Identify implantable cardioverter defibrillator (ICD) patients at risk of distress (i.e., depression, anxiety, and ICD concerns) and associated risk factors.First-time ICD patients (n = 1503) from the Danish national DEFIB-WOMEN study completed questionnaires at baseline, 3, 6, 12 and 24 months.Of patients with low scores on distress, only 4%–7.2% experienced an increase in distress during 24 months of follow-up (FU), while 30.5%–52.5% with increased levels were likely to maintain increased levels at FU. Higher education, higher age, female sex, and good physical functioning at baseline were associated with less depression, anxiety and ICD concerns at FU. Previous psychological problems, smoking, Type D personality, NYHA class III-IV – all assessed at baseline – and shocks during FU were associated with depression, anxiety and ICD concerns.Generally, patients' psychological health improved, but patients with increased baseline scores were more likely to have increased scores at FU. We need to be vigilant if patients report elevated distress, particularly if they have depression at baseline, as depression seems more persistent. Given the impact of depression on health-related quality of life and prognosis, they should be screened and monitored closely.

BACKGROUND:A growing literature demonstrates the value of the proactive consultation-liaison psychiatry model for health care systems through reductions in hospital length of stay. Few studies include financial outcomes. OBJECTIVE:We evaluated the return on investment of a 1-year proactive consultation-liaison psychiatry pilot in a hospital medicine unit. METHODS:We used a pre-post method with an active comparison of three hospital medicine units with regular psychiatric consultation on demand. We staffed the pilot unit with one full-time psychiatrist who focused on early case finding, close communication with unit staff, frequent follow-up visits, and proactive discharge planning. We assessed the 1-year change in mean length of stay for all patients receiving psychiatric consultation, from which we estimated the direct contribution margin from bed-backfills and the program's return on investment. RESULTS:On the pilot unit, the percent of discharges that received psychiatric consultation increased from 7.34% to 13.79%, and the length of stay for patients who consulted declined by a mean of 1.82 days (P < 0.05), as compared to an increase of 0.15 days (P > 0.05) on the usual-care units. The pilot unit reduction in length of stay saved 451.71 days in total, allowing for 73.81 bed-backfills, a direct contribution margin of $419,343 (95% confidence interval, $50,754 to $787,933), a net direct contribution margin of $298,245 (-$70,344 to $666,835), and an return on investment of 132% (-31% to 295%). CONCLUSION:This study strengthens existing evidence for the relative cost-effectiveness of proactive consultation-liaison psychiatry for hospital medicine compared with usual psychiatric consultation on demand.

Leave passes provide authorized leave for hospitalized patients from a psychiatric inpatient unit. Although providing day passes was once a relatively common practice, there are relatively few data describing their safety and efficacy. This descriptive study examines the use of leave passes in an adult inpatient unit at a university hospital between 2017 and 2021, with attention to reasons for granting the day pass, duration, and outcome of the pass. During the study period, 10 patients with primary psychotic or mood disorders received 12 passes for housing coordination, COVID-19 vaccination, or major family events. There were no fatalities or abscondments. One patient experienced severe agitation and engaged in nonsuicidal self-injurious behavior. A second patient showed mild, redirectable psychomotor agitation upon return to the unit. The remaining 10 passes were uneventful. Our findings support the view that patients with diverse diagnoses can safely be provided leave from an inpatient setting with adequate planning and support, yielding a low incidence of adverse events.

Abstract Leave passes provide authorized leave for hospitalized patients from a psychiatric inpatient unit. Although providing day passes was once a relatively common practice, there are relatively few data describing their safety and efficacy. This descriptive study examines the use of leave passes in an adult inpatient unit at a university hospital between 2017 and 2021, with attention to reasons for granting the day pass, duration, and outcome of the pass. During the study period, 10 patients with primary psychotic or mood disorders received 12 passes for housing coordination, COVID-19 vaccination, or major family events. There were no fatalities or abscondments. One patient experienced severe agitation and engaged in nonsuicidal self-injurious behavior. A second patient showed mild, redirectable psychomotor agitation upon return to the unit. The remaining 10 passes were uneventful. Our findings support the view that patients with diverse diagnoses can safely be provided leave from an inpatient setting with adequate planning and support, yielding a low incidence of adverse events.

Pancreatic cancer has been noted to be associated with psychiatric illnesses, mostly anxiety or depression. As a disease with considerable mortality, additional manifestations that can lead to further morbidity need to be considered. We present a case of a 66-year-old male with stage IV pancreatic adenocarcinoma and no previous psychiatric history who developed worrisome behavior and mood change in the setting of his cancer characterized by impulsivity, insomnia, irritability, and paranoia. This caused significant impairment for the patient and difficulty for his family. He was treated successfully with risperdal consta, risperidone, lithium, and trazodone, needing only risperdal consta and trazodone once behaviorally stabilized. Pancreatic cancer can be associated with new onset mania and should be considered in such patients.

Introduction: This study compares rates of depression, suicidal ideation, and burnout among resident/fellow and attending physicians in orthopaedic surgery to other specialties during height/end of the first wave of the coronavirus disease 2019 (COVID-19) pandemic at our institution. Main outcomes and measures included suicidal ideation, Patient Health Questionnaire for Depression (PHQ-9) scores for depression, and 2 single-item measures for emotional exhaustion and depersonalization. This study provides valuable information regarding orthopaedic surgeon mental health during world crises. Methods: This is a cross-sectional survey-based study of resident, fellow, and attending physicians from 26 specialties during and after the first wave of the COVID-19 pandemic at our institution from April 24, 2020 to May 15, 2020. The survey contained 22 items. This includes consent, demographics and general data, 2 single-item questions of emotional exhaustion and depersonalization, and the PHQ-9. Subjects were eligible if they were a resident/fellow or attending physician at our institution. Results: The response rate for the study was 16.31%. Across all specialties rates were 6.2% depression, 19.6% burnout, and 6.6% suicidal ideation. The results for orthopaedic surgeons are as follows: 0% tentative diagnosis of depression, 3.8% suicidal ideation, and 4% burnout. Anesthesiology had the highest rate of depression (14.3%). Internal medicine and other non-surgical specialties had the highest rate of suicidal ideation (10.2%). Orthopaedic surgeons were significantly more likely to achieve work–life balance and experience less burnout than anesthesiologists and pediatricians. Discussion: Depression, suicidal ideation, and burnout continue to affect physicians across all specialties. These issues are amplified in light of crisis. Job satisfaction and rigorous training may be protective factors that allow orthopaedic surgeons to adapt to novel clinical settings under stress when compared to anesthesiologists and pediatricians. Resilience training and stress management strategies should continue to be investigated to better prepare physicians for world crises.

Objectives Frontline workers have been a bulwark in the fight against COVID-19, while being subject to major unexpected stressors. These include conflicting news, evolving guidelines, perceived inadequate personal protective equipment, overflow of patients with rising death counts, absence of disaster training, and limitations in the implementation of social distancing. This study investigates the incidence and associated factors of depression, suicidal thoughts, and burnout among physicians during the COVID-19 pandemic. Methods In a cross-sectional survey-based study of resident, fellow, and attending physicians from a tertiary university hospital during the height of the COVID-19 pandemic in New York from April 24 to May 15, 2020, demographics and practice specialty, attending vs. resident/fellow status, call frequency, emotional exhaustion, depersonalization, and depression severity were examined. Results Two hundred twenty-five subjects completed the survey (response rate of 16.3%), with rates of 6.2% depression, 6.6% suicidal ideation, and 19.6% burnout. Depression, suicidal ideation, and burnout were all associated with history of prior depression/anxiety and frequency of on call. Suicidal ideation and burnout were also associated with younger age. There was no difference in rates of depression, suicidal ideation, or burnout between attending and resident physicians. Female physicians reported less work-life balance and more burnout. Conclusions These findings highlight the importance of considering physician mental health during times of peak stress, such as natural or man-made disasters. The prominence of premorbid depression/anxiety as a relevant factor underscores the need to further understand physician mental health and provide early screening and treatment.

IntroductionMany patients admitted to hospitals with acute trauma have positive serum blood alcohol levels. Published associations between alcohol use, injury patterns, and outcomes are inconsistent. We sought to further delineate the impact of alcohol use and alcohol withdrawal on hospital outcomes amongst acute trauma patients.MethodsWe performed a retrospective analysis of adult trauma patients hospitalized at a suburban level 1 trauma center between January 2015 and September 2019 with a blood alcohol level measurement and/or classification as alcohol withdrawal syndrome (AWS). Patients were separated into three groups: BAL ≤10 mg/dL, BAL >10 mg/dL, and alcohol withdrawal syndrome (AWS).ResultsOverall, 3896 patients met study criteria with 75.6% BAL ≤10, 23.2% BAL >10, and 1.2% AWS. The median age was significantly different (BAL ≤ 10: 59 years, BAL > 10: 44 years, AWS: 53.5 years). Alcohol withdrawal was experienced by patients with BAL ≤10 and BAL >10. While injury severity and mortality were similar across all 3 groups, AWS patients experienced significantly longer hospital and ICU lengths of stay, unplanned ICU admission, need for mechanical ventilation, and higher rates of complications. Patients with AWS had high rates of acute neuropsychiatric symptoms, complicating their management.ConclusionsExcept for mortality, AWS patients experienced worse outcomes. The complex nature of alcohol withdrawal cases, including the possibility of developing AWS despite a negative BAL on admission, emphasizes the need for early assessment for alcohol withdrawal risk factors and input from specialists.

Background: Medical directors need management skills, yet few studies describe the specific tasks that directors consider most important, their confidence for these tasks, and how their confidence develops. We studied these questions among directors in the subspecialty of Consultation-Liaison Psychiatry. Methods: A needs survey was sent to 48 registrants of a new forum for Consultation-Liaison Psychiatry directors. The survey asked about 6 professional experiences, the relative importance of 14 management tasks, and the directors' confidence in managing these tasks, using 7-point Likert scales. Correlations between experiences, task importance, and task confidence were performed. Results: Twenty-seven directors responded (56% response). The experiences that correlated most with management confidence were years in practice and health care leadership training, yet approximately half of responders were directors for <= 5 years and had received minimal training. Management tasks with the highest importance included demonstrating value of their service and roles for nonphysician clinical staff on their teams. Significant associations were identified between years in practice and confidence for leading faculty scholarship, trainee staffing ratios and roles, fee coding, measurement of faculty clinical productivity, and faculty recruitment. Leadership training correlated with confidence in demonstrating service value, measuring faculty clinical productivity, novel models of care, and growing a new service. Conclusion: Consultation-Liaison directors with fewer years of experience and minimal health care management training need time and support to grow into their roles. They should be pointed toward training opportunities to improve their confidence to lead the wide range of management tasks that are important to their roles.

Background: Psychiatric comorbidity is highly prevalent in general medicine inpatient settings and is associated with increased duration and cost of hospitalization. Objective: To evaluate the impact of integrated, proactive psychiatric care on hospital medicine length of stay (LOS), expanding upon methods from earlier studies. Methods: A full-time psychiatrist was dedicated to a single hospital medicine unit to focus on early case finding and intensified treatment, interdisciplinary communication, and discharge planning. To a pre post intervention design, we added a simultaneous usual care comparison. We also added adjustments for age, sex, insurance type, and whether the patient was discharged home or to a facility. We included a sensitivity analysis to remove outliers for whom LOS was <= 30 days. Results: Statistically significant differences in LOS occurred on the pilot unit in the pre post analysis (-1.66 d, P = 0.04) and on the pilot versus control units in the intervention year (-1.91 d, P = 0.003). The differential pre-post change in LOS on the pilot versus control units revealed a positive trend but was not statistically significant (-1.59 d, P = 0.14). This more rigorous test approached statistical significance when patients with LOS >30 days were excluded (-1.15 d, P = 0.07). Conclusion: This analysis strengthens existing evidence that dedicated, proactive psychiatric services integrated into hospital medicine units lower LOS more than does usual psychiatric consultation upon request, particularly in patients with an LOS <= 30 days.

Background: The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) is an assessment tool used to quantify alcohol withdrawal syndrome (AWS) severity and inform benzodiazepine treatment for alcohol withdrawal. Objectives: To evaluate the prescribing patterns and appropriate use of the CIWA-Ar protocol in a general hospital setting, as determined by the presence or absence of documented AWS risk factors, patients' ability to communicate, and provider awareness of the CIWA-Ar order. Methods: This retrospective chart review included 118 encounters of hospitalized patients placed on a CIWA-Ar protocol during one year. The following data were collected for each encounter: patient demographics, admitting diagnosis, ability to communicate, and admission blood alcohol level; and medical specialty of the clinician ordering CIWA-Ar, documentation of the presence or absence of established AWS risk factors, specific parameters of the protocol ordered, service admitted to, provider documentation of awareness of the active protocol within 48h of initial order, total benzodiazepine dose equivalents administered and associated adverse events. Results: 57% of patients who started on a CIWA-Ar protocol had either zero or one documented risk factor for AWS (19% and 38% respectively). 20% had no documentation of recent alcohol use. 14% were unable to communicate. 19% of medical records lacked documentation of provider awareness of the ordered protocol. Benzodiazepine associated adverse events were documented in 15% of encounters. Conclusions: The judicious use of CIWA-Ar protocols in general hospitals requires mechanisms to ensure assessment of validated alcohol withdrawal risk factors, exclusion of patients who cannot communicate, and continuity of care during transitions.

Department of Psychiatry SUNY Stony Brook University Hospital Stony Brook, NY [email protected] Consult and Liaison Psychiatry SUNY Stony Brook University Hospital Stony Brook, NY Department of Psychiatry SUNY Stony Brook University Hospital Stony Brook, NY

Cognitive impairment is now recognized as a frequent consequence of treatments for cancers localized outside the central nervous system (CNS). In contrast, little attention has been given to the potentially deleterious cognitive effects from non-CNS cancers themselves. The present case study proposes that cognitive deficits occur in a subset of treatment-naïve patients with diffuse large B-cell lymphoma in whom no gross evidence of lymphoma-related CNS involvement is apparent. Evidence is presented from a case study and elaborate putative mechanisms centering on deleterious effects of B-cell-mediated inflammatory cytokine secretion on neurons. Moreover, this case study speculates that genetic variability involving apolipoprotein E or other factors may mediate cognitive variability among these patients.

interval (CI) 5 7.18–9.96, coefficient of variation (r) 5 0.98). Although MRSA and CDAD hospitalization incidences each rose (slopes for the linear trends 5 2.63, 95% CI 5 1.71–3.55, r 5 0.91 and 5.69, 95% CI 5 4.69– 6.70, r 5 0.98, respectively), PA and Candida remained essentially unchanged over this time frame (Table 1). Although VRE incidence remained constant between 2000 and 2003, it began to rise in 2004 and continued for the rest of the time examined, with a slope for the linear trend between 2003 and 2006 of 0.59 (95% CI 5 0.28–0.90, r 5 0.97). Comparisons between age groups revealed that the cross-sectional incidence in people aged 85 and older was nearly twice that in those aged 65 to 84 in any of the years examined and that the longitudinal growth in those aged 85 and older outpaced that in those aged 65 to 84 by nearly a factor of two, with slopes for linear trends of 12.33 (95% CI 5 8.87–15.76) and 7.30 (95% 5 CI 6.08–8.52), respectively. Despite limitations inherent in administrative data, this study demonstrated a large and increasing volume of hospitalizations with resistant infections in elderly people in the United States between 2000 and 2006, and people aged 85 and older contributed disproportionately to this volume. The overall crude rate of growth in resistant hospitalizations in elderly people was an alarming 10% per annum. If this average rate of growth should continue along with the anticipated demographic shifts, by 2020, there may be 2.7 million annual hospitalizations with resistant pathogens in this population, a volume roughly equal to the total volume experienced within the entire time frame covered by this study. Given the magnitude of the issue, there is an urgent need to advance understanding of evidence-based prevention strategies of this major public health threat.

Back to table of contents Previous article Next article Letter to the EditorFull AccessNeuroleptic Malignant Syndrome and Low-Dose OlanzapineHESTER SUH, B.S., BRIAN BRONSON, M.D., and ROBERT MARTIN, M.D., HESTER SUHSearch for more papers by this author, B.S., BRIAN BRONSONSearch for more papers by this author, M.D., and ROBERT MARTINSearch for more papers by this author, M.D., Woodside, N.Y.Published Online:1 Apr 2003https://doi.org/10.1176/appi.ajp.160.4.796AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Neuroleptic malignant syndrome is a rare yet potentially fatal adverse reaction generally associated with typical neuroleptics (1). Some case reports describe neuroleptic malignant syndrome associated with olanzapine, an atypical neuroleptic, at high doses or when combined with other neuroleptics (2–5). We report on a patient taking a low dose of olanzapine who developed neuroleptic malignant syndrome. Upon his recovery, neuroleptic malignant syndrome recurred after olanzapine was restarted.Mr. A, an 86-year-old man with an 8-month history of dementia with paranoia, was successfully treated for several months with olanzapine, 5 mg/day, until signs of parkinsonism led to a dose decrease to 2.5 mg/day. Two months later, when the daytime temperature was 96°F, he came to the hospital with uncontrollable shaking, confusion, a temperature of 105.6°F, and significant cogwheel rigidity. Paramedics believed his apartment’s temperature had exceeded 110°F. His admission and 2-hour blood pressures were notable for fluctuation: 110/72 mm Hg and 162/62 mm Hg, respectively. The results of laboratory tests included an aspartate aminotransferase level of 72 U/liter (normal=10–47), a creatinine kinase level of 1184 U/liter (normal=45–230), and a mildly elevated cardiac isoenzyme level of 39 U/liter (normal=0–6), with a relative index of 3.3 (normal=0–2.5). Mr. A was diagnosed with myocardial infarction, and olanzapine was suspended, given presumptive neuroleptic malignant syndrome.By hospital day 5, Mr. A’s tremors had resolved, his cogwheel rigidity had minimized, his alertness had improved, his temperature had returned to normal, his creatinine kinase level had decreased to 245 U/liter, and his aspartate aminotransferase level had returned to normal. That night, he was rechallenged with one dose of olanzapine, 2.5 mg. The next morning, he was shaking vigorously, his temperature was 100.6°F, and he was notably more rigid. Olanzapine was discontinued, and his temperature again returned to normal, his tremor disappeared, and his cogwheel rigidity decreased substantially. His creatinine kinase level returned to normal, and he was treated with quetiapine, 25 mg/day, for several days with no signs of neuroleptic malignant syndrome.This case differs from prior reports of neuroleptic malignant syndrome with olanzapine in that the olanzapine dose was notably lower and olanzapine was not given with other dopamine-blocking agents. The rechallenge symptoms also strengthen the association. Dehydration is a possible risk factor for neuroleptic malignant syndrome, and the overheated apartment may have contributed to it (1). It is unlikely that the patient’s symptoms can be attributed to heatstroke, which generally is seen with hypotension and limb flaccidity—not fluctuating blood pressure and rigidity (1). Furthermore, the myocardial infarction does not account for the increased skeletal muscle breakdown, rigidity, tremors, fever, or rechallenge exacerbation. Clinicians should be aware that neuroleptic malignant syndrome can occur with low doses of olanzapine and that extremes of heat may precipitate such cases.References1. Jeste DV, Naimark D: Medication-induced movement disorders, in Psychiatry, 1st ed. Edited by Tasman A, Kay J, Lieberman JA. Philadelphia, WB Saunders, 1997, pp 1334-1350Google Scholar2. Philibert RA, Adam LA, Frank FM, Carney-Doebbeling C: Olanzapine usage associated with neuroleptic malignant syndrome. Psychosomatics 2001; 42:528-529Crossref, Medline, Google Scholar3. Hickey C, Stewart C, Lippmann S: Olanzapine and NMS (letter). Psychiatr Serv 1999; 50:836-837Link, Google Scholar4. Apple JE, Van Hauer G: Neuroleptic malignant syndrome associated with olanzapine therapy (letter). Psychosomatics 1999; 40:267-268Crossref, Medline, Google Scholar5. Stanfield SC, Privette T: Neuroleptic malignant syndrome associated with olanzapine therapy: a case report. J Emerg Med 2000; 19:355-357Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited bySchizophrenia and Related Psychoses2 December 2021Journal of Clinical Pharmacy and Therapeutics, Vol. 42, No. 4Neuroleptic malignant syndrome and its controversies19 March 2010 | Pharmacoepidemiology and Drug Safety, Vol. 19, No. 5Schizophrenia8 March 2013Medication and substance-induced disorders3 January 2013Neuroleptic Malignant Syndrome: No Longer Exclusively a “Neuroleptic” Phenomenon3 August 2016 | Journal of Pharmacy Technology, Vol. 21, No. 5Psychotic Behavior Associated with Opioids in Elderly Patients Montelukast-Induced Hepatotoxicity Neuroleptic Malignant Syndrome and Low-Dose Olanzapine Visual Hallucinations with Zonisamide Thrombotic Complications Associated with IV Immunoglobulin Therapy20 July 2017 | Hospital Pharmacy, Vol. 38, No. 6Pharmacoepidemiology and Drug Safety, Vol. 12, No. 7 Volume 160Issue 4 April 2003Pages 796-796 Metrics PDF download History Published online 1 April 2003 Published in print 1 April 2003

New York University Medical Center; New York, New York 10016 (Bronson) Manhattan Psychiatric Center; New York University Medical Center; New York, New York (Lindenmayer)