Low and very low lithium levels: Thyroid effects are small but still require monitoring.

AIM: Low doses of lithium, as might be used for mood or dementia prevention, do not carry the same renal, toxicity, and tolerability problems of doses used for prophylaxis or treatment of mania. However, thyroid effects of low doses have not been investigated. Our goal in this study was to assess the changes in thyroid-stimulating hormone (TSH) associated with a broad range of lithium levels, including those well below the therapeutic range for bipolar disorders. METHODS: This study was conducted in a small healthcare system with 19 associated primary care clinics served by a Collaborative Care program of psychiatric consultation. In this retrospective review of electronic records, we searched for patients who had received a lithium prescription and both pre- and post-lithium thyroid-stimulating hormone (TSH) levels. RESULTS: Patients with low lithium levels (<0.5 mEq/L, N = 197) had a mean thyroid-stimulating hormone (TSH) increase of 0.52 mIU/L. Patients with maintenance lithium levels (0.5-0.8 mEq/L; N = 123) had a mean TSH increase of 1.01 mIU/L; and patients with antimanic lithium levels (>0.8 mEq/L; N = 79) had a mean TSH increase of 2.16 mIU/L. The probability of TSH exceeding the upper limit of normal in our laboratory (>4.2 mIU/L) was positively associated with pre-lithium TSH. CONCLUSION: These results suggest that the risk of lithium-induced hypothyroidism is dose-related, and relatively small with very low doses, but thyroid monitoring, including a pre-lithium TSH, is still warranted.

Impostor Phenomenon Among Family Medicine Residency Program Directors: A CERA Study.

BACKGROUND AND OBJECTIVES: Impostor phenomenon (IP) can be described as feelings of inadequacy that exist despite apparent success. Although IP may be related to multiple important outcomes in physicians, it has not been examined among residency program directors (PDs). METHODS: The seven-item Leary Impostorism Scale (LIS) was added to the 2021 Council of Academic Family Medicine Educational Research Alliance (CERA) PD survey. In addition to standard questions, we surveyed PDs about their likelihood to leave their role, whether they started their PD role due to an unexpected transition, their beliefs concerning workplace evaluations relative to self-assessed performance, and their perceived support in completing PD responsibilities. RESULTS: Of the 257 PDs included in the survey (response rate approximately 41%), 28% (N=71) reported no IP. IP did not statistically differ across gender or race. LIS scores were lower among Hispanic/Latino respondents, but only 8% of our sample (N=20) identified as Hispanic/Latino. LIS scores did not significantly differ by PD likelihood to leave their position or for PDs starting their position due to a sudden transition. Respondents who felt that evaluations overestimated actual performance had higher LIS scores, as did those with lower levels of perceived support in completing administrative responsibilities and those with less time in their PD role. CONCLUSIONS: Most PD respondents did not report high levels of IP. Short duration of PD role, lack of programmatic support, and negative self-evaluations were correlated with higher levels of IP. Future research should examine interventions or resources to help those with IP thrive.

The Efficacy of Tranexamic Acid for Reducing Blood Transfusion Rates in Extracapsular Hip Fractures: A Single-Center Randomized Controlled Trial.

Perioperative allogenic blood transfusions for patients with hip fractures are associated with increased costs and complications. This prospective randomized controlled trial evaluated whether tranexamic acid (TXA) reduces blood transfusion rates and blood loss in extracapsular hip fractures, when administered at the time of hospital admission. Patients with closed intertrochanteric or subtrochanteric femur fractures undergoing intramedullary nailing (n=100) were enrolled from October 2015 to January 2019. On arrival to the hospital, patients were randomized to receive either 1 g of intravenous TXA or normal saline. Blood transfusion rates from hospital arrival to postoperative day 5 or discharge, blood loss from hospital arrival to postoperative day 3 or 4, intraoperative blood loss, length of hospital stay, 30-day mortality, and major complications were evaluated. Six patients from the TXA group and five from the placebo group were excluded because of canceled surgery, study drug infusion after incision, multiple fractures, or dropout. Patient characteristics were similar between the groups. Postoperative transfusion rates were 17.5% (7 of 40) in the TXA group and 36.7% (18 of 49) in the placebo group (relative risk, 0.48; 95% CI, 0.22-1.03; P=.046). Total blood loss was significantly less in the TXA group (mean difference, 367 mL; 95% CI, 76-657; P=.01). No significant differences were found for intraoperative blood loss, length of hospital stay, 30-day mortality, or 30-day major complications. TXA administered on hospital arrival decreased the risk of postoperative blood transfusion and mean perioperative blood loss in patients with extracapsular hip fractures. We recommend a single-dose intravenous administration of TXA at the time of hospital admission for patients with extracapsular hip fractures. [Orthopedics. 2023;46(5):e303-e309.].

Antidepressant Tapering Is Not Routine But Could Be.

INTRODUCTION: When antidepressants are discontinued, severe withdrawal symptoms are possible. Some patients have few or no problems stopping, whereas others struggle. That struggle can be minimized or prevented with careful dose tapering. How often is that done? METHODS: Using 7 years of medical records, we determined the percentage of patients who received a prescription for the lowest available dose of their antidepressant before it was discontinued, as an indicator of a deliberate taper. RESULTS: Over that period, 8.9% of patients had evidence of tapering. The percentage increased from 4.9% in 2014 to a plateau around 10% in the past 4 years. DISCUSSION: While reports of severe withdrawal are increasingly recognized and must be addressed, our data suggest that many patients can discontinue their antidepressants without a taper through the lowest dose. However, it is difficult to identify which patients will struggle without a careful taper. A "one-size-fits-all" taper approach is recommended, balancing the need for withdrawal prevention with the need to avoid unnecessary complexity for the majority of patients. The first decrement is key for all patients: it must go well. Thereafter many patients may accelerate but all should receive a prescription for the lowest available dose of their antidepressant.