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Neuropsychiatric Manifestations of Arteriovenous Malformation: A Case of Acute Mania.
No full textCurrent literature shows very few case reports about manic symptoms arising in patients with arteriovenous malformations and no other predisposing factors, where these cases presented with mania before the initiation of treatment. We report a rare case of a 46-year-old male patient, with a history of a left arteriovenous malformation (AVM) status post radiation treatment with associated seizures, who presented to the emergency department of a local hospital with acute mania and other behavioral changes. The patient had manic symptoms, including mood lability, impulsivity, insomnia, decreased appetite, jealous delusions, pressured speech, and suicidal ideations. The patient\u27s escitalopram dose for depression was reduced from 20 mg to 10 mg, and valproate was started during admission. After a three-day hospital admission, his psychiatric symptoms gradually improved. He was subsequently discharged home with additional instructions to follow up with his neurologist. In this case report, we show that organic manic disorder should be considered in any manic patient who presents outside the usual age of onset for idiopathic manic-depressive disease, lacks a family or personal history of affective disturbance, or exhibits concomitant neurologic deficits. In addition, we emphasize that distinguishing between primary psychiatric conditions and those secondary to medical causes for patients who present with acute mania can significantly impact the care a patient receives and can make a difference in their psychiatric and medical prognosis
Understanding the Complexity of Early-Onset Dementia.
No full textDementia, particularly Alzheimer\u27s disease, affects millions globally, with its prevalence increasing notably with age. Early-onset Alzheimer\u27s disease, however, affects individuals under 65 years old. Unfortunately, diagnosing dementia in patients under 65 years old is quite challenging and is often delayed, missed, or wrong. Thus, we present the case of a 60-year-old female, with a medical history of hypothyroidism and presumed dementia on donepezil, who presented to the emergency department for agitation, dramatic change in personality and behavior, as well as cognitive decline that started in her late 50s. We discuss the importance of performing a thorough history and physical examination, as well as a comprehensive workup for patients who present with dramatic changes in behavior due to the wide range of potential diagnoses. While certain reversible causes, such as hypothyroidism, nutritional deficiencies, and polypharmacy, can be promptly identified and treated, chronic neurocognitive disorders such as Alzheimer\u27s disease demand a timely evaluation for early multidisciplinary treatment to enhance patient outcomes
Urinary Retention Following Methamphetamine and Cannabis Abuse in a 33-Year-Old Male.
No full textUrinary retention is described as an inability to voluntarily empty the bladder, with potential etiologies including mechanical obstruction and neurologic dysfunction. Abused substances like methamphetamine and cannabis can induce this dysfunction. We report a case about a patient with no prior psychiatric history with concomitant methamphetamine and cannabis use, presenting with an acute delirious state and urinary retention. Due to the multifactorial nature and acuity of a patient\u27s presentation, clinicians should be aware of the potential for substance abuse to impact bladder function and consider this in patients who present with urinary symptoms, including urinary retention
Does the timing of oral feeding affect the fistulization risk among head and neck cancer patients undergoing free flap reconstruction?
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Evaluation of a clinical decision support alert to identify hepatic dysfunction and need for medication therapy adjustment in hospitalized patients.
No full textDISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
PURPOSE: To optimize the hepatic dysfunction alert tool at our institution to identify appropriate patients and minimize irrelevant alerts.
METHODS: This single-center, retrospective review included adults hospitalized over a 1-month period for whom a hepatic dysfunction alert fired for a medication order placed in the electronic health record. The existing alert determines hepatic dysfunction based on laboratory tests. The primary objective was to determine the proportion of patients with an alert that was deemed to be clinically relevant. Alerts were considered relevant if the patient had a Child-Pugh score in class B or C and were ordered a medication with a hepatic warning from FDA or LiverTox. The performance of 14 alternative models was evaluated.
RESULTS: A total of 1,541 alerts fired for 309 patients. Of these patients, 155 were randomly selected for the analysis, and the alert was deemed relevant in 86 patients (55%). Patients with relevant alerts were more likely to have documented liver disease and worsening measures on liver function tests. Of the alternative models evaluated, a model that excluded INR and albumin resulted in a 27% decrease in the number of alerts fired, of which 73% were relevant; however, it failed to identify 30% of patients with relevant hepatic dysfunction. None of the other models performed better.
CONCLUSION: The existing hepatic dysfunction clinical decision support tool correctly identifies patients with relevant hepatic dysfunction only 55% of the time. Alternative models were able to improve the rate of relevant results, but not without missing patients with relevant hepatic dysfunction
Sarcopenia Exacerbates Liver-Related Complications in Patients with Cirrhosis and Hepatic Encephalopathy: A Nationwide Analysis Highlighting Inpatient Outcomes and Gender Differences
No full textBackground: Sarcopenia, characterized by the loss of skeletal muscle mass and strength, is a common clinical manifestation among patients with cirrhosis. Sarcopenia may exacerbate hepatic encephalopathy due to altered pathophysiological mechanisms of ammonia metabolism. This study aimed to investigate the impact of sarcopenia on liver-related complications and outcomes in patients with encephalopathy secondary to cirrhosis using a nationwide inpatient database. Methods: A retrospective analysis was conducted using data from the National Inpatient Sample (NIS) database from 2016 to 2020. Patients with a principal diagnosis of encephalopathy in the setting of liver cirrhosis were identified using ICD-10 codes. The study population was divided into two groups: those with and without sarcopenia. Primary outcomes included inpatient mortality and the prevalence of cirrhosis-related complications. Multivariable regression analyses were performed, adjusting for demographics and confounders. Results: Among 115,335 hepatic encephalopathy hospitalizations, 165 (0.14%) had a diagnosis of sarcopenia. Sarcopenic patients had significantly higher odds of developing spontaneous bacterial peritonitis (OR 2.89, 95% CI 1.05-7.96), portal venous thrombosis (PVT) (OR 3.39, 95% CI 1.28-9.00), ascites (OR 2.92, 95% CI 1.48-5.76), varices with and without bleeding (OR 3.36, 95% CI 1.49-7.54), non-bleeding varices (OR 2.75, 95% CI 1.23-6.18), needing transjugular intrahepatic portosystemic shunt (OR 10.68, 95% CI 2.42-47.00), and have liver failure (OR 4.88, 95% CI 2.27-10.49) compared to non-sarcopenic patients (Table 1). Although sarcopenic patients had lower odds of inpatient mortality (OR 0.15, 95% CI 0.15-0.16), the association was not statistically significant (p = 0.072). Sarcopenic patients also had a longer average length of stay and higher total hospital charges. Moreover, there is a higher proportion of males among patients with sarcopenia (72.7%) compared to those without sarcopenia (59.5%). Conversely, the proportion of females is lower in the sarcopenia group (27.3%) compared to the non-sarcopenia group (40.5%). Conclusion: This nationwide retrospective study revealed that sarcopenia is associated with a significantly higher prevalence of liver-related complications in patients with cirrhosis and hepatic encephalopathy, especially males. These findings underscore the importance of identifying and managing sarcopenia in patients with hepatic encephalopathy to potentially improve outcomes and reduce the risk of complications
Initiation of a Skills-Based Boot Camp Orientation for Incoming OB/GYN Resident Physicians
Get PDFBackground: Residency orientations are often focused on administrative obligations and less often focused on program-specific skills training. Introduction of these skills during the orientation period has been shown to improve resident confidence and proficiency. The purpose of this quality improvement project is to propose the introduction of a skills-focused portion of orientation in a condensed “boot camp” fashion to improve the transition to residency from medical school.
Methods: The skills-based orientation curriculum was developed by reviewing the Accreditation Council for Graduate Medical Education (ACGME) milestones and prior literature on the topic. The simulations were planned using resident and faculty collaboration. A pre- and post-orientation survey was created to evaluate skill improvement after completing orientation. The survey was completed in 2023 and 2024 by the incoming resident classes. A paired T-test was performed for data analysis of the survey results with a two-tailed p-value \u3c 0.05 considered significant.
Results: There were 10 participants in the orientation boot camp with a 100% completion rate of the pre- and post-orientation surveys. Overall, 14/25 questions noted statistically significant improvement during the orientation period. The most noticeable advances were in tasks that had dedicated sessions focused on an isolated skill. There were marked improvements in resident comfort level with interpreting fetal heart rate tracings (p=0.0095), placing a fetal scalp electrode (p=0.0005), and inserting an intrauterine device (IUD) or Nexplanon (p=0.0019 and 0.0012, respectively). Sessions where multiple skills were covered in one session did not yield significant results.
Conclusion: Adding the boot camp to orientation served as an effective way to improve the procedural abilities and clinical acumen of incoming residents. Given the success of this program among the OB/GYN residency at Reading Hospital, other surgical and procedural-based residency programs may benefit from implementation of a skills-based boot camp as part of their standard orientation curriculum
Prediction Models for Successful External Cephalic Version: An Updated Systematic Review.
No full textPURPOSE: To review the decision aids currently available or being developed to predict a patient\u27s odds that their external cephalic version (ECV) will be successful.
METHODS: We searched PubMed/MEDLINE, Cochrane Central, and ClinicalTrials.gov from 2015-2022. Articles from a pre-2015 systematic review were also included. We selected English-language articles describing or evaluating models (prediction rules) designed to predict an outcome of ECV for an individual patient. Acceptable model outcomes included cephalic presentation after the ECV attempt and whether the ECV ultimately resulted in a vaginal delivery. Two authors independently performed article selection following PRISMA 2020 guidelines. Since 2015, 380 unique records underwent title and abstract screening, and 49 reports underwent full-text review. Ultimately, 17 new articles and 8 from the prior review were included. Of the 25 articles, 22 proposed 1-2 models each for a total of 25 models, while the remaining 3 articles validated prior models without proposing new ones.
RESULTS: Of the 17 new articles, 10 were low, 6 moderate, and 1 high risk of bias. Almost all articles were from Europe (11/25) or Asia (10/25); only one study in the last 20 years was from the USA. The models found had diverse presentations including score charts, decision trees (flowcharts), and equations. The majority (13/25) had no form of validation and only 5/25 reached external validation. Only the Newman-Peacock model (USA, 1993) was repeatedly externally validated (Pakistan, 2012 and Portugal, 2018). Most models (14/25) were published in the last 5 years. In general, newer models were designed more robustly, used larger sample sizes, and were more mathematically rigorous. Thus, although they await further validation, there is great potential for these models to be more predictive than the Newman-Peacock model.
CONCLUSION: Only the Newman-Peacock model is ready for regular clinical use. Many newer models are promising but require further validation
Cost Effectiveness Analyses of Preimplantation Genetic Testing.
No full textCapsule: A systematic review of cost-effectiveness analyses regarding pre-implantation genetic testing reveals a growing, heterogeneous body of literature not uniformly adhering to recommended reporting guidelines