Mental Health Polypharmacy in "Non-Coded" Primary Care Patients: The Effect of Deprescribing.

Background: Mental health (MH) polypharmacy, defined as prescribing multiple mental health medications for the same condition, presents significant challenges in clinical practice. With varying prevalence rates and an increasing trend, particularly in the UK, this deprescribing prospective quality improvement project aimed to address the complexities and risks associated with MH polypharmacy. Patients and Methods: A large primary care centre in London was selected for this project. Electronic records of 667 patients (non-coded in mental health lists) were analysed as a result of the absence of a Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) for mental health. Seventy-two non-coded patients exhibiting "same-class" as well as "adjunctive" and "augmentation" polypharmacy were identified. Their demographic and health data, including MH diagnoses, physical status, and lifestyle habits, were evaluated. This deprescribing prospective project included 68 patients and employed a model inspired by the Plan-Do-Study-Act (PDSA) cycle, focusing on reducing psychotropic, adjunctive, and augmentative medications while monitoring mental health control through face-to-face consultations using the Patient Health Questionnaire-9 (PHQ-9) and Generalised Anxiety Disorder Assessment-7 (GAD-7) scores, alongside physical health parameters. Results: The project revealed a significant decrease in the average number of psychotropic and adjunct medications from initial consultations to the end of the 18-month period. Additionally, a marked reduction in reported side effects and drug interactions was observed. Improvements in mental health control, as evidenced by PHQ-9 and GAD-7 scores, were noted. Physical health parameters, including BMI, blood pressure, heart rate, HbA1c, and cholesterol levels, also showed significant improvements. Educational initiatives for patients and clinicians were successfully implemented, contributing to these positive outcomes. Discussion: The project faced challenges like balancing medication reduction with mental health stability, patient apprehension, and the absence of standardised protocols. However, the successful reduction in medication numbers and the improvement in health outcomes highlight the effectiveness of the model. This project underscores the necessity of a tailored approach to MH polypharmacy, emphasising continuous education, clinical titration, and adherence to guidelines. Future research is needed to develop clear guidelines for medication combination in mental health care and to understand the long-term effects of polypharmacy in mental health populations. Conclusions: This project demonstrates the potential for significant improvements in the management of MH polypharmacy. By carefully managing medication reductions and employing a comprehensive care approach, including patient education and clinician training, the project achieved improvements in both mental and physical health outcomes. These findings suggest a promising direction for future practices in MH polypharmacy management.

Effect of chronic heavy tobacco smoking on ankle fracture healing.

INTRODUCTION: Tobacco smoking is linked to an elevated risk of osteomyelitis and delayed healing in long bone fractures. However, the impact of smoking on bone union and soft tissue recovery following ankle fractures remains unclear. This study presents a retrospective comparative analysis evaluating the effects of chronic heavy tobacco smoking on the healing process and outcomes of ankle fractures after surgical interventions. MATERIALS AND METHODS: We examined 220 consecutive cases of chronic heavy smokers (CHS) with closed ankle fractures who were referred to our unit for further treatment. A control group, consisting of 220 age- and sex-matched individuals (non-smokers with closed ankle fractures), was identified for comparative analysis. We collected clinical data, including pre-existing comorbidities, Lauge-Hansen fracture classification, necessity for surgery, and the surgical procedures performed. The primary outcomes investigated were the time required for fracture union and wound healing. Secondary outcomes included postoperative complications such as prolonged pain, bleeding, swelling, infection, compartment syndrome, and neurovascular impairment, as well as the incidence of delayed union, non-union, and the need for further intervention. Both cohorts were monitored for a minimum of 24 months. RESULTS: Our analysis revealed that the surgical cohort of chronic heavy smokers exhibited a statistically significant delay in fracture union compared to both the conservatively managed smokers and the control group. Further scrutiny of the surgical cohort of chronic smokers indicated a significant correlation between smoking and extended postoperative pain duration, persistent swelling at the fracture site, and both superficial and deep wound infections. Additionally, these patients experienced delays in both fracture union and wound healing when compared to the control group. Similarly, the conservatively managed chronic smokers showed a marginal increase in the incidence of post-injury pain duration, extended swelling at the fracture site, and delayed union compared to the control group. CONCLUSION: Patients who are chronic heavy smokers and require surgical intervention for ankle fractures should be made aware of their increased risk for delayed fracture union and poor wound healing. Orthopedic surgeons should proactively encourage these patients to participate in smoking cessation programs.

Kisspeptin-neuron control of LH pulsatility and ovulation.

Feedback from oestradiol (E2) plays a critical role in the regulation of major events in the physiological menstrual cycle including the release of gonadotrophins to stimulate follicular growth, and the mid-cycle luteinising hormone (LH) surge that leads to ovulation. E2 predominantly exerts its action via oestrogen receptor-alpha (ERα), however, as gonadotrophin releasing hormone (GnRH) neurons lack ERα, E2-feedback is posited to be indirectly mediated via upstream neurons. Kisspeptin (KP) is a neuropeptide expressed in hypothalamic KP-neurons that control GnRH secretion and plays a key role in the central mechanism regulating the hypothalamic-pituitary-gonadal (HPG) axis. In the rodent arcuate (ARC) nucleus, KP is co-expressed with Neurokinin B and Dynorphin; and thus, these neurons are termed 'Kisspeptin-Neurokinin B-Dynorphin' (KNDy) neurons. ARC KP-neurons function as the 'GnRH pulse generator' to regulate GnRH pulsatility, as well as mediating negative feedback from E2. A second KP neuronal population is present in the rostral periventricular area of the third ventricle (RP3V), which includes anteroventral periventricular (AVPV) nucleus and preoptic area neurons. These RP3V KP-neurons mediate positive feedback to induce the mid-cycle luteinising hormone (LH) surge and subsequent ovulation. Here, we describe the role of KP-neurons in these two regions in mediating this differential feedback from oestrogens. We conclude by considering reproductive diseases for which exploitation of these mechanisms could yield future therapies.

Quality of life following photodynamic therapy for head and neck pathologies: An exploratory study.

INTRODUCTION: Healthcare related quality of life (QoL) is defined as the impact one's level of health and wellbeing has on a number of domains, including physical, mental, spiritual and social functions. Photodynamic therapy (PDT), a cancer treatment modality, is increasingly used to treat or palliate head and neck pathologies. Due to the complex nature of this area of the body, both the pathology and the treatment of it can severely affect the quality of life. Thus far, no questionnaire has been developed which focuses on quality-of-life post-PDT of head and neck pathologies. PATIENTS AND METHODS: We have developed the University College London Quality of Life Questionnaire for Patients undergoing PDT in the Head and Neck, using meta-tetra(hydroxyphenyl)chlorin (mTHPC) as the photosensitiser. This was modified from the University of Washington quality of life (UW-QOL) questionnaire. Thirty-eight patients who received mTHPC-PDT for various head and neck pathologies completed the questionnaire, with a mean follow-up of 56 days. RESULTS: All patients reported improved QoL following mTHPC-PDT. The main problem that was reported was post-PDT pain, which is a common side effect. Visual symptoms, breathing, speaking and swallowing problems improved significantly in the 4th week following treatment and significant improvement in activities of daily living, social life, mood and anxiety were reported in the subsequent weeks. CONCLUSIONS: mTHPC-PDT confers improvement in QoL score in selected head and neck cancer patients with figures comparable to other treatment modalities. This exploratory study demonstrated patterns of QoL outcome. Further work needs to be done for survey validation and inclusion of a larger cohort which will allow optimal sub-group analysis and help guide further interventions.

From Basic Mechanisms to Clinical Research: Photodynamic Therapy Applications in Head and Neck Malignancies and Vascular Anomalies.

Head and neck cancers are largely squamous cell carcinomas derived from the epithelial lining of the structures in the region, and are often classified anatomically into oral, oropharyngeal, nasopharyngeal and laryngeal carcinomas. The region's component structures serve complex and intricate functions, such as speaking, swallowing and breathing, which are often compromised by these neoplasms. Such lesions may also cause disfigurement, leading to distressing social and psychological issues. Conventional treatments of these neoplasms usually involve surgical intervention with or without chemoradiotherapy. These have shown to be efficacious; however, they can also cause damage to healthy as well as diseased tissue, exacerbating the aforementioned problems. Access to a given region to deliver the treatments is also often a problem, due to the complex anatomical structures involved. The use of photodynamic therapy in the head and neck region has been established for about two decades. In this review, we looked at the basic mechanisms of this intervention, examined its use in common head and neck malignancies and vascular anomalies, and reported on the most recent clinical studies. We further included a clinical guide which can help replicate the use of this technology by any unit. Based on this review, photodynamic therapy has been shown to be efficacious in the treatment of head and neck malignancies and vascular tumours. This therapy can be targeted to the diseased tissue and causes no damage to underlying structures. Recent studies have shown this therapy to be as effective as conventional therapies, without causing major adverse effects.