Introducing a psychosomatic medicine interest group for psychiatry residents.

BACKGROUND: Having gained subspecialty certification in 2003, the field of psychosomatic medicine (PM) addresses the mental health needs of individuals who suffer from general medical conditions. The rising prevalence of chronic illness, along with trends in medical delivery toward more collaborative models of care, underscores the value of recruitment to PM specialty programs. OBJECTIVES: To foster interest and education in PM, we have developed and implemented a Psychosomatic Medicine Interest Group for trainees within a psychiatry residency program. RESULTS: Participants have found the Psychosomatic Medicine Interest Group to be an enjoyable experience that has improved their clinical practice and interest in PM. CONCLUSION: The Psychosomatic Medicine Interest Group has also been a successful vehicle to enhance clinical knowledge and mentoring opportunities during training, while bolstering residents' desire to pursue a career in PM.

Inefficacy of antipsychotics in treatment of delirium and agitation in two cases of bickerstaff brainstem encephalitis.

The authors report two unusual cases of Bickerstaff encephalitis that presented with encephalopathy and severe agitation. Management with neuroleptics typically used for management of delirium was not effective and worsened agitation. Valproic acid was effective in treatment of agitation and well tolerated.

Immediate-release oxybutynin for the treatment of clozapine-induced sialorrhea.

OBJECTIVE: To describe a case of clozapine-induced sialorrhea alleviated by immediate-release oxybutynin. CASE SUMMARY: A 53-year-old female with schizoaffective disorder-bipolar type was admitted to a psychiatric unit and initiated on clozapine. During titration to a dose of 300 mg daily and despite taking concomitant oral benztropine 1 mg twice daily, the patient began to experience mild sialorrhea. The sialorrhea became profuse when the clozapine dose reached 400 mg daily, and the patient was routinely seen with a saliva-soaked shirt. Additionally, she had become self-conscious and wanted to stop clozapine therapy. Immediate-release oxybutynin 5 mg daily was started, resulting in significant reduction of the sialorrhea within 24 hours. The patient was discharged on clozapine 300 mg daily, risperidone 6 mg at bedtime, immediate-release oxybutynin 5 mg twice daily, and oral benztropine 1.5 mg daily, with only mild sialorrhea. DISCUSSION: It is unknown why clozapine induces sialorrhea. One speculation is that clozapine interrupts muscarinic receptor homeostasis. Immediate-release oxybutynin is an anticholinergic agent with high affinity for salivary gland M3 receptors that may have restored muscarinic receptor imbalance in our patient. N-Desethyl-oxybutynin, an active metabolite of oxybutynin, is largely responsible for oxybutynin's anticholinergic activity. The activity of oxybutynin and its metabolite may result in dry mouth in over 80% of patients taking the immediate-release formulation, while producing dry mouth in only 40% and 7.5% of patients taking the extended-release and topical formulations, respectively. CONCLUSIONS: To our knowledge, this is the first report of immediate-release oxybutynin successfully reducing clozapine-induced sialorrhea. If oxybutynin is considered for this indication, use of the immediate-release formulation seems prudent. Additional data, including randomized controlled trials, are needed to confirm whether immediate-release oxybutynin has a significant role in the management of this stigmatizing adverse effect.

Stutter exacerbated by lithium in a pediatric patient with bipolar disorder.

OBJECTIVE: To report the first known case of a lithium-exacerbated stutter in a pediatric patient. CASE SUMMARY: A 10-year-old male with a history of developmental stuttering, bipolar disorder not otherwise specified (NOS), attention-deficit/hyperactivity disorder, and conduct disorder was admitted to the psychiatric hospital because of recurrent suicidal ideations and increased physical aggression toward staff at his residential facility. The patient was being treated with lithium at initial dose of 150 mg/day at bedtime for bipolar disorder NOS. When the lithium dose was increased to 900 mg twice daily to better control the bipolar symptoms, his developmental stutter worsened intensely. When the lithium dose was reduced to 600 mg in the morning and 900 mg at night, the stutter returned to baseline. No other medication changes were made during this interval. His serum lithium concentration was 0.62 mEq/L at baseline, 1.24 mEq/L during the height of his exacerbated stutter, and returned to 0.64 mEq/L after dose reduction. DISCUSSION: To our knowledge, only 1 case of lithium-exacerbated stutter has been reported in the literature, and this was in an adult. The developmental stutter of our pediatric patient worsened when he was treated with higher doses of lithium. He was on stable doses of his other medications during the adjustments to the lithium dose, making it less likely that the stutter was due to one of these medications. However, it is possible that the exacerbation involved an interaction between lithium and one or several of the other medications. Based on the Naranjo probability scale, this case represents a probable adverse drug reaction. CONCLUSIONS: Clinicians should be aware that an additional adverse effect of lithium may be an exacerbation of stutter.

Lateral retinacular release during primary total knee arthroplasty: effect on outcomes and complications.

Intraoperative lateral retinacular release performed during primary total knee arthroplasty (TKA) can improve patellar tracking. This study compares the outcomes of patients who did and did not have lateral retinacular release during primary TKA. One thousand one hundred eight consecutive primary TKAs were reviewed. Lateral release was performed on 314 patients; 794 patients did not undergo release. Comparisons of range of motion, Knee Society Score, and postoperative complications were made between the 2 groups. At an average follow-up of 4.7 years, no statistically significant difference in range of motion, Knee Society Score, or postoperative complications of patella fracture, subluxation, postoperative manipulation, or wound complications was demonstrated. Lateral retinacular release to achieve improved patellar tracking does not compromise the clinical outcomes or complication rate of primary TKA.

Digital output volumetric pulmonary artery catheters eliminate interoperator interpretation variability and improve consistency of treatment decisions.

BACKGROUND: The pulmonary artery catheter (PAC) has been fraught with controversy over issues of safety and impact on outcomes variables for many years. Multiple attempts to quantify the utility of this diagnostic instrument have failed to resolve the matter. Previous investigations have focused on either quantifying inter-rater variability of waveform output interpretation from PACs or on clinical outcomes when PACs are used in care. We tested the hypothesis that the true link between a diagnostic tool and outcomes is treatment selection, and an instrument that minimizes or eliminates the need for data interpretation would also minimize the variability of treatment selections. STUDY DESIGN: We performed a prospective, single institutional, single blinded survey study. RESULTS: The inter-rater variability of waveform interpretation among all raters was notable (p < 0.01); for continuous end diastolic volume index interpretation, there was no notable inter-rater variability (p=1.0). Inter-rater variability of treatment selections based on waveform interpretation was notable for all raters (p < 0.01). Continuous end diastolic volume index data presentation of hemodynamic status did not result in notable inter-rater variability in treatment selections (p=0.10). Treatment choices based on continuous end diastolic volume index among raters with 5 or more years of experience are not different from clinical practice guideline-directed choices (p > 0.05), independent of patient ventilator status. CONCLUSIONS: Digital output volumetric PACs eliminate inter-rater variability of data interpretation, decrease inter-rater variability of data-driven treatment selections, and improve rater agreement with clinical practice guidelines when compared with traditional waveform output PACs.

Technique for impaction bone grafting of large bone defects in revision total knee arthroplasty.

Impaction bone grafting is an important tool in managing the irregularly sized and shaped bone defects observed in revision total knees. The technique is described in detail and includes tightly packing cancellous bone chips about an intramedullary stem and into the periprosthetic bone defects, then fully cementing a component in place. If needed, wire mesh can be used to contain bone defects. Results to date in 42 patients with 2 to 7 years of follow up are reported. They show the average flexion was 111 degrees; the final Knee Society score was 89 points, and there were no mechanical failures. There were 2 infections and 2 late periprosthetic fractures. The results have been encouraging, and this technique remains our procedure of choice for managing large bone defects in revision knee surgery.

Impaction grafting for bone defects in revision total knee arthroplasty.

UNLABELLED: Bone loss in revision total knee arthroplasty is a complex and challenging problem. Frequently, the defects encountered are irregular in size and shape. Since 1998, we have been using impaction bone allografting for constrained and unconstrained defects in revision total knee arthroplasty. We prospectively studied the mid-term results of 48 consecutive revision total knee arthroplasties with substantial bone loss treated with impaction allograft. Average followup was 3.8 years. Knee Society scores improved from a preoperative average of 57.0 to a postoperative average of 89.8 points (p < 0.001). Knee Society functional scores improved from a pre-operative average of 52.3 to a postoperative average of 80.3 points (p < 0.001). There have been no mechanical failures of the revisions and all radiographs have shown incorporation and remodeling of the bone graft. There were six complications out of the 42 revisions available for followup (14%); two periprosthetic fractures, one early infection salvaged with irrigation and antibiotics, one late infection resulting in fusion, and two patellar clunk syndromes. Though time consuming and technically demanding, impaction grafting for bone loss in revision total knee arthroplasty has excellent durability and versatility. It has become our preferred technique for the management of substantial bone loss in revision total knee arthroplasty. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series).