Development of a curricular thread to foster medical students' critical reflection and promote action on climate change, health, and equity.

INTRODUCTION: Due to the health consequences arising from climate change, medical students will inevitably interact with affected patients during their training and careers. Accordingly, medical schools must incorporate education on the impacts of climate change on health and equity into their curricula. We created a curricular thread called "Climate Change, Health, and Equity" in the first-year preclinical medical program to teach foundational concepts and foster self-reflection and critical consciousness. METHODS: The authors developed a continuum of practice including administrators, educators and faculty members, students, and community partners to plan and design curricular activities. First-year medical students at Duke University School of Medicine participated in seven mandatory foundational lectures and two experiential learning opportunities in the local community. Following completion of activities, students wrote a critical reflection essay and completed a self-directed learning exercise. Essays were evaluated using the REFLECT rubric to assess if students achieved critical reflection and for thematic analysis by Bloom's Taxonomy. RESULTS: All students (118) submitted essays. A random sample of 30 (25%) essays underwent analysis. Evaluation by the REFLECT rubric underscored that all students were reflecting or critically reflecting on thread content. Thematic analysis highlighted that all students (30/30, 100%) were adept at identifying new areas of medical knowledge and connecting concepts to individual experiences, institutional practices, and public health and policy. Most students (27/30; 90%) used emotionally laden words, expressing negative feelings like frustration and fear but also positive sentiments of solidarity and hope regarding climate change and effects on health. Many students (24/30; 80%) expressed actionable items at every level including continuing self-directed learning and conversing with patients, minimizing healthcare waste, and advocating for climate-friendly policies. CONCLUSION: After participating in the curricular thread, most medical students reflected on cognitive, affective, and actionable aspects relating to climate change, health, and equity.

Experiences and opinions of health professional students participating in an opioid use disorder educational event.

INTRODUCTION: The objectives of this study were to describe health professional students' experiences and opinions about patients with opioid-use disorder (OUD), to summarize evaluation results from an OUD educational event and to compare results by sex, discipline, and clinical experience. METHODS: The OUD educational event lasted 75 minutes and covered the epidemiology of the opioid epidemic, evidence-based prevention and treatment services, stigma, and recommendations on how to improve care. An anonymous pre-event survey collected information on attendees' experiences and opinions about patients with OUD. The postevent survey collected information on the attendees' evaluation of the event. RESULTS: Forty percent of students reported having a friend or family member who has/had an OUD. A minority (29.1%) reported that they would be uncomfortable working with patients with OUD or would prefer not to interact with patients with OUD (27.7%). Overall, the event evaluation results were very positive, and 85.5% reported that the information would change or influence their clinical practices. The open-ended responses found that the content was informative (n = 36); the attendees liked the inclusion of statistics (n = 19) and that the content was locally focused (n = 13). DISCUSSION: Health professional students participating in this event had fewer negative opinions of patients with OUD than previous research has found, and this may, in part, be explained by their personal experiences. Overall, health professional students want to learn more about patients with OUD.

The Emergency Department as an Opportunity for Naloxone Distribution.

INTRODUCTION: Substance use disorders, including opioid use disorders, are a major public health concern in the United States. Between 2005 and 2014, the rate of opioid-related emergency department (ED) visits nearly doubled, from 89.1 per 100,000 persons in 2005 to 177.7 per 100,000 persons in 2014. Thus, the ED presents a distinctive opportunity for harm-reduction strategies such as distribution of naloxone to patients who are at risk for an opioid overdose. METHODS: We conducted a systematic review of all existing literature related to naloxone distribution from the ED. We included only those articles published in peer-reviewed journals that described results relating to naloxone distribution from the ED. RESULTS: Of the 2,286 articles we identified from the search, five met the inclusion criteria and had direct relevance to naloxone distribution from the ED setting. Across the studies, we found variation in the methods of implementation and evaluation of take-home naloxone programs in the ED. In the three studies that attempted patient follow-up, success was low, limiting the evidence for the programs' effectiveness. Overall, in the included studies there is evidence that distributing take-home naloxone from the ED has the potential for harm reduction; however, the uptake of the practice remained low. Barriers to implementation included time allocated for training hospital staff and the burden on workflow. CONCLUSION: This systematic review of the best evidence available supports the ED as a potential setting for naloxone distribution for overdose reversal in the community. The variability of the implementation methods across the studies highlights the need for future research to determine the most effective practices.

Surveys of substance use disorders education in US pharmacy programs.

INTRODUCTION: Substance use disorders (SUDs) are a significant US health problem affecting roughly 20 million Americans, but there continues to be limited access to SUD treatment and inadequate addiction medicine training. Therefore, it is important to understand how SUD education is being delivered to US health professionals, including pharmacists. METHODS: A recent survey of US pharmacy programs' neuropsychiatry curricula was evaluated to identify any progress made toward increasing SUD education since the last national survey in 2004 and determine any remaining gaps between what is currently being taught and American Association of Colleges of Pharmacy (AACP) curricular guidelines for SUD education updated in 2010. A survey of psychiatric pharmacists, regarding what they thought should be taught, was also evaluated and compared with the 2010 AACP curricular guidelines. RESULTS: Our survey of US pharmacy programs demonstrated that 94% of programs reported teaching SUD content in 2014-15, which has increased from 81% reported in a survey study from 2004. There was also an increase for average hours of SUD didactic instruction, which increased from 2.2 hours in 2004 to 2.7 hours in 2015. The majority of members (84%) recommended at least 2 hours of SUD instruction, and 27% recommended teaching ≥4 hours. DISCUSSION: There was an overall increase in SUD instruction, but the average hours taught still falls short of 2010 AACP curricular guideline recommendation suggesting ≥4 hours. Furthermore, a majority of the psychiatric pharmacists we surveyed did not agree with the AACP curricular guideline recommendation because only 27% of members recommended ≥4 hours of SUD instruction, and the average hours recommended was only 2.7 hours.

Utilizing Bloom's taxonomy to design a substance use disorders course for health professions students.

BACKGROUND: Substance use disorders (SUDs) are a public health problem affecting millions of Americans. Despite their prevalence, there are few health care resources allocated for SUDs treatment. Relatively few health care professionals are exposed to SUDs education in their respective programs, which may be one reason for this resource insufficiency. In hopes of rectifying this gap, the authors developed a SUDs course for health professions students combining classroom learning with practical application to patient care. METHODS: The authors used Bloom's taxonomy of cognitive, affective, and psychomotor learning domains as an educational framework to create numerous opportunities for students to deepen their knowledge, assess their attitudes, and develop their motivational interviewing skills. The primary outcome of the study was a comparison of students' scores on the Substance Abuse Attitude Scale (SAAS) pre- and post-course completion. Secondary outcome was to compare students' self-assessment scores of their patient counseling with residents' assessments of them on the Liverpool Communication Skills Assessment Scale (LCSAS). RESULTS: One hundred twelve students participated in the authors' SUDs course over a 9-month period. Ninety-five students completed both the pre- and post-course SAAS surveys. The total SAAS survey score and individual domain scores for nonmoralizing, treatment optimism, and treatment intervention demonstrated significant improvement post-course. Eighty-nine students completed a motivational interview with a patient. Eighty students had a LCSAS self-assessment paired with a residents' assessment. Mean scores for individual items on the LCSAS for both groups' assessment were approximately 3.5, indicating that students' communication was assessed as "acceptable" to "good." CONCLUSIONS: This study demonstrates that Bloom's taxonomy was a useful educational framework to ensure a systematic development of the authors' SUDs course. Through participation in our course, students touched each of the 3 domains in Bloom's taxonomy. The authors believe their course design may serve as a framework for future SUDs courses.

Discharge Plans for Geriatric Inpatients with Delirium: A Plan to Stop Antipsychotics?

BACKGROUND: Studies show inpatient geriatric patients with reversible conditions like delirium may continue on antipsychotic medications without clear indications after hospital discharge. We conducted this study to determine how often geriatric patients were discharged on a newly started antipsychotic during admission with a plan for discontinuation of the antipsychotic documented in the discharge summary. DESIGN: We conducted retrospective chart review identifying geriatric inpatients in our health system started on a new antipsychotic during admission. In patients discharged from the hospital on a new antipsychotic, we examined the discharge summary for a discontinuation treatment plan. RESULTS: Of 487 patients started on a new antipsychotic, 147 (30.2%) were discharged on the antipsychotic. Of those, 121 (82.3%) had a diagnosis of delirium. Discharge summaries of 15 (12.4%) patients discharged on an antipsychotic with a diagnosis of delirium included instructions for discontinuation of the antipsychotic. Of those patients discharged with instructions for discontinuation, 12 (80%) received a psychiatric or geriatric medicine consult. CONCLUSION: In our health system, the majority of geriatric patients with delirium, discharged on a new antipsychotic had no instructions outlined to outpatient providers for discontinuation management. Further interventions could target increasing antipsychotic guidance at transitions of care.

Substance use education in US schools of pharmacy: A systematic review of the literature.

BACKGROUND: The authors sought to systematically review the quantity and quality of literature describing substance use disorders (SUDs) education in US schools of pharmacy and determine the effectiveness of the educational interventions employed. METHODS: The authors conducted a systematic review of SUDs education studies in US pharmacy schools. All literature database searches were performed on April 30, 2016, in 5 databases: Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Embase.com, ERIC via FirstSearch, and CINAHL via EBSCOhost. The study authors conducted this systematic review according to the Preferred Reporting Items for Systemic Reviews and Meta-analyses guidelines and registered it with PROSPERO, which is an international prospective register of systematic reviews. The PROSPERO registration number is CRD42016037443. The study authors created a modified data extraction sheet based on the Best Evidence in Medical Education coding sheet. A Medical Education Research Study Quality Instrument (MERSQI) score was calculated for included articles. Results: From the 1626 retrieved records, 7 were included in the present review. The studies assessed students' impressions and abilities regarding SUDs pre- and post-intervention. The mean ± SD MERSQI score of the 7 studies was 9.86 ± 1.21 (range: 8-11.5). The included articles assessed pharmacy students at various academic years, with the majority students in either their first or second year of pharmacy school, and described both required and elective courses. The educational interventions varied in design and outcomes measured. Education included nicotine, alcoholism, and SUDs in general. None of the included articles reported on education regarding opioid use disorders. Conclusions: The studies included in this systematic review demonstrate that teaching pharmacy students about SUDs produces a positive impact in their attitudes and knowledge on this subject.

Development of a Diverse Learning Experience for Diverse Psychiatry Resident Needs: A Four-Year Biological Psychiatry Curriculum Incorporating Principles of Neurobiology, Psychopharmacology, and Evidence-Based Practice.

OBJECTIVE: A clinically relevant approach to patient care grounded in neurobiological constructs and evidence based practice which emphasizes a relevant psychopharmacology is needed to optimally train psychiatry residents. METHODS: We implemented a biological psychiatry course that now incorporates neurobiology, psychopharmacology, and evidence-based practice in conjunction with a Research Domain Criteria (RDoC) perspective. A survey launched prior to course implementation and following each class session, served as the outcome metric of residents' attitudes toward the new curriculum and followed a baseline attitudinal survey designed to evaluate the program. RESULTS: Greater than 90% of the psychiatry residents at Duke University who took the attitudinal survey agreed or strongly agreed with needing a course that helped them develop an understanding of neurobiology, psychopharmacology, and evidence-based practice concepts. Most residents also indicated a less than adequate understanding of the neurobiology and psychopharmacology of psychiatric disorders prior to sessions. CONCLUSION: Our biological psychiatry curriculum was associated with enthusiasm among residents regarding the incorporation of neurobiology, psychopharmacology, and evidence-based practice into course topics and discussions. A biological psychiatry curriculum with integrated neurobiology and psychopharmacology built on an evidence base approach is possible, well-received, and needed in training of future psychiatrists.

An Interprofessional Course on Substance Use Disorders for Health Professions Students.

PROBLEM: Substance use disorders (SUDs) affect millions of Americans. Nevertheless, there is insufficient health care resource allocation for these patients. One reason may be the lack of education and training about SUDs in health professions programs. APPROACH: The authors developed a required, interprofessional SUDs course for health professions students completing a one-month psychiatry clerkship within the Duke University Health System starting in November 2015. Students participated in six 1-hour class sessions led by an interdisciplinary faculty. Sessions focused on core areas in SUDs education and used either a lecture with discussion or a small-group team-based learning format. Students completed one motivational interview, attended a 12-step recovery meeting, and wrote a reflection paper. On the first and last day of the clerkship, students measured their attitudes toward individuals with SUDs using the Substance Abuse Attitude Scale (SAAS) and toward interprofessionalism using the Interprofessional Attitudes Scale (IPAS). OUTCOMES: Seventy-one students participated in the course from November 2015 to May 2016. Fifty-nine (83%) students had paired pre- and postcourse SAAS and IPAS data. On the SAAS, students showed significant improvement in their median total score and nonmoralizing, treatment optimism, and treatment intervention scores. On the IPAS, students showed significant improvement in their median score on the teamwork, roles, and responsibilities domain. NEXT STEPS: The authors will continue to assess the course. Starting in academic year 2016-2017, the course will include four additional elements, and beginning in July 2016, accelerated bachelor of science in nursing students will participate in the course.

Impact of an Alcohol Withdrawal Treatment Pathway on Hospital Length of Stay: A Retrospective Observational Study Comparing Pre and Post Pathway Implementation.

OBJECTIVE: To determine if the implementation of a hospital-specific alcohol withdrawal treatment pathway used in a medical-surgical patient population decreased hospital length of stay (LOS) compared with the standard of care. METHODS: This retrospective observational study, conducted in a large academic tertiary care hospital, involved 582 subjects who met criteria for study inclusion, with 275 subjects in the 2010 cohort and 307 in the 2012 cohort. The Alcohol Withdrawal Project Team was formed with the goal of creating a standardized approach to the recognition and treatment of alcohol withdrawal at Duke University Hospital. The group created a computerized physician order entry alcohol withdrawal treatment pathway with 4 possible treatment paths chosen on the basis of current withdrawal symptoms, vital signs, and alcohol withdrawal history. The 4 treatment paths are 1 prophylaxis; 2 mild-to-moderate withdrawal; 3 moderate-to-severe withdrawal, and 4 severe withdrawal/alcohol withdrawal delirium. Each treatment path corresponds to a different lorazepam dose and dose schedule and symptom assessment. This pathway was implemented in the hospital at the end of 2011. RESULTS: Using a Cox proportional hazards model and adjusting for covariates, there was a 1 day [95% confidence interval (CI), 1-2 d] reduction in median hospital LOS between the 2010 and 2012 cohorts, 5 versus 4 days, respectively. The average ratio in hospital LOS between the 2 cohorts was 1.25 (95% CI, 1.25-1.67). The CI was estimated by bootstrapping and indicated a significantly longer LOS in the 2010 cohort compared with the 2012 cohort. Nonsignificant changes were found in the proportion of subjects admitted to the intensive care unit (24% in 2010 vs. 29.3% in 2012), LOS in the intensive care unit (7.1±8 d in 2010 vs. 5.6±6.9 d in 2012), and proportion of patients discharged with a diagnosis of delirium tremens (17.8% in 2010 vs. 15.3% in 2012). CONCLUSIONS: This study demonstrates the successful implementation of an alcohol withdrawal treatment pathway in a medical-surgical population hospitalized in a large tertiary care facility with significant impact on hospital LOS.

Emphasizing Bloom's Affective Domain to Reduce Pharmacy Students' Stigmatizing Attitudes.

Objective. To create a learning environment using Bloom's affective domain as a framework that would reduce third-year pharmacy students' stigmatizing attitudes toward patients with mental illness. Design. Prior to the start of the module, students were asked to complete the 27-question Attribution Questionnaire Short Form (AQ-27). The teaching approach and in-class activities were designed to allow students' to experience the major categories within Bloom's affective domain. The module used patient cases, interactive-learning activities, and reflective discussions to augment pharmacological and therapeutic knowledge with a humanistic understanding of mental illness. Students were asked to retake the AQ-27 after completing the module. Assessment. Paired responses on the AQ-27 were reported for 74 of 104 students, which represents a response rate of 71.2%. Students' scores changed significantly on nine of the 27 questions. Students' attitudes pre- to post-module revealed a significant increase in the help construct, while there was a significant decrease in the dangerousness and fear constructs. Conclusion. Designing and implementing a course along the continuum of Bloom's affective domain resulted in appropriate changes in students' attitudes toward patients with mental illness.

Examination of QTc Values in Critically Ill Patients Diagnosed with Delirium and Prescribed Atypical Antipsychotics.

OBJECTIVE: To determine the extent of QTc prolongation following administration of an atypical antipsychotic in critically ill patients diagnosed with delirium and to conduct an assessment of risk factors to identify the presence of specific risk factors associated with QTc prolongation in this patient population. METHODS: Patients were included if they were at least 18 years of age, admitted to an Intensive Care Unit (ICU) at the study institution from July 1, 2013 through January 30, 2014, had a documented diagnosis of delirium within their electronic medical record, and received an atypical antipsychotic for delirium during their hospital admission. Excluded patients were those who received an atypical antipsychotic for an indication other than delirium, received fewer than two doses of the atypical antipsychotic, had an atypical antipsychotic documented as a home medication, or demonstrated a lack of EKG data at baseline or post administration of their atypical antipsychotic dose. RESULTS: Of the 360 patient charts screened, 118 subjects met inclusion criteria. For the study's primary outcome, the proportion of change from baseline EKG to the first EKG following atypical antipsychotic administration, 72 (61.0%) patients had a decrease in their QTc interval, 1 (0.85%) patient stayed the same, and 45 (38.1%) patients had an increase in their QTc interval. The median change in QTc interval was a decrease of 12.5 msec. Of the 45 (38%) subjects who had an increase in their QTc interval, the mean change from baseline to the first EKG post atypical antipsychotic administration was an increase of 30 msec. Sixty-six (56%) subjects reached steady state while on their first atypical antipsychotic. With respect to the secondary outcome, 40 of 66 (60.1%) had a decrease in their QTc interval, while 26 (39.4%) subjects had an increase in their QTc interval. The median change in QTc interval was a decrease of 10.5 msec. Receipt of a pro-arrhthymic medication was used concomitantly among 25 (21.2%) of patients at baseline. Antibiotics were the most commonly observed class used concomitantly in 39 (21.7%) of the 180 observed total instances of concomitant QTc prolonging agent use, followed by antidepressants (18.9%). Amiodarone was the single most commonly observed agent utilized (10%). CONCLUSION: This retrospective analysis of a mixed ICU population demonstrates that following initiation of an atypical antipsychotic, QTc interval increase occurred less frequently then a QTc interval decrease from baseline. Providers should correct modifiable risk factors and minimize concomitant QTc prolonging medications as much as possible.

Prolonged Delirium With Catatonia Following Orthotopic Liver Transplant Responsive to Memantine.

A 59-year-old man with nonalcoholic steatohepatitis cirrhosis underwent an orthotopic liver transplant and experienced a complicated postoperative course, including a prolonged delirium. After discharge to rehabilitation, he had 2 subsequent admissions for delirium. On the first readmission, the transplant team started the patient on risperidone and resumed treatment with sertraline. On his second readmission, neurology and psychiatry were consulted. On evaluation, the patient demonstrated signs of catatonia. On the basis of recommendations from psychiatry, the risperidone and sertraline were stopped, and the patient was started on mirtazapine. He failed to demonstrate improvement within the next 48 hours. Extensive work-up demonstrated a multifactorial etiology for his delirium, including calcineurin-related neuropsychiatric toxicity from tacrolimus leading to possible posterior reversible encephalopathy syndrome. However, after the initiation of memantine on hospital day 3-before the cessation of tacrolimus-the patient demonstrated marked improvement in mental status and motor symptoms. His magnetic resonance imaging, in addition to findings that raised concerns about posterior reversible encephalopathy syndrome, had demonstrated bilateral basal ganglia abnormalities on T1 imaging of uncertain origin. It is postulated that these findings served as predisposing factors for the patient's catatonic symptoms. Although it has been described in case reports following liver transplant, catatonia remains an underrecognized neuropsychiatric complication following liver transplant. This case demonstrates the effectiveness of memantine, an N-methyl-D-aspartic acid antagonist that decreases glutamine excitotoxicity, as a potential treatment for catatonia in postliver transplant patients.

Bipolar Depression: Pregnancy, Postpartum, and Lactation.

Medication management of bipolar depression in pregnancy and lactation is best done by assessing each patient's and family's needs in detail. Keeping pregnant patients as psychiatrically stable as possible is the most important principle for clinicians. Unfortunately, there is no risk-free situation for patients with psychiatric illness. This is often the most difficult and hard to accept reality for these patients, families, and clinicians. Clinicians serve these patients best by being as transparent as possible about the risk/benefit analysis of each patient's situation with the realization that ultimately the decisions are made by the patient and family.

Impact of a US Food and Drug Administration Drug Safety Communication on Zolpidem Dosing: An Observational Retrospective Cohort.

INTRODUCTION/BACKGROUND: Zolpidem is a sedative-hypnotic widely prescribed in the United States. Recently, the US Food and Drug Administration (FDA) issued a drug safety communication regarding its dosing in women. OBJECTIVE: To compare compliance with FDA-approved dosing for zolpidem in women before and after a drug safety communication, and to evaluate compliance based on pharmacy location and prescriber type. METHOD: This was a retrospective, observational cohort study. New prescriptions for Ambien, Ambien CR, Edluar, or Zolpimist or their respective generics dispensed from Kerr Drug pharmacies in North Carolina to women 18-64 years of age between April and September of 2012 ("before" cohort) or April and September of 2013 ("after" cohort) were included. χ(2) tests were conducted to assess overall compliance, as well as compliance based on location (urban or rural) and prescriber type (physician or midlevel), with FDA-approved dosing for zolpidem. Trends in total prescription volume and total zolpidem prescription volume for all Kerr Drug pharmacies over the study period were also described. RESULTS: A total of 14,156 prescriptions for zolpidem were included in the primary analysis. Sixteen percent of prescriptions dispensed were in compliance with FDA recommendations following the FDA alert. A statistically significant increase was observed in compliance with FDA-approved dosing for zolpidem (odds ratio = 1.49; 95% CI, 1.35-1.65; P < .0001) postdrug safety communication. Significant increases in compliance were also observed in the post-FDA communication subgroups based on location and prescriber type, though no subgroup was found to be significantly more compliant than another. CONCLUSIONS: The release of a drug safety communication by the FDA resulted in a statistically significant increase in proper dosing of zolpidem in women. Further research is needed in order to determine the impact of FDA alerts on prescribing patterns and the reasons for therapeutic substitution after such alerts.

Evaluation of Changes in Citalopram Prescribing Patterns Following a US Food and Drug Administration Alert: A Retrospective Cohort Study.

OBJECTIVE: The US Food and Drug Administration (FDA) issued a warning stating that patients older than 60 years are not recommended to receive doses of citalopram exceeding 20 mg daily due to concerns of corrected QT (QTc) prolongation. The purpose of this study is to assess the impact of the FDA warning on prescribing patterns of citalopram in patients 60 years of age and older. METHOD: This is a retrospective cohort study of hospitalized patients 60 years of age and older prescribed citalopram from October 24, 2010, to August 24, 2011 and from November 24, 2011, to September 24, 2012. Records were examined for the presence of baseline risk factors for QTc prolongation and torsades de pointes. RESULTS: The issuance of an FDA warning was not associated with an observable change in prescribing patterns of citalopram. A total of 98.8% of patients had at least 1 risk factor for QTc prolongation. No significant difference in the total number of risk factors was seen between groups (P = .915). No differences were seen in risk factors prewarning and postwarning, except a higher percentage had left ventricular hypertrophy (P = .001) or history of syncope (P = .043) prior to the warning. More subjects were prescribed concomitant proarrhythmic medications (P = .009) after the FDA warning was issued. Similar percentages of each group were receiving daily dosages > 20 mg of citalopram (P = .600). CONCLUSIONS: The issuance of an FDA warning did not produce observable changes in prescribing patterns of citalopram. Modifiable risk factors and optimal dosing may be targets of interventions aimed at promoting safer use of citalopram.

A psychopharmacology course for psychiatry residents utilizing active-learning and residents-as-teachers to develop life-long learning skills.

OBJECTIVE: The authors describe the implementation and evaluation of a 1-year psychopharmacology course using residents-as-teachers and active-learning exercises intended to improve understanding of current psychopharmacology and its evidence base, and skills for life-long learning. METHOD: Weekly classes were devoted to psychotropic medications, treating specific disorders, and use of psychotropics in special patient populations. Each class was divided into three sections: a pharmacology review, a literature review and a faculty-led discussion of clinical questions. Each class included residents as teachers, an audience response system and questions for self-assessment. Resident and faculty presenters evaluated the course weekly and all residents were given a year-end evaluation RESULTS: Resident and faculty evaluations indicated an overall positive response. The residents reported improved perception of knowledge and engagement with this interactive format. CONCLUSION: The course was well received, demonstrating the viability and value of residents taking a more active role in their own learning.

Dexmedetomidine for the treatment of alcohol withdrawal syndrome: rationale and current status of research.

Dexmedetomidine is currently used in the US in the treatment of alcohol withdrawal syndrome (AWS) in the intensive care unit (ICU) setting, although data to support this practice are limited. Dexmedetomidine targets the noradrenergic system, an important but frequently overlooked secondary mechanism in the development of AWS, and, in doing so, may reduce the need for excessive benzodiazepine use which can increase the risk of γ-aminobutyric acid (GABA)-mediated deliriogenesis and respiratory depression. The purpose of this narrative review is to evaluate available literature reporting on the safety and efficacy of dexmedetomidine for AWS in the ICU setting. An English-language MEDLINE search (1966 to July 2013) was performed to identify articles evaluating the efficacy and safety of dexmedetomidine for AWS. Case series, case reports and controlled trials were evaluated for topic relevance and clinical applicability. Reference lists of articles retrieved through this search were reviewed to identify any relevant publications. Studies focusing on the safety and efficacy of dexmedetomidine for AWS in humans were selected. Studies were included if they were published as full articles; abstracts alone were not included in this review. Eight published case studies and case series were identified. Based on a limited body of evidence, dexmedetomidine shows promise as a potentially safe and possibly effective adjuvant treatment for AWS in the ICU. Prospective, well-controlled studies are needed to confirm the safety and efficacy of the use of dexmedetomidine in AWS.

Clinical effectiveness of baclofen for the treatment of alcohol dependence: a review.

Baclofen, an agonist at the B subunit of gaba-aminobutyric acid receptor, possesses pharmacologic properties that may confer utility for the treatment of alcohol dependence. Research suggests that not only can it be useful in promoting maintenance of alcohol abstinence but also it may play a key role in decreasing alcohol cravings and anxiety often associated with alcohol dependence. To assess the benefit of baclofen for alcohol dependence, a review of the literature was conducted to identify published data investigating this off-label treatment. Four randomized controlled trials to date have been published and were included in this review. Although primary outcomes differ between studies, patients randomized to baclofen experience higher rates of abstinence from alcohol than those taking placebo in two of the trials. Secondary analyses indicate that baclofen is safe in patients with alcohol dependence, including those with moderate to severe liver cirrhosis, and may provide beneficial anxiolytic effects. Despite some positive data, the largest available randomized controlled trial failed to find any differences between baclofen and placebo. In all studies, individuals with severe medical comorbidities, seizure disorders, and psychiatric disorders were excluded from trials, which may limit external validity. In summary, there may be beneficial effects from using baclofen for the treatment of alcohol dependence; however, limited conclusions can be drawn from the small number of studies currently available for review. Larger well-designed trials are needed to further define baclofen's role for the treatment of alcohol dependence.

Quetiapine for the treatment of delirium.

BACKGROUND: Delirium is associated with high rates of morbidity and mortality in hospitalized medically ill patients. Haloperidol has historically been the agent of choice for the treatment of delirium, but recent studies have explored the efficacy of second-generation antipsychotics such as quetiapine. The unique pharmacology of quetiapine may allow it to treat delirium and provide sedation without causing significant extrapyramidal side effects. PURPOSE: To evaluate the efficacy of quetiapine for the treatment of delirium. DATA SOURCES: A search was conducted in MEDLINE and Embase (January 1960-December 2012) using keywords "quetiapine," "second-generation antipsychotic," "atypical antipsychotic," "delirium," and "agitation." STUDY SELECTION AND DATA EXTRACTION: The search was limited to English-language articles and trials with treatment of delirium as the primary end point. Eight trials met this inclusion criterion. DATA SYNTHESIS: Two randomized controlled trials, 5 open-label studies, and 1 retrospective cohort study evaluating quetiapine for the treatment of delirium were reviewed. One randomized controlled trial showed no differences in total mean delirium scores, but found the rate of delirium improvement was significantly shorter with quetiapine. The second randomized controlled trial showed the time to first resolution of delirium was shorter with quetiapine compared to placebo. Results of the open-label and retrospective cohort trials have also shown significant resolution of delirium from baseline and equal efficacy with quetiapine compared to amisulpride and haloperidol. CONCLUSIONS: Quetiapine appears to be an effective and safe agent for the treatment of delirium in both general medicine and intensive care unit patients. The trials summarized suggest that quetiapine resolves symptoms of delirium more quickly than placebo and has equal efficacy compared to haloperidol and the atypical antipsychotic amisulpride. Further study is needed.