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Congenital long QT syndrome is a group of genetically transmitted disorders characterized by abnormal cardiac repolarization resulting in QT interval prolongation that predisposes patients to the acute onset of ventricular arrhythmias, most notably torsades de pointes, which may cause syncope or sudden cardiac death. Long QT syndrome is usually transmitted in an autosomal dominant pattern. Diagnosis remains challenging, as roughly 40% of patients with genotype-positive LQTS do not demonstrate QT prolongation on resting ECG. Clinical manifestations are heterogenous and include presyncope, syncope, aborted cardiac arrest, cardiac arrest, and sudden cardiac death but many patients are completely asymptomatic. Many of the medications administered during an anesthetic affect the QT interval. Additionally, patients with long QT syndrome may require the placement of pacemakers, implantable cardioverter-defibrillators and/or cardiovascular implantable electronic devices. This chapter discusses the perioperative management of patients with long QT syndrome and appropriate management of implanted devices during the perioperative period.
Existing research on psychological distress and mental health service utilization has focused on common types of solid tumor cancers, leaving significant gaps in our understanding of patients experiencing rare forms of hematologic cancers.
To examine distress, quality of life, and mental health service utilization among patients with aggressive, refractory B-cell lymphomas.
Patients (n = 26) with B-cell lymphomas that relapsed after first- or second-line treatment completed self-report measures of distress (Hospital Anxiety and Depression Scale) and quality of life (Short-Form Health Survey, SF-12). Patients also reported whether they had utilized mental health treatment since their cancer diagnosis.
Approximately 42% (n = 11) of patients reported elevated levels of psychological distress. Of patients with elevated distress, only one quarter (27.2%; n = 3) received mental health treatment, while more than half did not receive mental health treatment (54.5%; n = 6), and 18.1% (n = 2) did not want treatment. Patients with elevated distress reported lower mental quality of life than patients without elevated distress [F (1, 25) = 15.32, p = 0.001].
Significance of the results
A significant proportion of patients with advanced, progressive, B-cell lymphomas may experience elevated levels of distress. Yet, few of these distressed patients receive mental health treatment. Findings highlight the need to better identify and address barriers to mental health service utilization among patients with B-cell lymphoma, including among distressed patients who decline treatment.
Case of a 17yo patient with high functioning ASD and OCD with obsessions about being a pedophile, with suicidal ideation and self-harming behaviors. He was followed in outpatient care for one year since his first contact with Mental Health, following an inpatient admission for suicidal ideation.
Differential diagnosis between OCD, ASD and possible pedophilia. Learn about different levels of care involved, and other possibilities. Therapy resources used.
Description of the case report: description of initial and final Mental Status Exam Differential Diagnosis: ASD vs OCD vs Pedophilia vs Depressive Disorder Children’s Yale-Brown Obsessive Compulsive Scale Therapy: family based therapy, and Exposure response prevention therapy.
Intrusive images, and reassurance seeking, helped with OCD diagnosis. ASD made symptoms harder to manage with SSRIs alone, which drove to add Aripiprazol at low doses in outpatient care. CY-BOCS showed obsessions other than doubts about being a pedophile. He participated in Exposure response prevention therapy with response, especially when antipsychotic medication was added. Family based therapy worked with his parents in not providing excessive reassurance, and with the patient in gaining insight about his OCD. Decreased anxiety, decreased self-deprecation and no new suicidal thoughts Functionality of the patient in the community improved, with possibility of going college next year.
Recommendation of good assessment of sexuality in ASD population Importance of individual and family therapy for OCD and specially when there is poor judgement and insight in the patient. Importance of combined treatment: pharmacology + therapy
The bi-directional relationship between mental and physical illness is well established. Therefore, in order to lower the already high mortality rates associated with psychiatric disorders, physical health issues must be closely monitored in this population [1,2]. A recent Lancet commission highlights emerging strategies and recommendations for improvement of physical health outcomes in patients with chronic mental disorders. These strategies involve better integration of physical and mental health care, combined with broader implementation of lifestyle interventions to reduce elevated cardiometabolic risk and attenuate medication side-effects .
To assess psychiatrists’ confidence levels in physical healthcare competencies; to explore whether confidence was related to learning opportunities.
Physical healthcare learning objectives were extracted from the Irish College of Psychiatrists’ training curriculum. An electronic questionnaire was sent to 50 psychiatrists in one Irish healthcare region with a catchment area of c. 450,000. Participants had to rate confidence levels for each competency on a five-point Likert scale and the availability of learning opportunities for attaining each competency.
66% response rate was achieved. A majority reported confidence in cardiovascular examination, interpreting blood results and evaluating comorbidities. A minority reported confidence in interpreting imaging, electrocardiograms and recognising medical emergencies. This corresponds to a relative paucity of learning opportunities.
Clinical implication Programmes for trainee doctors and CME opportunities for consultant psychiatrists would benefit from an emphasis on physical health examination and modules on interpreting investigations and the recognition of medical emergencies.
This study aimed to describe meat consumption rationalisation and relationships with meat consumption patterns and food choice motivations in New Zealand adolescents.
This was a cross-sectional study of adolescents from high schools across New Zealand. Demographics, dietary habits, and motivations and attitudes towards food were assessed by online questionnaire and anthropometric measurements taken by researchers. The 4Ns questionnaire assessed meat consumption rationalisation with four subscales: ‘Nice’, ‘Normal’, ‘Necessary’ and ‘Natural’.
Nineteen secondary schools from eight regions in New Zealand, with some purposive sampling of adolescent vegetarians in Otago, New Zealand.
Questionnaires were completed by 385 non-vegetarian and vegetarian (self-identified) adolescents.
A majority of non-vegetarian adolescents agreed that consuming meat was ‘nice’ (65 %), but fewer agreed that meat consumption was ‘necessary’ (51 %). Males agreed more strongly than females with all 4N subscales. High meat consumers were more likely to agree than to disagree that meat consumption was nice, normal, necessary and natural, and vegetarians tended to disagree with all rationalisations. Adolescent non-vegetarians whose food choice was motivated more by convenience, sensory appeal, price and familiarity tended to agree more with all 4N subscales, whereas adolescents motivated by animal welfare and environmental concerns were less likely to agree.
To promote a reduction in meat consumption in adolescents, approaches will need to overcome beliefs that meat consumption is nice, normal, necessary and natural.
Hyperemesis gravidarum (HG), severe nausea and vomiting in pregnancy, can lead to vitamin deficiencies. Little is known about HG-related vitamin K deficiency. We aimed to summarise available evidence on the occurrence of HG-related vitamin K deficiency and corresponding maternal and neonatal complications. A systematic review was conducted, searching Medline and EMBASE from inception to 12 November 2020. We identified 1564 articles, of which we included fifteen in this study: fourteen case reports (n 21 women) and one retrospective cohort study (n 109 women). Nine out of twenty-one women reported in case reports had a prolonged prothrombin time (PT). The cohort study measured PT in 39/109 women with HG, of whom 10/39 women (26 %) had prolonged PT. In total, 30–50 % women received vitamin K supplementation after vitamin K deficiency had been diagnosed. Four case reports (n 4 women) reported corresponding maternal complications, all consisting of coagulopathy-related haemorrhage. Nine case reports (n 16 neonates) reported corresponding neonatal complications including intracranial haemorrhage (n 2 neonates) and embryopathy (n 14 neonates), which consisted of Binder phenotype (n 14 neonates), chondrodysplasia punctata (n 9 neonates) and grey matter heterotopia (n 3 neonates). In conclusion, vitamin K deficiency and related complications occur among women with HG. In our systematic review, we were unable to assess the incidence rate.
Patients with single-ventricle CHD undergo a series of palliative surgeries that culminate in the Fontan procedure. While the Fontan procedure allows most patients to survive to adulthood, the Fontan circulation can eventually lead to multiple cardiac complications and multi-organ dysfunction. Care for adolescents and adults with a Fontan circulation has begun to transition from a primarily cardiac-focused model to care models, which are designed to monitor multiple organ systems, and using clues from this screening, identify patients who are at risk for adverse outcomes. The complexity of care required for these patients led our centre to develop a multidisciplinary Fontan Management Programme with the primary goals of earlier detection and treatment of complications through the development of a cohesive network of diverse medical subspecialists with Fontan expertise.
Previously reported associations between hospital-level antibiotic use and hospital-onset Clostridioides difficile infection (HO-CDI) were reexamined using 2012–2018 data from a new cohort of US acute-care hospitals. This analysis revealed significant positive associations between total, third-generation, and fourth-generation cephalosporin, fluoroquinolone, carbapenem, and piperacillin-tazobactam use and HO-CDI rates, confirming previous findings.
People with severe mental illness and intellectual disabilities are overrepresented in the criminal justice system worldwide and this is also the case in Ireland. Following Ireland’s ratification of the United Nations’ Convention on the Rights of People with Disabilities in 2018, there has been an increasing emphasis on ensuring access to justice for people with disabilities as in Article 13. For people with mental health and intellectual disabilities, this requires a multi-agency approach and a useful point of intervention may be at the police custody stage. Medicine has a key role to play both in advocacy and in practice. We suggest a functional approach to assessment, in practice, and list key considerations for doctors attending police custody suites. Improved training opportunities and greater resources are needed for general practitioners and psychiatrists who attend police custody suites to help fulfill this role.
The decision to discontinue isolation in hospitalized patients with persistently positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) molecular testing is nuanced. Improvement in clinical status should be evaluated with expert consultation when considering whether discontinuation of isolation is appropriate. The cycle threshold value may serve as a useful adjunct to this decision-making process.
Structure M13-1 is a public monumental building in the heart of ancient El Perú-Waka’, Petén, Guatemala, and is the location of Burial 61, an entombed Late Classic (seventh-century) ruler. In this report, we discuss mortuary evidence that we believe permits identification of the interred as the historically known queen, Lady K'abel.
ABSTRACT IMPACT: Younger patients receiving biologics for rheumatoid arthritis have higher medical expenditure. OBJECTIVES/GOALS: TNF inhibiting biologic disease modifying antirheumatic drugs are among the most highly regarded treatment options for rheumatoid arthritis (RA). We aimed at evaluating the medical and prescription costs associated with monoclonal antibody use vs. other RA treatment options in subjects diagnosed with RA. METHODS/STUDY POPULATION: Records from the Medical Panels Expenditure Survey (MEPS) database made available by the Agency for Healthcare Research and Quality were used to identify all RA subjects (n=_____). Demographics and MEPS-provided flags for RA were abstracted from the medical condition files for all the subjects surveyed (2008-2018). Prescribed biologics were identified based on generic and brand names following a manual review to detect any misspellings. Total medical expenses and prescription expenses were abstracted for all identified RA subjects. Subject were surveyed for two consecutive years, thus expenses were assessed for each of the two surveyed years. Costs were adjusted for inflation and expressed in 2018 dollars. The relationship between biologics use, cost and age or gender was evaluated by Fisher’s exact test. RESULTS/ANTICIPATED RESULTS: Most RA subjects did not use biologics. RA was more prevalent in women than in men with no significant correlation between sex and the use of biologics in year 1, year 2, or the combined years (p=.44, p=.63, and p=.65, respectively). Biologics users were found to be significantly younger (p<.001), with a mean of 52.8 years compared to 59 years in those who did not use biologics. The 95% confidence interval was 3.7 to 8.6 years younger than non-users. Total medical and prescription costs were higher for biologics users (p<.001) in all analyses. The mean prescription cost difference was $24,038 more per year for biologics users, and $26,296 more total medical expenses, CI $20,502-$27,230 and CI $21,947-$30,646, respectively. There was a trend for biologics users to have higher non-prescription medical expenses (p=.05). DISCUSSION/SIGNIFICANCE OF FINDINGS: Interestingly, biologics non-users had some extreme outliers with expenses far higher than any biologics users, possibly due to poorly controlled RA due to age and/or comorbidities. Yet, our most interesting findings are the higher use of biologics among younger RA subjects and the elevated costs of care being driven mainly by prescriptions cost.
To develop a fully automated algorithm using data from the Veterans’ Affairs (VA) electrical medical record (EMR) to identify deep-incisional surgical site infections (SSIs) after cardiac surgeries and total joint arthroplasties (TJAs) to be used for research studies.
Retrospective cohort study.
This study was conducted in 11 VA hospitals.
Patients who underwent coronary artery bypass grafting or valve replacement between January 1, 2010, and March 31, 2018 (cardiac cohort) and patients who underwent total hip arthroplasty or total knee arthroplasty between January 1, 2007, and March 31, 2018 (TJA cohort).
Relevant clinical information and administrative code data were extracted from the EMR. The outcomes of interest were mediastinitis, endocarditis, or deep-incisional or organ-space SSI within 30 days after surgery. Multiple logistic regression analysis with a repeated regular bootstrap procedure was used to select variables and to assign points in the models. Sensitivities, specificities, positive predictive values (PPVs) and negative predictive values were calculated with comparison to outcomes collected by the Veterans’ Affairs Surgical Quality Improvement Program (VASQIP).
Overall, 49 (0.5%) of the 13,341 cardiac surgeries were classified as mediastinitis or endocarditis, and 83 (0.6%) of the 12,992 TJAs were classified as deep-incisional or organ-space SSIs. With at least 60% sensitivity, the PPVs of the SSI detection algorithms after cardiac surgeries and TJAs were 52.5% and 62.0%, respectively.
Considering the low prevalence rate of SSIs, our algorithms were successful in identifying a majority of patients with a true SSI while simultaneously reducing false-positive cases. As a next step, validation of these algorithms in different hospital systems with EMR will be needed.
Cognitive screening is an efficient method of detecting cognitive impairment in adults and may signal need for comprehensive assessment. Cognitive screening is not, however, routinely used in youth aged 12–25, limiting clinical recommendations. The aims of this review were to describe performance-based cognitive screening tools used in people aged 12–25 and the contexts of use, review screening accuracy in detecting cognitive impairment relative to an objective reference standard, and evaluate the risk of bias of included studies.
Electronic databases (Scopus, Medline, PsychINFO, and ERIC) were searched for relevant studies according to pre-determined criteria. Risk of bias was rated using the Quality Assessment of Diagnostic Accuracy Studies-2. Dual screening, extraction, and quality ratings occurred at each review phase.
Twenty studies met the review inclusion criteria. A diverse range of screening tools (length, format) were used in youth aged 12–25 with or without health conditions. Six studies investigating cognitive screening were conducted as primary accuracy studies and reported some relevant psychometric parameters (e.g., sensitivity and specificity). Fourteen studies presented correlational data to investigate the cognitive measure utility. Studies generally presented limited data on classification accuracy, which impacted full screening tool appraisal. Risk of bias was high (or unclear) in most studies with poor adherence to the Standards for Reporting Diagnostic Accuracy Studies (STARD) criteria.
Few, high quality studies have investigated the utility of cognitive screening in youth aged 12–25, with no screening measure emerging as superior at detecting cognitive impairment in this age group.
Due to shortages of N95 respirators during the coronavirus disease 2019 (COVID-19) pandemic, it is necessary to estimate the number of N95s required for healthcare workers (HCWs) to inform manufacturing targets and resource allocation.
We developed a model to determine the number of N95 respirators needed for HCWs both in a single acute-care hospital and the United States.
For an acute-care hospital with 400 all-cause monthly admissions, the number of N95 respirators needed to manage COVID-19 patients admitted during a month ranges from 113 (95% interpercentile range [IPR], 50–229) if 0.5% of admissions are COVID-19 patients to 22,101 (95% IPR, 5,904–25,881) if 100% of admissions are COVID-19 patients (assuming single use per respirator, and 10 encounters between HCWs and each COVID-19 patient per day). The number of N95s needed decreases to a range of 22 (95% IPR, 10–43) to 4,445 (95% IPR, 1,975–8,684) if each N95 is used for 5 patient encounters. Varying monthly all-cause admissions to 2,000 requires 6,645–13,404 respirators with a 60% COVID-19 admission prevalence, 10 HCW–patient encounters, and reusing N95s 5–10 times. Nationally, the number of N95 respirators needed over the course of the pandemic ranges from 86 million (95% IPR, 37.1–200.6 million) to 1.6 billion (95% IPR, 0.7–3.6 billion) as 5%–90% of the population is exposed (single-use). This number ranges from 17.4 million (95% IPR, 7.3–41 million) to 312.3 million (95% IPR, 131.5–737.3 million) using each respirator for 5 encounters.
We quantified the number of N95 respirators needed for a given acute-care hospital and nationally during the COVID-19 pandemic under varying conditions.
Recently, artificial intelligence-powered devices have been put forward as potentially powerful tools for the improvement of mental healthcare. An important question is how these devices impact the physician-patient interaction.
Aifred is an artificial intelligence-powered clinical decision support system (CDSS) for the treatment of major depression. Here, we explore the use of a simulation centre environment in evaluating the usability of Aifred, particularly its impact on the physician–patient interaction.
Twenty psychiatry and family medicine attending staff and residents were recruited to complete a 2.5-h study at a clinical interaction simulation centre with standardised patients. Each physician had the option of using the CDSS to inform their treatment choice in three 10-min clinical scenarios with standardised patients portraying mild, moderate and severe episodes of major depression. Feasibility and acceptability data were collected through self-report questionnaires, scenario observations, interviews and standardised patient feedback.
All 20 participants completed the study. Initial results indicate that the tool was acceptable to clinicians and feasible for use during clinical encounters. Clinicians indicated a willingness to use the tool in real clinical practice, a significant degree of trust in the system's predictions to assist with treatment selection, and reported that the tool helped increase patient understanding of and trust in treatment. The simulation environment allowed for the evaluation of the tool's impact on the physician–patient interaction.
The simulation centre allowed for direct observations of clinician use and impact of the tool on the clinician–patient interaction before clinical studies. It may therefore offer a useful and important environment in the early testing of new technological tools. The present results will inform further tool development and clinician training materials.