Lithium is an effective mood stabiliser in the management of Bipolar affective Disorder. Timing and decision to restart lithium after an episode of toxicity can be challenging. National guidelines offer advice on management of acute toxicity but little information on restarting lithium. Abrupt withdrawal of lithium can provoke relapse. Clinical experience of the authors was that patients who had Lithium stopped following toxicity often relapsed, leading to poor mental health, frequent admissions to acute and psychiatric hospitals and sometimes death. Restarting of lithium in hospital or after discharge was often variable. The aim of the evaluation was to review the outcomes of patients admitted to the University Hospitals Birmingham NHS Foundation Trust (UHB) with a lithium level over 1.2 mmol/L.

Patients were selected if recorded lithium level was over 1.2mmol/L on admission to UHB. Case note review of electronic patient records was carried out to identify demographic factors of participants alongside medical and psychiatric outcomes over the following 2 years.

84 patients were identified as having lithium levels over 1.2mmol/L. 76% Female. Mean age 61 years (range 20-95 years). 77% of patients had been prescribed lithium for more than 6 years. Mean lithium level was 1.68 mmol/L (range 1.2-3.44 mmol/L). Around 2/3 of patients admitted with lithium above therapeutic range were referred to the liaison psychiatry team. 12% of the patients died during that admission. Just over 2/3 (69%) of those discharged from hospital had been restarted on lithium. When lithium was not restarted during the acute admission, only 13% were restarted in the community within the next 2 months. Two year mortality of patients admitted with elevated lithium levels was 31%. 10% of patients were admitted to a psychiatric hospital within 1 year. The mean number of admissions to the acute hospital (UHB ) within one year was 1.6 (range 0-26).

Admission to hospital with high lithium levels appears to be associated with a number of negative outcomes. These data cannot attribute causality. Conditions predisposing to lithium toxicity such as frailty could contribute to negative outcomes. Given these high mortality figures for this group, discussions on restarting lithium following high levels may need to focus more on the priorities for the patient. Further studies looking at the outcomes of restarting and discontinuing lithium and comparing with those who have not experienced elevated levels would be helpful.

After reading this paper, the reader will be aware of:

1. (1) Recent developments in the classification and diagnosis of personality disorder leading to the conceptualisation of subthreshold presentations.

2. (2) The feasibility of conducting a primary care intervention for individuals with emotional intensity difficulties.

3. (3) The preliminary beneficial outcomes of utilising a primary care intervention for individuals with emotional intensity difficulties.

4. (4) Potential issues for participants and providers of primary care programmes with future direction for improvement and implementation.

To describe epidemiologic and genomic characteristics of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in a large skilled-nursing facility (SNF), and the strategies that controlled transmission.

This cohort study was conducted during March 22–May 4, 2020, among all staff and residents at a 780-bed SNF in San Francisco, California.

Contact tracing and symptom screening guided targeted testing of staff and residents; respiratory specimens were also collected through serial point prevalence surveys (PPSs) in units with confirmed cases. Cases were confirmed by real-time reverse transcription–polymerase chain reaction testing for SARS-CoV-2, and whole-genome sequencing (WGS) was used to characterize viral isolate lineages and relatedness. Infection prevention and control (IPC) interventions included restricting from work any staff who had close contact with a confirmed case; restricting movement between units; implementing surgical face masking facility-wide; and the use of recommended PPE (ie, isolation gown, gloves, N95 respirator and eye protection) for clinical interactions in units with confirmed cases.

Of 725 staff and residents tested through targeted testing and serial PPSs, 21 (3%) were SARS-CoV-2 positive: 16 (76%) staff and 5 (24%) residents. Fifteen cases (71%) were linked to a single unit. Targeted testing identified 17 cases (81%), and PPSs identified 4 cases (19%). Most cases (71%) were identified before IPC interventions could be implemented. WGS was performed on SARS-CoV-2 isolates from 4 staff and 4 residents: 5 were of Santa Clara County lineage and the 3 others were distinct lineages.

Early implementation of targeted testing, serial PPSs, and multimodal IPC interventions limited SARS-CoV-2 transmission within the SNF.