Valproic acid for agitation in the intensive care unit: an observational study of psychiatric consults.

BACKGROUND: Agitation is a common clinical problem encountered in the intensive care unit (ICU). Treatment options are based on clinical experience and sparse quality literature. AIM: The aim of this study was to describe the effect of valproic acid (VPA) as adjuvant treatment for agitation in the ICU, identify predictors of response to VPA and evaluate the independent effect of VPA on agitation compared to standard of care (SOC). METHOD: This retrospective single center observational study evaluated adult patients admitted to the ICU for whom a psychiatric consultation was requested for agitation management, with agitation defined as a Richmond Agitation Sedation Score of 2 or greater. A descriptive analysis of the proportion of agitation-free patients per day of follow-up, the incidence of agitation-related-events, as well as the evolution of co-medications use over time are presented. A logistic regression model was used to assess predictors of VPA response, defined as being agitation-free on Day 7 and generalized estimating equations were used to evaluate the independent effect of VPA as adjuvant therapy for agitation in the critically ill. RESULTS: One hundred seventy-five patients were included in the study with 78 receiving VPA. The percentage of agitation-free patients on VPA was 6.5% (5/77) on Day 1, 14.1% (11/78) on Day 3 and 39.5% (30/76) on Day 7. Multivariate regression model for clinical and demographic variables identified female gender as predictor of response on Day 7 (OR 6.10 [1.18-31.64], p = 0.03). The independent effect of VPA was non-significant when compared to SOC. CONCLUSION: Although VPA used as adjuvant treatment was associated with a decrease in agitation, its effect when compared to SOC did not yield significant results.

Emerging concepts in the CanMEDS physician competency framework.

Background: The CanMEDS physician competency framework will be updated in 2025. The revision occurs during a time of disruption and transformation to society, healthcare, and medical education caused by the COVID-19 pandemic and growing acknowledgement of the impacts of colonialism, systemic discrimination, climate change, and emerging technologies on healthcare and training. To inform this revision, we sought to identify emerging concepts in the literature related to physician competencies. Methods: Emerging concepts were defined as ideas discussed in the literature related to the roles and competencies of physicians that are absent or underrepresented in the 2015 CanMEDS framework. We conducted a literature scan, title and abstract review, and thematic analysis to identify emerging concepts. Metadata for all articles published in five medical education journals between October 1, 2018 and October 1, 2021 were extracted. Fifteen authors performed a title and abstract review to identify and label underrepresented concepts. Two authors thematically analyzed the results to identify emerging concepts. A member check was conducted. Results: 1017 of 4973 (20.5%) of the included articles discussed an emerging concept. The thematic analysis identified ten themes: Equity, Diversity, Inclusion, and Social Justice; Anti-racism; Physician Humanism; Data-Informed Medicine; Complex Adaptive Systems; Clinical Learning Environment; Virtual Care; Clinical Reasoning; Adaptive Expertise; and Planetary Health. All themes were endorsed by the authorship team as emerging concepts. Conclusion: This literature scan identified ten emerging concepts to inform the 2025 revision of the CanMEDS physician competency framework. Open publication of this work will promote greater transparency in the revision process and support an ongoing dialogue on physician competence. Writing groups have been recruited to elaborate on each of the emerging concepts and how they could be further incorporated into CanMEDS 2025.

Contexte: Le référentiel de compétences CanMEDS pour les médecins sera mis à jour en 2025. Cette révision arrive à un moment où la société, les soins de santé et l'enseignement médical sont bouleversés et en pleine mutation à cause de la pandémie de la COVID-19. On est aussi à l'heure où l'on reconnaît de plus en plus les effets du colonialisme, de la discrimination systémique, des changements climatiques et des nouvelles technologies sur les soins de santé et la formation des médecins. Pour effectuer cette révision, nous avons avons extrait de la littérature scientifique les concepts émergents se rapportant aux compétences des médecins. Méthodes: Les concepts émergents ont été définis comme des idées ayant trait aux rôles et aux compétences des médecins qui sont débattues dans la littérature, mais qui sont absentes ou sous-représentées dans le cadre CanMEDS 2015. Nous avons réalisé une recherche documentaire, un examen des titres et des résumés, et une analyse thématique pour repérer les concepts émergents. Les métadonnées de tous les articles publiés dans cinq revues d'éducation médicale entre le 1er octobre 2018 et le 1er octobre 2021 ont été extraites. Quinze auteurs ont effectué un examen des titres et des résumés pour relever et étiqueter les concepts sous-représentés. Deux auteurs ont procédé à une analyse thématique des résultats pour dégager les concepts émergents. Une vérification a été faite par les membres de l'équipe. Résultats: Parmi les 4973 articles dépouillés, 1017 (20,5 %) abordaient un concept émergent. Les dix thèmes suivants sont ressortis de l'analyse thématique: l'équité, la diversité, l'inclusion et la justice sociale; l'antiracisme; l'humanité du médecin; la médecine fondée sur les données; les systèmes adaptatifs complexes; l'environnement de l'apprentissage clinique; les soins virtuels; le raisonnement clinique; l'expertise adaptative; et la santé planétaire. L'ensemble de ces thèmes ont été approuvés comme concepts émergents par l'équipe de rédaction. Conclusion: Cet examen de la littérature a permis de relever dix concepts émergents qui peuvent servir à éclairer la révision du référentiel de compétences CanMEDS pour les médecins qui aura lieu en 2025. La publication en libre accès de ce travail favorisera la transparence du processus de révision et le dialogue continu sur les compétences des médecins. Des groupes de rédaction ont été recrutés pour développer chacun des concepts émergents et pour examiner la façon dont ils pourraient être intégrés dans la version du référentiel CanMEDS de 2025.

Transitional Pain Care in Quebec: Did We Forget Our Youths? A Brief Research Report.

Adolescents and young adults (AYAs) represent a unique population with distinct psycho-social risks and care needs. About 10% of AYAs live with chronic pain (CP) and transition to adult pain care between 16 and 25 years of age. These transitions in care happen simultaneously with other bio-psycho-social changes and require flexible multi-disciplinary support models. As it stands, transitional pain care appears suboptimal, fragmented, and opportunistic in Quebec (Canada). The objective of this Brief Report is, therefore, to present our study findings and propose a multi-disciplinary transitional framework vision applicable to AYAs living with CP. Data were collected using a sequential-consensual qualitative design with a longitudinal participatory component. The consecutive stages of this work included an exploratory stage, semi-structured interviews with primary care providers, and inter-disciplinary deliberative stakeholder consultation groups. The deductive inductive thematic approach and the three-level Health Care Transition Research Consortium's theoretical framework were used to analyze the data. A representative group of stakeholders discussed findings from the first two steps, made fifteen actionable recommendations and formulated their vision of a transitional pain care model that can be further adapted in other settings. The study results present important insights into various psycho-social factors associated with transitional pain care for AYAs.

Accuracy of initial psychiatric diagnoses given by nonpsychiatric physicians: A retrospective chart review.

ABSTRACT: Despite the increased morbidity and mortality associated with psychiatric illnesses, there remains a substantial level of inaccuracy of the initial psychiatric diagnoses given by nonpsychiatric physicians. This study examines the accuracy of initial psychiatric diagnoses by non-psychiatric physicians at the McGill University Health Center (MUHC).We conducted a retrospective chart review for all consultations requested from the consultation-liaison psychiatry service at MUHC. We included all the consultations from January 1, 2018, to December 30, 2018, and excluded patient data with established psychiatric diagnoses. In all requested consults, each diagnosis of a referring physician was compared with the final diagnosis given by the C-L psychiatry team. Conformity between the 2 was validated as accurate.Of the 980 referred inpatients, 875 were enrolled. Patients ranged in age and those older than 70 years constituted the largest group: 54.4% were male. For 467 patients (55.20%), the initial diagnostic impression given by the referring physicians agreed with the final diagnosis made by the C-L psychiatry team, while in 379 patients (44.80%), the initial diagnostic impression was not consistent with the final diagnosis made by the C-L team.Diagnostic impressions of neurocognitive and substance use disorders were highly accurate, but this was not the case when the referring physicians suspected depression or bipolar, personality, or psychotic disorders. This study shows that around half of the referrals were accurately diagnosed, which evinces that nonpsychiatric physicians' knowledge regarding psychiatric conditions is not optimal and that might negatively impact screening and treating these conditions.

Depression and functional status in colorectal cancer patients awaiting surgery: Impact of a multimodal prehabilitation program.

OBJECTIVE: Depression and poor functional status (FS) frequently co-occur. Though both predict adverse surgical outcomes, research examining preoperative functional performance (FP; self-reported) and functional capacity (FC; performance-based) measures in depressed cancer patients is lacking. Prehabilitation, a preoperative intervention including exercise, nutrition, and stress-reduction, may improve FC; however, whether depressed patients benefit from this intervention remains unknown. The primary objectives were to (a) assess differences in FP and FC and (b) explore the impact of prehabilitation on FC in individuals with depressive symptoms versus those without. METHOD: A secondary analysis was conducted on 172 colorectal cancer patients enrolled in three studies comparing prehabilitation with a control group (rehabilitation). Measures were collected at 4 weeks pre- and 8 weeks postoperatively. FP, FC, and psychological symptoms were assessed using the 36-Item Short Form Health Survey, Six-Minute Walk Distance (6MWD), and Hospital Anxiety and Depression Scale (HADS), respectively. Subjects were divided into three groups according to baseline psychological symptoms: no psychological-symptoms (HADS-N), anxiety-symptoms (HADS-A), or depressive-symptoms (HADS-D). Main objectives were tested using analyses of variance, chi-square tests, and multivariate logistic regression. RESULTS: At baseline, HADS-D reported lower FP, had shorter 6MWD, and a greater proportion walked ≤ 400 m. Prehabilitation was associated with significant improvements in 6MWD in HADS-D group but not in HADS-N or HADS-A groups. CONCLUSION: Poorer FS was observed in subjects with depressive symptoms, and these subjects benefited most from prehabilitation intervention. Future research could examine whether severity of depression and co-occurrence of anxiety differentially impact FS and whether prehabilitation can improve psychological symptoms and quality of life. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Treatment Options for the Cardinal Symptoms of Disruptive Mood Dysregulation Disorder.

OBJECTIVE: DSM-5 has added a new developmentally appropriate child and adolescent mood disorder subtype called disruptive mood dysregulation disorder (DMDD). The core features of DMDD are temper outbursts (manifested by either verbal rages and/or physical aggression) and unrelenting irritability or anger. Currently, the literature is lacking a thorough review of the possible treatment options for the cardinal symptoms constituting DMDD. The objective of this article is to provide a thorough review of peer-reviewed studies on the subject of pharmacological treatment options for children and adolescents with the cardinal symptoms of DMDD. METHODS: Relevant articles for this study were obtained through Pubmed, Medline, PsychINFO and PsychINDEXplus using the key words: "adolescents," "children," "paediatric," "youth," "irritability," "temper outbursts," "aggression," "rage," "disruptive behaviour," "treatment," "dysphoria," "autism," "mental retardation/intellectual disability," "impulsivity," "ADHD," "oppositional defiant disorder," and "conduct disorder." A total of 823 studies were generated; only English studies focusing on pharmacological treatment were retained. RESULTS: Currently there are no established guidelines or thorough reviews summarizing the treatment of DMDD. Pharmacotherapeutic treatment options of both aggression and chronic irritability include: antidepressants/selective norepinephrine reuptake inhibitors, mood stabilizers, psychostimulants, antipsychotics, and alpha-2 agonists. CONCLUSION: Treatment options of severe, persistent irritability in youth are numerous, and a consensual treatment algorithm has not yet emerged from the literature. Further studies and clinical trials are warranted to determine efficacious and safe treatment modalities.

OBJECTIF: Le DSM-5 a ajouté un nouveau sous-type de trouble de l'humeur adapté au développement des enfants et des adolescents qui porte le nom de trouble disruptif avec dysrégulation de l'humeur (TDDH). Les principales caractéristiques du TDHE sont des accès de colère (manifestés soit par des rages verbales et/ou une agression physique) et une irritabilité ou une colère persistante. À l'heure actuelle, la littérature ne présente pas de revue approfondie des options de traitement possibles des symptômes cardinaux constituant le TDHE. L'objectif de cet article est d'offrir une revue approfondie des études révisées par des pairs sur le sujet des options de traitement pharmacologique pour les enfants et les adolescents présentant les symptômes cardinaux du TDHE. MÉTHODES: Les articles pertinents pour cette étude ont été obtenus dans Pubmed, Medline, PsychINFO et PsychINDEXplus à l'aide des mots clés: « adolescents ¼, « enfants ¼, « pédiatrie ¼, « jeunesse ¼, « irritabilité ¼, « accès de colère ¼, « agressivité ¼, « rage ¼, « comportement perturbateur ¼, « traitement ¼, « dysphorie ¼, « autisme ¼, « retard mental/déficience intellectuelle ¼, « impulsivité ¼, « TDAH ¼, « trouble oppositionnel avec provocation ¼, et « trouble des conduites ¼. Au total, 823 études ont été relevées; seulement les études en anglais portant sur le traitement pharmacologique ont été retenues. RÉSULTATS: À l'heure actuelle, il n'y a pas de lignes directrices établies ou de revues approfondies qui résument le traitement du TDHE. Les options de traitement pharmacologique de l'agressivité et de l'irritabilité chronique sont notamment: les antidépresseurs/inhibiteurs spécifiques du recaptage de la noradrénaline, les stabilisateurs de l'humeur, les psychostimulants, les antipsychotiques, et les agonistes alpha-2. CONCLUSION: Les options de traitement de l'irritabilité grave et persistante chez les adolescents sont nombreuses, et un algorithme de traitement consensuel n'a pas encore été dégagé de la littérature. D'autres études et essais cliniques sont nécessaires pour déterminer des modes de traitement efficaces et sûrs.

p38alpha, but not p38beta, inhibits the phosphorylation and presence of c-FLIPS in DISC to potentiate Fas-mediated caspase-8 activation and type I apoptotic signaling.

Pharmacological inhibitors of JNK (SP600125) and p38 (PD169316) sensitize tumor cells to Fas-mediated apoptosis. PD169316 is less potent than SP600125 and diminishes its effect when present together. Because the p38 isoforms that promote (p38alpha) or inhibit (p38beta) apoptosis are both suppressed by PD169316, we investigated their regulatory involvement in Fas-signaling. We report here, that p38alpha, but not p38beta, exerts its proapoptotic effect by inhibiting the phosphorylation and presence of c-FLIPS, but not c-FLIPL, in the DISC to promote caspase-8 activation and type I signaling in Fas-activated Jurkat cells. Its effect was enhanced by enforced expression of Flag-tagged p38alpha and was attenuated by its inactive mutant (p38alpha-AGF) or by translational silencing. By contrast, type II signaling was facilitated by p38alpha-dependent mitochondrial presence of tBid and inhibition of Bcl-2 (Ser70) phosphorylation as well as by p38alpha/beta-dependent mitochondrial localization of Bax and inhibition of phosphorylation of Bad (Ser112/Ser155). Potentiation of Fas-mediated apoptosis by the inhibition of JNK1/2 correlated with the loss of Bad (Ser136) phosphorylation and was dependent on the stimulatory effect of p38alpha on DISC and the downstream effects of both p38alpha and p38beta. These data underscore the need to reassess the findings obtained with pan-p38 inhibitors and suggest that activation of p38alpha coupled with targeted inhibition of p38beta and JNK1/2 should optimally sensitize tumor cells to Fas-mediated apoptosis.