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An Evidence-Based Update on Anticholinergic Use for Drug-Induced Movement Disorders
No full textDrug-induced movement disorders (DIMDs) are associated with use of dopamine receptor blocking agents (DRBAs), including antipsychotics. The most common forms are drug-induced parkinsonism (DIP), dystonia, akathisia, and tardive dyskinesia (TD). Although rare, neuroleptic malignant syndrome (NMS) is a potentially life-threatening consequence of DRBA exposure. Recommendations for anticholinergic use in patients with DIMDs were developed on the basis of a roundtable discussion with healthcare professionals with extensive expertise in DIMD management, along with a comprehensive literature review. The roundtable agreed that extrapyramidal symptoms is a non-specific term that encompasses a range of abnormal movements. As such, it contributes to a misconception that all DIMDs can be treated in the same way, potentially leading to the misuse and overprescribing of anticholinergics. DIMDs are neurobiologically and clinically distinct, with different treatment paradigms and varying levels of evidence for anticholinergic use. Whereas evidence indicates anticholinergics can be effective for DIP and dystonia, they are not recommended for TD, akathisia, or NMS; nor are they supported for preventing DIMDs except in individuals at high risk for acute dystonia. Anticholinergics may induce serious peripheral adverse effects (e.g., urinary retention) and central effects (e.g., impaired cognition), all of which can be highly concerning especially in older adults. Appropriate use of anticholinergics therefore requires careful consideration of the evidence for efficacy (e.g., supportive for DIP but not TD) and the risks for serious adverse events. If used, anticholinergic medications should be prescribed at the lowest effective dose and for limited periods of time. When discontinued, they should be tapered gradually
Bingo as a Novel Approach to Skill Building in the Initial Months of Surgical Internship: A Pilot Implementation
No full textINTRODUCTION: We have observed inconsistencies in residents\u27 experiences regarding important procedures and tasks necessary for patient care. We aimed to improve individual motivation to learn and become facile with specific practices earlier in the timeline of the internship years. METHODS: Intern Bingo was implemented in a single general surgery residency. Two sites, both tertiary care centers with institutional practices, were utilized. Twenty-four procedures/tasks important to clinical practice were identified, including but not limited to Nasogastric Tube placement, IV insertion, incision and drainage, laceration repair, vascular doppler exam, and clinical documentation. Bingo cards were randomly generated. To assess comprehension, interns taught back necessary components to a senior resident or attending to complete each bingo square; including indications, supplies, steps, troubleshooting techniques, and complications. First, the residents were awarded prizes to complete a row and a full card (a cloth scrub cap and portable pulse-oximeter, respectively). A Likert-scale survey assessing satisfaction was administered following the completion of the internship period. RESULTS: The first row was completed in two weeks and the first full card at four weeks. All participants finished the cards within 8 weeks. 54% of the participants returned the survey and 100% reported positive experiences. 50% felt that bingo created a healthy learning environment with improved teaching, and the remaining 50% were neutral. 75% reported that Bingo positively influenced decisions to seek out opportunities. 100% conveyed a desire to repeat Bingo as mentors. Feedback from the attendings was gathered, with positive assessments of the interns\u27 skills and confidence. CONCLUSION: Bingo is a simple and easily implemented educational tool that works to alleviate variations in experience early in the internship period. It represents a novel and effective way to motivate the interns to learn important procedures and tasks within the first two months of residency. Cards may be effortlessly tailored to a variety of residency programs and rotations
Bilateral Tonic Pupils Secondary to Anti-Gd2 Antibody Therapy for Neuroblastoma
No full textWe report the case of a 12-year-old girl with stage 4 neuroblastoma who developed tonic pupils secondary to immunotherapy with dinutuximab, an anti-GD2 antibody, based on the timeline provided by her mother with regard to onset of symptoms. The patient presented with difficulty reading and chronic dilated pupils bilaterally, according to her mother\u27s observations over 6 months prior to presentation. Testing with dilute pilocarpine supported our presumption of tonic pupils
