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Successful Use of Oral-Disintegrating Mirtazapine for Treatment of Major Depression in a Patient With Recurrent Intussusception and No Enteral Access 成功使用米氮平口腔崩解剂治疗一名反复肠梗阻且无肠道通路的重度抑郁症患者。
IF 2.7 4区 心理学 Q2 PSYCHIATRY Pub Date : 2024-07-01 DOI: 10.1016/j.jaclp.2024.02.002
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引用次数: 0
Addressing Issue of Fast-Tracking in Consultation-Liaison Psychiatry Fellowship Training: Expanding Access or Undermining Competence? 会诊-联络精神病学研究员培训中的快速通道问题:扩大机会还是削弱能力?
IF 2.7 4区 心理学 Q2 PSYCHIATRY Pub Date : 2024-07-01 DOI: 10.1016/j.jaclp.2024.02.008

Fast-tracking is an option for residents to pursue fellowship training in place of their final residency year. It is currently permissible to fast-track into a child and adolescent psychiatry fellowship, but this remains a controversial idea for other psychiatry subspecialties. In 2022, the Annual Meeting of the Academy of Consultation-Liaison Psychiatry featured a plenary session debate about the pros and cons of fast-tracking. Here, the authors present some of the information discussed at that session and highlight the potential benefits and pitfalls of fast-tracking into consultation-liaison psychiatry.

快速通道是指住院医师可以选择在最后一年的住院医师培训中继续接受研究员培训。目前允许快速通道进入儿童与青少年精神病学研究员培训,但对于其他精神病学亚专科来说,这仍然是一个有争议的想法。2022 年,美国会诊联络精神病学学会(ACLP)年会就快速通道的利弊展开了全会辩论。在此,作者介绍了会上讨论的一些信息,并强调了快速通道进入会诊联络(C-L)精神病学的潜在好处和隐患。
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引用次数: 0
An Observational Study of Proactive and On-Request Psychiatry Consultation Services: Evidence for Differing Roles and Outcomes 一项关于主动和应要求提供精神科咨询服务的观察研究:不同作用和结果的证据。
IF 2.7 4区 心理学 Q2 PSYCHIATRY Pub Date : 2024-07-01 DOI: 10.1016/j.jaclp.2024.03.003

Background

Proactive psychiatric consultation services rapidly identify and assess medical inpatients in need of psychiatric care. In addition to more rapid contact, proactive services may reduce the length of stay and improve staff satisfaction. However, in some settings, it is impractical to integrate a proactive consultation service into every hospital unit; on-request and proactive services are likely to coexist in the future. Prior research has focused on changes in outcomes with the implementation of proactive services.

Objective and Methods

This report describes differences between contemporary proactive and on-request services within the same academic medical center, comparing demographic and clinical data collected retrospectively from a 4-year period from the electronic medical record.

Results

The proactive service saw patients over four times as many initial admissions (7592 vs. 1762), but transitions and handoffs between services were common, with 434 admissions involving both services, comprising nearly 20% of the on-request service's total contacts. The proactive service admissions had a shorter length of stay and a faster time to first psychiatric contact, and the patients seen were more likely to be female, of Black race, and to be publicly insured. There were over three times as many admissions to psychiatry from the proactive service. The on-request service's admissions had a longer length of stay, were much more likely to involve intensive care unit services, surgical services, and transfers among units, and the patients seen were more likely to die in the hospital or to be discharged to subacute rehabilitation.

Conclusions

Overall, the results suggest that the two services fulfill complementary roles, with the proactive service's rapid screening and contact providing care to a high volume of patients who might otherwise be unidentified and underserved. Simultaneously, the on-request service's ability to manage patients in response to consult requests over a much larger area of the hospital provided important support and continuity for patients with complex health needs. Institutions revising their consultation services will likely need to consider the best balance of these differing functions to address perceived demand for services.

背景:积极主动的精神科咨询服务可以快速识别和评估需要精神科治疗的住院病人。除了更快速的联系之外,主动服务还能缩短住院时间,提高员工满意度。然而,在某些情况下,将主动咨询服务整合到每个医院科室是不切实际的;应要求提供的服务和主动服务很可能在未来并存。之前的研究主要集中在主动服务实施后的结果变化:本报告通过比较从电子病历(EMR)中回顾性收集的四年期间的人口统计学和临床数据,描述了同一学术医疗中心内当代主动服务和应要求服务之间的差异:结果发现:主动服务的患者初次入院人数是按需服务的四倍多(7592 对 1762),但服务之间的转换和交接很常见,有 434 例入院患者涉及两种服务,占按需服务总接触人数的近 20%。主动服务的入院患者住院时间较短,首次接触精神科的时间较快,而且就诊患者更可能是女性、黑人和有公共保险的人。主动服务的精神病入院人数是主动服务的三倍多。根据请求提供服务的患者住院时间更长,更有可能涉及重症监护室服务、外科手术服务和转科;就诊患者更有可能在医院死亡或出院后接受亚急性康复治疗:总之,研究结果表明,这两种服务具有互补作用,主动服务的快速筛查和联系可为大量病人提供护理,否则这些病人可能无法被识别或得不到充分护理。同时,应要求提供的服务能够在医院更大的范围内根据咨询要求管理病人,这为有复杂健康需求的病人提供了重要的支持和连续性。机构在修订其咨询服务时,可能需要考虑这些不同功能之间的最佳平衡,以满足对服务的预期需求。
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引用次数: 0
Response to Margolis et al. CL case conference: a case of factitious disorder imposed on self 对 Margolis 等人 "CL 病例会议:一例强加于自身的事实性失调 "的回应。
IF 2.7 4区 心理学 Q2 PSYCHIATRY Pub Date : 2024-07-01 DOI: 10.1016/j.jaclp.2024.03.001
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引用次数: 0
Words Matter: Why Distinguishing Medical Aid in Dying From Suicide Should Matter to a Consultation-Liaison Psychiatrist 言语很重要:为什么咨询/联络精神科医生应该重视临终医疗救助与自杀的区别?
IF 2.7 4区 心理学 Q2 PSYCHIATRY Pub Date : 2024-07-01 DOI: 10.1016/j.jaclp.2024.04.003
J. Michael Bostwick M.D., M.F.A. , Margaret Pabst Battin M.F.A., Ph.D. , Lewis Cohen M.D. , Thomas B. Strouse M.D.

As more and more American states legalize medical aid in dying (MAID), Consultation-Liaison Psychiatrists will increasingly be asked to assist medical and surgical colleagues in differentiating this end-of-life practice from suicide. Where suicide is traditionally understood as an act clouded by depression, desperation, or both, MAID represents a terminally medically ill patient's effort to take control of their dying process when death is imminent, likely to occur within 6 months, and inevitable. Rendering opinions on patient suicidality in the setting of a complex co-occurring medical illness is a Consultation-Liaison Psychiatrist's bread and butter. This paper seeks to elucidate 4 points that distinguish MAID from suicide: (1) Hastening death when the end of natural life is approaching is not synonymous with suicide in the vernacular American usage of the term. (2) Unlike suicide, MAID is a highly collaborative process in which dying, mentally capable adults involve their doctors and loved ones in legally recognized decisions to hasten death. (3) The clinical presentation of patients requesting MAID differs from that of individuals whose suicidality is driven by psychopathology. (4) Certain behavioral traits differentiate such MAID patients from suicidal ones. Understanding and applying these distinctions in the consultation-liaison arena will help remove the stigma of suicide from end-of-life care deliberations where it does not belong while ensuring appropriate end-of-life care for dying individuals for whom MAID is the culmination of a carefully considered process of self-determination rather than suicide.

随着越来越多的美国州将临终医疗协助(MAID)合法化,咨询联络精神科医生将越来越多地被要求协助内科和外科同事将这种临终做法与自杀区分开来。传统上,自杀被理解为抑郁、绝望或两者兼而有之的行为,而临终医疗协助则代表着身患绝症的病人在死亡迫在眉睫、可能在 6 个月内发生且不可避免的情况下控制自己的死亡过程。在并发复杂内科疾病的情况下,就患者的自杀倾向提出意见是会诊联络精神科医生的主要工作。本文试图阐明 MAID 与自杀的四点区别:(1)在自然生命即将结束时加速死亡,在美国人的一般用法中并不等同于自杀。(2)与自杀不同,MAID 是一个高度合作的过程,在这个过程中,濒死的、有精神能力的成年人会让他们的医生和亲人参与到法律认可的加速死亡的决定中来。(3)要求MAID的患者的临床表现不同于由精神病理学驱动的自杀者。(4) 某些行为特征将这类 MAID 患者与有自杀倾向的患者区分开来。在会诊联络领域理解并应用这些区别,将有助于在生命末期护理讨论中消除自杀的污名,因为自杀并不属于生命末期护理,同时确保为临终患者提供适当的生命末期护理,对这些患者而言,MAID 是经过深思熟虑的自我决定过程的最终结果,而不是自杀。
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引用次数: 0
Toward Globalization of Consultation-Liaison Psychiatry as a Clinical Model 将会诊-联络精神病学作为一种临床模式推向全球化。
IF 2.7 4区 心理学 Q2 PSYCHIATRY Pub Date : 2024-07-01 DOI: 10.1016/j.jaclp.2024.07.003
Hochang Benjamin Lee M.D., F.A.C.L.P.
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引用次数: 0
Physical Violence and Aggression in Parkinson's Disease: A Systematic Review 帕金森病患者的肢体暴力和攻击行为系统综述。
IF 2.7 4区 心理学 Q2 PSYCHIATRY Pub Date : 2024-07-01 DOI: 10.1016/j.jaclp.2024.01.007

Background

Physical violence and aggression (PVA), defined as behaviors with the potential to cause bodily injury, are unfortunate risks in the management of all-cause neurodegenerative dementias. While dementia in Parkinson's disease (PD) may not be evident for many years after clinical onset, neuropsychiatric disturbances occur at all stages of the disease. At issue is whether PVA in PD is associated with clinical factors that can be targets for prevention and management in the absence of a prevailing dementia syndrome.

Objective

This systematic review examined the extent to which PVA in PD without dementia is a clinically significant concern and whether it is associated with factors that could warrant proactive management.

Methods

A systematic search of 9 electronic databases used MeSH headings and equivalent terms for PD, aggression, and violence. Eligible manuscripts were original articles that were published in peer-reviewed journals and reported on adults with PD in the awake state with PVA as possible outcomes. Extracted data included study design, PD ascertainment methods and characteristics, PVA assessment methods, subject demographics, psychiatric and medical comorbidities, and pertinent results. Inciting and confounding factors were extracted from case reports. Quality assessment tools were applied in accordance with the study design (e.g., observational, qualitative, or case report).

Results

The search identified 10 manuscripts: 2 observational quantitative studies (total n with PD = 545), 1 qualitative study (n with PD = 20), and 7 case reports (n = 7). The observational studies suggested that PVA is less common than other neuropsychiatric disturbances, but heterogeneous methods and quality concerns prevented further conclusions. In the case reports, all patients were male, and most were early onset. In 6 of the reports, PVA occurred in the context of bilateral subthalamic nucleus deep brain stimulation.

Conclusions

PVA, while relatively rare in PD, can be a significant management issue that is associated with select premorbid characteristics and antiparkinsonian motor treatments. As PVA may be under-reported, further understanding of its frequency, causes, risk factors, and outcomes would benefit from its systematic assessment, ideally using self-report and informant-based questionnaires.

背景:肢体暴力和攻击行为(PVA)是指可能造成身体伤害的行为,是治疗全因性神经退行性痴呆症的不幸风险。帕金森病(Parkinson's disease,PD)的痴呆症可能在临床发病多年后才显现出来,而神经精神障碍则发生在疾病的各个阶段。目前的问题是,帕金森病中的PVA是否与临床因素有关,而这些因素在没有普遍痴呆综合征的情况下是否可以作为预防和管理的目标:本系统综述研究了无痴呆症的 PD 患者的 PVA 在多大程度上具有临床意义,以及它是否与需要积极管理的因素有关:对 9 个电子数据库进行了系统性检索,使用了 MeSH 标题和与 PD、攻击性和暴力相关的术语。符合条件的稿件是发表在同行评议期刊上的原创文章,这些文章报道了在清醒状态下患有帕金森氏症的成人的情况,PVA是可能的结果。提取的数据包括研究设计、PD确定方法和特征、PVA评估方法、受试者人口统计学特征、精神和医疗合并症以及相关结果。从病例报告中提取了诱发因素和混杂因素。根据研究设计(如观察性、定性或病例报告)使用质量评估工具:搜索共发现 10 篇手稿:2 项观察性定量研究(PD=545)、1 项定性研究(PD=20)和 7 项病例报告(N=7)。观察性研究表明,与其他神经精神障碍相比,PVA 的发病率较低,但由于研究方法不尽相同和质量问题,无法得出进一步的结论。在病例报告中,所有患者均为男性,且大多数患者发病较早。在六份报告中,PVA发生在双侧丘脑下核深部脑刺激(STN-DBS)的情况下:PVA虽然在帕金森病中相对罕见,但可能是一个重要的管理问题,与特定的病前特征和抗帕金森病运动疗法有关。由于 PVA 的报告可能不足,对其频率、原因、风险因素和结果的进一步了解将得益于对其进行系统评估,最好使用自我报告和基于信息的问卷调查。
{"title":"Physical Violence and Aggression in Parkinson's Disease: A Systematic Review","authors":"","doi":"10.1016/j.jaclp.2024.01.007","DOIUrl":"10.1016/j.jaclp.2024.01.007","url":null,"abstract":"<div><h3>Background</h3><p><span><span><span>Physical violence and aggression (PVA), defined as behaviors with the potential to cause bodily </span>injury, are unfortunate risks in the management of all-cause neurodegenerative dementias. While dementia in </span>Parkinson's disease (PD) may not be evident for many years after clinical onset, neuropsychiatric disturbances occur at all stages of the disease. At issue is whether PVA in PD is associated with clinical factors that can be targets for prevention and management in the </span>absence of a prevailing dementia syndrome.</p></div><div><h3>Objective</h3><p>This systematic review examined the extent to which PVA in PD without dementia is a clinically significant concern and whether it is associated with factors that could warrant proactive management.</p></div><div><h3>Methods</h3><p>A systematic search of 9 electronic databases used MeSH headings and equivalent terms for PD, aggression, and violence. Eligible manuscripts were original articles that were published in peer-reviewed journals and reported on adults with PD in the awake state with PVA as possible outcomes. Extracted data included study design, PD ascertainment methods and characteristics, PVA assessment methods, subject demographics, psychiatric and medical comorbidities, and pertinent results. Inciting and confounding factors were extracted from case reports. Quality assessment tools were applied in accordance with the study design (e.g., observational, qualitative, or case report).</p></div><div><h3>Results</h3><p><span>The search identified 10 manuscripts: 2 observational quantitative studies (total n with PD = 545), 1 qualitative study (n with PD = 20), and 7 case reports (n = 7). The observational studies suggested that PVA is less common than other neuropsychiatric disturbances, but heterogeneous methods and quality concerns prevented further conclusions. In the case reports, all patients were male, and most were early onset. In 6 of the reports, PVA occurred in the context of bilateral </span>subthalamic nucleus<span> deep brain stimulation.</span></p></div><div><h3>Conclusions</h3><p>PVA, while relatively rare in PD, can be a significant management issue that is associated with select premorbid characteristics and antiparkinsonian motor treatments. As PVA may be under-reported, further understanding of its frequency, causes, risk factors, and outcomes would benefit from its systematic assessment, ideally using self-report and informant-based questionnaires.</p></div>","PeriodicalId":52388,"journal":{"name":"Journal of the Academy of Consultation-Liaison Psychiatry","volume":"65 4","pages":"Pages 366-378"},"PeriodicalIF":2.7,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139681886","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"心理学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
C-L Case Conference: Assessment of Dispositional Capacity in Medically Complex Patients C-L 病例会议:评估病情复杂患者的处置能力。
IF 2.7 4区 心理学 Q2 PSYCHIATRY Pub Date : 2024-07-01 DOI: 10.1016/j.jaclp.2024.03.006

We present the case of a 76-year-old male with mild cognitive impairment and delirium who was referred to consultation-liaison psychiatry for an assessment of capacity to choose discharge. Cases involving “dispositional capacity” are complex and increasingly frequent, with momentous consequences for patients and their families, but are rarely discussed in the literature. In this article, experts in functional assessment, cognition, and ethics provide guidance for this commonly encountered clinical scenario based on their experience and available literature. We review the content and formulation of occupational and physical therapy assessments and their utility to the consultation-liaison psychiatrist. We also examine the relationship of cognitive impairment to decisional capacity and offer suggestions on a structured approach to evaluation. Finally, we discuss the ethical and systemic considerations of dispositional capacity and explore potential pitfalls that can lead to interprofessional conflict and missed opportunities in patient care.

我们介绍了一名 76 岁男性患者的病例,他患有轻度认知障碍和谵妄,被转诊至精神科会诊中心,要求对其选择出院的能力进行评估。涉及 "处置能力 "的病例非常复杂,而且越来越频繁,对患者及其家属造成了重大影响,但文献中却很少讨论。在这篇文章中,功能评估、认知和伦理学方面的专家根据他们的经验和现有文献,为这种常见的临床情况提供了指导。我们回顾了职业和物理治疗评估的内容和表述,以及它们对 CL 精神科医生的作用。我们还研究了认知障碍与决策能力之间的关系,并就结构化评估方法提出了建议。最后,我们讨论了处置能力的伦理和系统考虑因素,并探讨了可能导致跨专业冲突和错失患者护理机会的潜在隐患。
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引用次数: 0
Dextroamphetamine as Adjunctive Pharmacotherapy for Aggression Secondary to Korsakoff Syndrome: A Case Report 右旋安非他明辅助药物治疗继发于科萨科夫综合征的攻击行为:病例报告。
IF 2.7 4区 心理学 Q2 PSYCHIATRY Pub Date : 2024-07-01 DOI: 10.1016/j.jaclp.2024.02.006
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引用次数: 0
Medical and Psychiatric Characteristics of Patients Hospitalized for Severe Restrictive Eating Disorders: Analysis of 545 Consecutive Patients with Severe Anorexia Nervosa or Avoidant/Restrictive Food Intake Disorder 因严重限制性进食障碍而住院的患者的医学和精神特征。
IF 2.7 4区 心理学 Q2 PSYCHIATRY Pub Date : 2024-07-01 DOI: 10.1016/j.jaclp.2024.02.001

Background

People with severe eating and feeding disorders regularly require hospitalization due to complications inherent to their disease, though formal training regarding this care is limited.

Methods

This retrospective study included 545 patients with severe anorexia nervosa (AN) or avoidant restrictive food intake disorder hospitalized in a medical stabilization unit between 2018 and 2021. Biometrics were obtained throughout hospitalization. Nutrition was increased until patients were gaining 0.2 kg/day.

Results

Average admission body mass index was 13 kg/m2 with diagnoses of 46% AN-R (restricting), 39% AN-BP (binge-purge), and 15% avoidant restrictive food intake disorder. Average daily Kcals by discharge were 3343 for females and 3962 for males; 26% required nasogastric feeding. Hypoglycemia was common until day 7, correlated with elevated liver function tests and low prealbumin. Liver function tests were abnormal in 31% of patients. Refeeding hypophosphatemia developed in 26% of patients starting day 2 and was associated with lower body mass index. Hypokalemia appeared on admission among 39%, twice as common in patients diagnosed with AN-BP. Initial electrocardiograms were abnormal in 50% of patients, usually sinus bradycardia. Average QTc was normal, but only 14% prolonged. Bone density testing revealed 70% osteoporosis. History of suicide attempts were present in 19%, while 76% and 50% presented with anxiety and depressive disorders, respectively.

Conclusions

Given the inextricability of medical complications from severe eating and feeding disorders, familiarity among consult-liaison psychiatrists with the prevalence of frequently observed abnormal findings can inform consultation, prevent adverse events, prevent unnecessary intervention, and facilitate weight restoration and medical stabilization.

背景:严重进食和进食障碍患者因其疾病固有的并发症经常需要住院治疗,但有关这种护理的正规培训却很有限:这项回顾性研究纳入了2018年至2021年期间在医疗稳定病房住院的545名严重神经性厌食症(AN)或回避性限制性食物摄入障碍(ARFID)患者。住院期间全程采集生物计量学数据。增加营养,直到患者每天增加 0.2 千克:入院时平均体重指数(BMI)为 13 kg/m2,诊断结果为:46% AN-R(限制型)、39% AN-BP(暴饮暴食型)和 15% ARFID。出院时,女性的日均热量为 3,343 千卡,男性为 3,962 千卡;26% 的患者需要鼻饲。低血糖在第 7 天之前很常见,与肝功能检测(LFT)升高和低白蛋白有关。31% 的患者 LFT 异常。从第 2 天开始,26% 的患者出现再喂养性低磷血症,并与较低的体重指数有关。39%的患者在入院时出现低钾血症,是确诊为 AN-BP 患者的两倍。50%的患者初始心电图异常,通常为窦性心动过缓。平均 QTc 正常,只有 14% 的患者 QTc 延长。骨密度检测显示,70%的患者患有骨质疏松症。19%的患者有自杀企图,76%和50%的患者分别患有焦虑症和抑郁症:鉴于严重进食和喂养障碍的医疗并发症是不可分割的,CL 精神科医生熟悉经常观察到的异常结果的发生率可以为咨询提供参考,防止不良事件和不必要的干预,促进体重恢复和医疗稳定。
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引用次数: 0
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Journal of the Academy of Consultation-Liaison Psychiatry
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