Phentermine is a sympathomimetic amine that the U.S Food and Drug Administration has approved for short-term use in the treatment of obesity. However, there have been case reports of phentermine being associated with neuropsychiatric symptoms, and thus caution is needed to avoid drug-drug interactions when prescribing phentermine (Nathan PJ, et al. CNS Neurosci Ther 2011;17:490-505) We present a case of phentermine-induced psychosis that could have been precipitated after being co-prescribed with fluoxetine.

To discuss a case of phentermine-induced psychosis that could have been precipitated by CYP3A4 inhibition of phentermine by fluoxetine.

Miss X is a 61-year-old female with a history of major depressive disorder, generalized anxiety disorder, obesity, and rheumatoid arthritis. Her psychiatric symptoms were stable with oral fluoxetine 60 mg daily, oral aripiprazole 2mg daily, oral amitriptyline 100mg at night, and oral lorazepam 1mg daily. Miss X was prescribed oral phentermine 15mg daily for appetite suppression for weight loss. Subsequently, she started developing paranoid delusions against her family members, generalized anxiety, increased psychomotor activity, decreased appetite, and decreased sleep. Her symptoms continued to worsen even after discontinuing her medications on the 7th day. Miss X was eventually brought to the emergency room on the 14th day as her symptoms continued to deteriorate and she could not take care of herself.

Miss X’s symptoms resolved after a dose of Intramuscular injection of 2mg of lorazepam. No signs of serotonin syndrome were present during the examination. Drug-drug interaction between phentermine and fluoxetine is suspected to be a causative factor in the precipitation of psychosis as fluoxetine can inhibit the CYP3A4 metabolism of phentermine. Her electrocardiogram also demonstrated prolonged QTc (470ms), which could have been precipitated by co-prescribing phentermine and amitriptyline. Miss X was admitted to the inpatient psychiatric unit, and oral fluoxetine 60mg daily, oral aripiprazole 2mg daily, and oral lorazepam 1mg daily were restarted. Due to QTc prolongation oral trazodone 50mg daily was started instead of amitriptyline. After her psychiatric symptoms were stable on the medication regimen, Miss X was discharged on the third day of admission to the inpatient psychiatric unit.

Our case demonstrates the caution needs to be taken when prescribing phentermine not only for its neuropsychiatric side-effects but also for drug-drug interactions.

None Declared

Despite several treatment strategies for treatment-resistant depression (TRD) exist, including the use of repetitive transcranial magnetic stimulation (rTMS), new therapeutic options are being introduced. Text4Support is a form of cognitive behavior therapy that allows patients with depression to receive daily supportive text messages that seek to correct or alter negative thought patterns through positive reinforcement. Text4Support is deemed a useful augmentation treatment strategy for patients with TRD. It is however currently unknown if adding the Text4Support intervention will enhance patients with TRD’s response to rTMS treatments

This study aims to assess the initial comparative clinical effectiveness of rTMS when used with and without the Text4Support program as an innovative patient-centered intervention for the management of participants diagnosed with TRD.

This study is a multicentered prospective, parallel-design, two-arm, rater-blinded randomized controlled pilot trial. In total, 200 participants diagnosed with TRD will be randomized to one of two treatment arms (rTMS alone and rTMS with Text4Support). Participants in each arm will be made to complete evaluation measures at baseline, 1,3, and 6 months. The primary outcome measure will be the mean change to scores on the Hamilton Depression Rating Scale. Patient service utilization data and clinician-rated measures will also be used to gauge patient progress. Patient data will be analyzed with descriptive statistics, repeated measures, and correlational analyses.

The result of the study is expected to be available 18 months after the start of recruitment. We hypothesize that participants enrolled in the rTMS plus Text4Support intervention will achieve superior outcomes compared with participants enrolled in the rTMS treatment alone.

The concomitant application of the combination of these two treatment techniques has not been investigated previously. Therefore, we hope that this project will provide a concrete base of data to evaluate the practical application and efficacy of using a novel combination of these two treatment modalities.

None Declared

Patients with unbalanced common atrioventricular canal can be difficult to manage. Surgical planning often depends on pre-operative echocardiographic measurements. We aimed to determine the added utility of cardiac MRI in predicting successful biventricular repair in common atrioventricular canal.

We conducted a retrospective cohort study of children with common atrioventricular canal who underwent MRI prior to repair. Associations between MRI and echocardiographic measures and surgical outcome were tested using logistic regression, and models were compared using area under the receiver operator characteristic curve.

We included 28 patients (median age at MRI: 5.2 months). The optimal MRI model included the novel end-diastolic volume index (using the ratio of left ventricular end-diastolic volume to total end-diastolic volume) and the left ventricle–right ventricle angle in diastole (area under the curve 0.83, p = 0.041). End-diastolic volume index ≤ 0.18 and left ventricle–right ventricle angle in diastole ≤ 72° yield a sensitivity of 83% and specificity of 81% for successful biventricular repair. The optimal multimodality model included the end-diastolic volume index and the echocardiographic atrioventricular valve index with an area under the curve of 0.87 (p = 0.026).

Cardiac MRI can successfully predict successful biventricular repair in patients with unbalanced common atrioventricular canal utilising the end-diastolic volume index alone or in combination with the MRI left ventricle–right ventricle angle in diastole or the echocardiographic atrioventricular valve index. A prospective cardiac MRI study is warranted to better define the multimodality characteristic predictive of successful biventricular surgery.

Alterations in heart rate (HR) may provide new information about physiological signatures of depression severity. This 2-year study in individuals with a history of recurrent major depressive disorder (MDD) explored the intra-individual variations in HR parameters and their relationship with depression severity.

Data from 510 participants (Number of observations of the HR parameters = 6666) were collected from three centres in the Netherlands, Spain, and the UK, as a part of the remote assessment of disease and relapse-MDD study. We analysed the relationship between depression severity, assessed every 2 weeks with the Patient Health Questionnaire-8, with HR parameters in the week before the assessment, such as HR features during all day, resting periods during the day and at night, and activity periods during the day evaluated with a wrist-worn Fitbit device. Linear mixed models were used with random intercepts for participants and countries. Covariates included in the models were age, sex, BMI, smoking and alcohol consumption, antidepressant use and co-morbidities with other medical health conditions.

Decreases in HR variation during resting periods during the day were related with an increased severity of depression both in univariate and multivariate analyses. Mean HR during resting at night was higher in participants with more severe depressive symptoms.

Our findings demonstrate that alterations in resting HR during all day and night are associated with depression severity. These findings may provide an early warning of worsening depression symptoms which could allow clinicians to take responsive treatment measures promptly.

Underrepresented researchers face more challenges than their well-represented counterparts. Perseverance and consistency of interest are associated with career success in well-represented physicians. Therefore, we examined associations of perseverance and consistency of interest with Clinical Research Appraisal Inventory (CRAI), science identity, and other factors related to career success among underrepresented post-doctoral fellows and early-career faculty.

This is a cross-sectional analysis of data collected from September to October 2020 among 224 underrepresented early-career researchers at 25 academic medical centers in the Building Up Trial. We used linear regression to test associations of perseverance and consistency of interest scores with CRAI, science identity, and effort/reward imbalance (ERI) scores.

The cohort is 80% female, 33% non-Hispanic Black, and 34% Hispanic. The median perseverance and consistency of interest scores were 3.8 (25th–75th percentile: 3.7,4.2) and 3.7 (25th–75th percentile: 3.2, 4.0), respectively. Higher perseverance was associated with a higher CRAI score (β = 0.82; 95% CI = 0.30, 1.33, p = 0.002) and science identity (β = 0.44; 95% CI = 0.19, 0.68, p = 0.001). Higher consistency of interest was associated with a higher CRAI score (β = 0.60; 95% CI = 0.23, 0.96, p = 0.001) and higher science identity score (β = 0.20; 95% CI = 0.03, 0.36, p = 0.02), while lower consistency of interest was associated with imbalance favoring effort (β = –0.22; 95% CI = –0.33, –0.11, p = 0.001).

We found that perseverance and consistency of interest are related to CRAI and science identity, indicating that these factors may positively influence one’s decision to stay in research.

Neuropsychiatric disorders are common in 22q11.2 Deletion Syndrome (22q11DS) with about 25% of affected individuals developing schizophrenia spectrum disorders by young adulthood. Longitudinal evaluation of psychosis spectrum features and neurocognition can establish developmental trajectories and impact on functional outcome.

157 youth with 22q11DS were assessed longitudinally for psychopathology focusing on psychosis spectrum symptoms, neurocognitive performance and global functioning. We contrasted the pattern of positive and negative psychosis spectrum symptoms and neurocognitive performance differentiating those with more prominent Psychosis Spectrum symptoms (PS+) to those without prominent psychosis symptoms (PS−).

We identified differences in the trajectories of psychosis symptoms and neurocognitive performance between the groups. The PS+ group showed age associated increase in symptom severity, especially negative symptoms and general nonspecific symptoms. Correspondingly, their level of functioning was worse and deteriorated more steeply than the PS− group. Neurocognitive performance was generally comparable in PS+ and PS− groups and demonstrated a similar age-related trajectory. However, worsening executive functioning distinguished the PS+ group from PS− counterparts. Notably, of the three executive function measures examined, only working memory showed a significant difference between the groups in rate of change. Finally, structural equation modeling showed that neurocognitive decline drove the clinical change.

Youth with 22q11DS and more prominent psychosis features show worsening of symptoms and functional decline driven by neurocognitive decline, most related to executive functions and specifically working memory. The results underscore the importance of working memory in the developmental progression of psychosis.

The goal of the Patient-Centered Outcomes Research Partnership was to prepare health care professionals and researchers to conduct patient-centered outcomes and comparative effectiveness research (CER). Substantial evidence gaps, heterogeneous health care systems, and decision-making challenges in the USA underscore the need for evidence-based strategies.

We engaged five community-based health care organizations that serve diverse and underrepresented patient populations from Hawai’i to Minnesota. Each partner nominated two in-house scholars to participate in the 2-year program. The program focused on seven competencies pertinent to patient-centered outcomes and CER. It combined in-person and experiential learning with asynchronous, online education, and created adaptive, pragmatic learning opportunities and a Summer Institute. Metrics included the Clinical Research Appraisal Inventory (CRAI), a tool designed to assess research self-efficacy and clinical research skills across 10 domains.

We trained 31 scholars in 3 cohorts. Mean scores in nine domains of the CRAI improved; greater improvement was observed from the beginning to the midpoint than from the midpoint to conclusion of the program. Across all three cohorts, mean scores on 52 items (100%) increased (p ≤ 0.01), and 91% of scholars reported the program improved their skills moderately/significantly. Satisfaction with the program was high (91%).

Investigators that conduct patient-centered outcomes and CER must know how to collaborate with regional health care systems to identify priorities; pose questions; design, conduct, and disseminate observational and experimental research; and transform knowledge into practical clinical applications. Training programs such as ours can facilitate such collaborations.

Many patients with Fontan physiology are unable to achieve the minimum criteria for peak effort during cardiopulmonary exercise testing. The purpose of this study is to determine the influence of physical activity and other clinical predictors related to achieving peak exercise criteria, signified by respiratory exchange ratio ≥ 1.1 in youth with Fontan physiology.

Secondary analysis of a cross-sectional study of 8–18-year-olds with single ventricle post-Fontan palliation who underwent cardiopulmonary exercise testing (James cycle protocol) and completed a past-year physical activity survey. Bivariate associations were assessed by Wilcoxon rank-sum test and simple regression. Conditional inference forest algorithm was used to classify participants achieving respiratory exchange ratio > 1.1 and to predict peak respiratory exchange ratio.

Of the n = 43 participants, 65% were male, mean age was 14.0 ± 2.4 years, and 67.4% (n = 29) achieved respiratory exchange ratio ≥ 1.1. Despite some cardiopulmonary exercise stress test variables achieving statistical significance in bivariate associations with participants achieving respiratory exchange ratio > 1.1, the classification accuracy had area under the precision recall curve of 0.55. All variables together explained 21.4% of the variance in respiratory exchange ratio, with peak oxygen pulse being the most informative.

Demographic, physical activity, and cardiopulmonary exercise test measures could not classify meeting peak exercise criteria (respiratory exchange ratio ≥ 1.1) at a satisfactory accuracy. Correlations between respiratory exchange ratio and oxygen pulse suggest the augmentation of stroke volume with exercise may affect the Fontan patient’s ability to sustain high-intensity exercise.

Outpatient antimicrobial therapy (OPAT) is managed by a variety of teams, but primarily through an infectious disease clinic. At our medical center, OPAT monitoring is performed telephonically by pharmacists through a collaborative practice agreement under the supervision of an infectious disease physician. The effect of telephonic monitoring of OPAT by pharmacists on patient outcomes is unknown.

This retrospective cohort study was conducted between July 2017 and July 2018 at a 350-bed academic medical center and included adult patients discharged home on IV antibiotics or oral linezolid. The experimental group comprised patients discharged with a consultation for the OPAT management program, whereas the control group comprised patients discharged home without a consultation. The primary outcome was 30-day readmission.

In total, 399 patients were included: 243 patients in the OPAT management program group and 156 patients in the control group. The 30-day readmission rates were similar in each cohort (20% vs 19%; P = .8193); however, the 30-day readmission rates were lower in the OPAT management program for patients discharged on vancomycin (19.4% vs 39.1%; P = .004).

We did not find a difference in 30-day readmissions between patients receiving pharmacy-driven OPAT management services and those who did not. Patients receiving vancomycin via OPAT had lower 30-day readmissions when included in the pharmacist-driven OPAT management program. Institutions with limited resources may consider reserving OPAT management services for patients receiving antimicrobials that require pharmacokinetic dosing and/or close monitoring.