Four Cases of Acute Kidney Injury Requiring Dialysis in Ultramarathoners.

Transient acute kidney injury (AKI) following ultraendurance footraces is a common biochemical diagnosis. However, severe AKI requiring renal replacement therapy is uncommon in ultramarathoners. We report 4 runners (3 men; mean age, 44 ± 3 y) who required prolonged (10-42 d) dialysis following the Western States 100 Mile Endurance Run over a 3-y span (0.38% of starters). The maximum ambient temperatures on the race day ranged from 36.6° to 38.3°C. The runners presented to local hospitals 17 to 32 h after running, with laboratories confirming rhabdomyolysis, hyponatremia (mean serum sodium concentration, 127±2 mmol⋅L-1), and AKI (mean serum creatinine concentration, 8.5±2 mg⋅dL-1). The case-cluster report highlights the potential synergistic effects of high ambient temperatures, muscle damage, and electrolyte imbalance on protracted renal dysfunction in ultramarathoners competing in a warming world.

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.

Depression in Ultra-endurance Athletes, A Review and Recommendations.

Depression affects 6.7% of the adult population each year and studies indicate the annual prevalence is similar or even higher in athletes. It is often insidious and not recognized. There continues to be stigma and misunderstanding about the disorder that is a barrier to getting an accurate diagnosis and effective treatment. It is important for people living with depression to get professional help because the condition itself can be disabling, increases risk of suicide, and reduces quality of life. There is some evidence that depression and suicide risk is higher in endurance athletes such as track and field, marathoner, and ultramarathoners. There have been studies of athletes looking at rates reporting depressive symptoms and on factors in suicide attempts in the athletes. Studies have reviewed risk factors unique to athletes for depression. This article will review depression in the endurance athlete and approaches in treatment in that population.

Understanding preventive health screening services use in persons with serious mental illness: how does integrated behavioral health primary care compare?

OBJECTIVE: People with serious mental illness have reduced life expectancy, in large part due to reduced access to medical services and underutilization of preventive health services. This is a cross-sectional study that compared preventive services use in an integrated behavioral health primary care clinic (IBHPC) with two existing community mental health programs. METHODS: Participants completed questionnaires about preventive health services use that contained 33 questions about demographic clinical information, and use of preventive health services, from October 2010 to December 2012. Services examined included mammogram, Papanicolaou Test, prostate specific antigen, digital rectal exam, fecal occult blood test, and flexible sigmoidoscopy or colonoscopy; blood pressure, height and weight, cholesterol, and blood sugar for diabetes; and influenza immunization, Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV) antibodies. A health service utilization score was developed and used as primary outcome for data analyses. RESULTS: In the multivariate analyses female gender (p < 0.05), race/ethnicity (p = 0.01 for Asian, p = 0.04 for Hispanic/Latino, both compared to White), program type (p < 0.001), and having a primary care provider (p < 0.001) were significant predictors of higher services use. IBHPC was associated with higher overall service utilization compared to one community mental health program (p < 0.001) but was similar when compared another (p = 0.34). There was high variability in use of individual services among the clinical programs. CONCLUSION: More studies are needed to examine the effectiveness of integrated care in improving use of health screening services. Characteristics of the clinic in relation to use of preventive services deserve further study.

The doctoring curriculum at the University of California, Davis School Of Medicine: leadership and participant roles for psychiatry faculty.

OBJECTIVE: The authors describe in detail the 3-year model of the Doctoring curriculum plus an elective fourth-year Doctoring course at University of California, Davis School of Medicine (UCDSOM) and University of California, Los Angeles (UCLA) School of Medicine and the critical role for psychiatry faculty leadership and participation. METHODS: The authors present a review of curricular materials and course operations for the different Doctoring courses for first-, second-, third-, and fourth-year curriculum. The authors describe the role of psychiatry faculty in both leadership and in group facilitation. RESULTS: The Doctoring curriculum offers case-based, small-group learning that relies heavily on standardized patients to teach core content around doctor-patient communication, ethics, behavioral medicine, and counseling approaches. There are frequent psychosocial issues woven in to these encounters. Psychiatry faculty members and other mental health professionals are well-prepared by virtue of their training to lead small group discussions and facilitate the supportive elements of the small groups in medical education. CONCLUSION: The Doctoring curriculum is both a biopsychosocial educational endeavor and a high-visibility leadership opportunity for the Department of Psychiatry. Other medical schools and departments of psychiatry may wish to pursue similar roles in their didactic programs.

A novel approach to medicine training for psychiatry residents.

OBJECTIVE: A unique rotation was developed to address limited outpatient internal medicine training in psychiatric residency by the University of California, Davis, Department of Psychiatry and Behavioral Sciences, which provides medical care to patients with mental illness. METHODS: The number of patients seen by the service and the number of psychiatric consults was determined from electronic records for the 2005-2006 academic year. Evaluations by psychiatry residents completing the rotation were reviewed. Three internist-psychiatrists and one family medicine-psychiatrist provided supervision. RESULTS: A total of 1,255 patients were treated during the 2005-2006 academic year. The quality of the educational experience was positive, with an overall rating of 4.43 on a scale from 1 to 5, with 5 being the highest. CONCLUSION: Training psychiatry residents in internal medicine can be better integrated into their psychiatry education in a creative fashion when the teaching and supervision is provided by jointly trained attendings in internal medicine/psychiatry or family medicine/psychiatry. The success of the rotation contributed to the development of a combined internal medicine and psychiatry residency program.