a 12-week ESC monotherapy. Twenty subjects were completers. Clinical assessments were carried out at each visit using the HAM-D, HAM-A, CGI and BDI rating scales. Blood samples were collected at each assessment and stored until analyzed. Cytokines were analyzed with Randox multiplex assay and tryptophan and kynurenine metabolites were analyzed using HPLC/GCMS. Baseline plasma concentrations of hsCRP, TNFα, IL6 and MCP-1 were significantly higher in patients compared to healthy controls. IL10 trended toward an increase. Baseline plasma IL1ß correlated significantly with IL1α, and IL4. Patients showed significant improvement in all outcome measures with a high remission rate. Significant correlations were obtained between specific symptoms and certain biomarkers at baseline but these correlations must be viewed as very preliminary. During ESC treatment concentrations of inflammatory biomarkers did not change except for TNFα that trended lower. Metabolites and ratios of the tryptophan/kynurenine pathway showed reductions of the neurotoxic metabolites, 3-hydroxykynurenine and quinolinic acid, 3-hydroxykynurenine/kynurenine, quinolinic acid/tryptophan, kynurenic acid/quinolinic acid and quinolinic acid/3-hydroxykynurenine. The results indicate that ESC may exert its antidepressant effect in part through inhibition of synthesis of certain neurotoxic kynurenine metabolites and possibly also through reduction of the inflammatory response, although there was no concordance in the time course of changes between antidepressant efficacy and reversal of the pro-inflammatory status.

Vascular Endothelial Growth Factor: a potential diagnostic biomarker for major depression.

Despite intense research efforts undertaken by investigators throughout the world over the past half century to identify a specific biomarker for major depressive disorder (MDD), none have so far met the rigorous test of specificity, reliability and reproducibility. Vascular Endothelial Growth Factor (VEGF) has been implicated in the neurotrophic model of depression and several studies have assessed VEGF levels in depressed patients. The results have been discrepant largely due to design and assay differences among studies. The aim of this study was to assess plasma VEGF levels in a cohort of MDD subjects prior to treatment with psychotropic medication and compare them to those of healthy control (HC) subjects. Prospective study participants underwent extensive medical and psychiatric assessments before they were enrolled. Plasma concentrations of VEGF were measured by the technique marketed by Randox Technologies. The mean baseline VEGF for the healthy and depressed groups was 5.91 pg/ml (SD: 3.04) and 10.51 pg/ml (SD: 9.04), respectively, and this difference was statistically significant (p = 0.001). We detected a very low univariate relationship between VEGF and demographic and clinical variables. Using the Optimal Data Analysis a cut score of 6.64 pg/ml for baseline plasma VEGF distinguished depressed from healthy subjects with a 63% overall accuracy. We conclude these results support a role of plasma VEGF as a useful biomarker of depression that can be measured with a routine blood draw at the point of service. The specificity of this potential biomarker must be confirmed in studies that include other psychiatric disease entities.

Central poststroke pain: current diagnosis and treatment.

Central post-stroke pain syndrome (CPSP) is a debilitating sequel that can follow thalamic sensory stroke. Less well recognized, CPSP follows lateral medullary stroke and parietal cortical stroke and may develop anywhere along the spinothalamic or trigemino-thalamic pathways. Patients describe sharp, stabbing, or burning pain and experience hyperpathia and especially allodynia. Although CPSP was first described over 100 years ago, CPSP is too frequently underrecognized. It is treatable disorder. Pharmacological therapy, magnetic stimulation, and invasive electrical stimulation are reviewed and recommendations made.