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1.
J Clin Psychiatry ; 81(1)2020 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-31917908

RESUMO

Buprenorphine is a partial-agonist opioid that is prescribed as a medication-assisted treatment (MAT) for opioid use disorder (OUD). Buprenorphine is also a potent analgesic with high opioid-receptor affinity and binding coefficient; when buprenorphine is administered simultaneously with a µ-opioid receptor full agonist ("full agonist opioid" [FAO]), the combination can yield unexpected outcomes depending on dosing and timing. Buprenorphine is sometimes perceived as a powerful competitive opioid blocker that will hamper pharmacologic management that necessitates the use of FAO. When patients receiving buprenorphine-MAT (BUP-MAT) formulations have presented for operative procedures, there has been clinical variance in approach to their BUP-MAT management. Recognizing the risk management challenge from both analgesia and BUP-MAT perspectives, we convened a multidisciplinary group of clinicians who treat BUP-MAT patients and completed a literature review with the goal of generating a guideline for appropriate management of these patients presenting for a broad spectrum of surgical procedures. Our conclusion is that continuous simultaneous administration of buprenorphine products with FAO is safe when accounting for dose and timing, including surgeries that historically produce moderate to severe pain, and may further provide an analgesic advantage, lessen FAO burden, and reduce relapse risk to this group.

4.
Psychosomatics ; 60(5): 458-467, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30876654

RESUMO

BACKGROUND: Benzodiazepine-based protocols offer a standard of care for management of alcohol withdrawal, though they may not be safe or appropriate for all patients. Phenobarbital, a long-acting barbiturate, presents an alternative to conventional benzodiazepine treatment, though existing research offers only modest guidance to the safety and effectiveness of phenobarbital in managing alcohol withdrawal syndrome (AWS) in general hospital settings. METHODS: To compare clinical effectiveness of phenobarbital versus benzodiazepines in managing symptoms of alcohol withdrawal, we conducted a retrospective chart review of 562 patients admitted over a 2-year period to a general hospital and treated for AWS. The development of AWS-related complications (seizures, alcoholic hallucinosis, and alcohol withdrawal delirium) post-treatment initiation was the primary outcome examined in both treatment groups. Additional outcomes measured included hospital length of stay, intensive care unit (ICU) admission rates/length of stay, medication-related adverse events, and discharge against medical advice. RESULTS: Despite being significantly more likely to have a history of prior complications related to AWS (including seizures and delirium), patients initiated on phenobarbital (n = 143) had overall similar primary and secondary treatment outcomes to those in the benzodiazepine treatment protocol (n = 419). Additionally, a subset of patients (n = 16) initially treated with benzodiazepines displayed signs of treatment nonresponse, including significantly higher rates of AWS-related delirium and ICU admission rates, but were well-managed following transition to the phenobarbital protocol. CONCLUSION: The data from this retrospective chart review lend further support to effectiveness and safety of phenobarbital for the treatment and management of AWS. Further randomized controlled trials are warranted.

6.
Psychosomatics ; 58(6): 581-591, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28760366

RESUMO

BACKGROUND: Intentional self-inflicted burn injuries are a rare occurrence in the United States, but they represent a considerable portion of all burn injuries in the developing world. Compared to nonintentional burns, patients with intentional self-inflicted burns have increased rates of higher total body surface area involvement and associated complications, including overall mortality. METHODS: We present 2 representative cases and review the available literature on the topic of self-inflicted burns. We review epidemiologic, social, and cultural factors of importance, and also provide an overview of most common psychiatric pathologies encountered in patients with self-inflicted burns. RESULTS: The patient demographics and motivation for intentional self-inflicted burn injuries differ considerably across the world. Although self-immolation is commonly associated with women experiencing domestic stress in the developing world, most cases of self-immolation in higher-income countries are males. Psychiatric pathologies, including primary mood and thought disorders and substance use, play a significant component in latter cases, while most patients in the developing world lack any premorbid psychiatric diagnosis, or carry diagnosis of adjustment disorder. CONCLUSIONS: Nonlethal self-burns present a distinct subset of intentional self-burn injuries, often occurring in the context of significant personality pathology, or with potential secondary gain.


Assuntos
Queimaduras , Comportamento Autodestrutivo/psicologia , Transtorno Bipolar/psicologia , Transtorno da Personalidade Borderline/psicologia , Unidades de Queimados , Transtornos da Alimentação e da Ingestão de Alimentos/psicologia , Feminino , Humanos , Masculino , Transtornos Psicóticos/psicologia , Adulto Jovem
7.
Psychosomatics ; 56(4): 319-28, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26002223

RESUMO

BACKGROUND: As systems of care become more complex and comorbid medical and psychiatric illness becomes more evident, it is essential to prepare psychiatric trainees for practice in more integrated models of care. OBJECTIVE: We sought to identify readings available for residency training in consultation-liaison (C-L) psychiatry/psychosomatic medicine with the intent to help educators and trainees identify appropriate and essential learning resources within the field. METHODS: We reviewed readings available to the residents (including commonly used textbooks in C-L psychiatry and C-L training programs' required reading lists) and identified areas of consensus regarding the topics germane to the care of patients with comorbid medical and psychiatric illness (namely depression, dementia, and delirium) and the education of trainees. RESULTS: There was considerable variation in the references cited by well-regarded textbooks and by reading lists created for trainees in C-L psychiatry. In the 4 textbooks reviewed, there were 83 shared citations on delirium (including 10 citations that were common to all 4 textbooks and 17 citations shared by 3 textbooks). Markedly less overlap was noted in the chapters on depression (only 2 references cited in all of the textbooks with relevant content) and dementia (only 7 shared references). CONCLUSION: Given the paucity of overlap of citations in commonly used textbooks, we recommend that practical topical reviews or textbook chapters be used as core (required) or recommended readings for residents on C-L psychiatry rotations, supplemented by a small number of studies or case series that illustrate key teaching points on each essential topic.


Assuntos
Livros , Internato e Residência , Medicina Psicossomática/educação , Inquéritos e Questionários , Humanos , Encaminhamento e Consulta , Livros de Texto como Assunto
8.
Emerg Med J ; 30(3): e15, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22492125

RESUMO

STUDY OBJECTIVE: The Meyer Pediatric Hospital in Florence, Italy recently implemented the single provider model of emergency medicine. Prior to these changes, patients were triaged to a paediatric surgeon or paediatrician based on the complaint. The authors assess the outcomes of patients evaluated by surgeons prior to this change and compare them with those of patients seen by emergency physicians. METHODS: A retrospective, cohort study was performed reviewing patients seen in the emergency department between 2005 and 2008 for the three most common surgical complaints encountered before the systems change: head trauma, testicular pain and abdominal pain. Outcomes include misdiagnoses, consultation rates, dispositions, imaging, interventions and surgeries. RESULTS: A total of 2415 patient visits were included. Emergency physicians saw more patients (1388 vs 1027) and obtained more consultations (25.6% vs 8.1%) than surgeons. Patients triaged directly to surgeons were more likely to be admitted to the hospital (10.3% vs 7.6%), undergo urgent interventions (9.5% vs 6.7%), undergo surgery (8.0% vs 4.8%), have more radiographic images to evaluate head trauma (12.1% vs 5.3%), be misdiagnosed (1.0% vs 0.3%) and have more plain films for abdominal pain (3.1% vs 1.3%). There is an overall trend towards fewer missed diagnoses by emergency physicians (0.3% vs 0.9%), but this difference is only statistically significant in the abdominal pain subset analysis (p=0.032, combined data p=0.052). CONCLUSIONS: The single provider model of emergency medicine where emergency physicians manage all patients presenting to the emergency department appears to be a safe and efficient model of emergency medical care.


Assuntos
Serviço Hospitalar de Emergência , Hospitais Pediátricos , Modelos Organizacionais , Dor Abdominal/diagnóstico , Dor Abdominal/terapia , Distribuição de Qui-Quadrado , Criança , Traumatismos Craniocerebrais/diagnóstico , Traumatismos Craniocerebrais/terapia , Diagnóstico Diferencial , Erros de Diagnóstico , Feminino , Humanos , Itália , Masculino , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , Doenças Testiculares/diagnóstico , Doenças Testiculares/terapia , Triagem , Recursos Humanos
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