Gender difference in QTc prolongation of people with mental disorders

Background

We examined gender difference in QTc interval distribution and its related factors in people with mental disorders.

Methods

We retrospectively reviewed medical charts of patients discharged from a university psychiatric unit between November 1997 and December 2000. Subjects were 328 patients (145 males and 183 females) taking psychotropics at their admission. We examined patient characteristics, medical history, diagnosis, and medication before admission.

Results

Mean QTc interval was 0.408 (SD = 0.036). QTc intervals in females were significantly longer than those in males. QTc of females without comorbidity was significantly longer than that of males.

Conclusion

The influence of gender difference on QTc prolongation in people with mental disorders merits further research.

     

Clinical Relevance of Steroid Use in Neuro-Oncology

Background

Corticosteroids are commonly used in the management of primary central nervous system (CNS) tumors and CNS metastases to treat cancer- and treatment-related cerebral edema and improve neurologic function. However, they are also associated with significant morbidity and mortality, given their wide range of adverse effects.

Purpose of Review

To review the mechanism of action, pharmacology, and toxicity profile of corticosteroids and to critically appraise the evidence that supports their use in neuro-oncologic practice based on the latest scientific and clinical data.

Recent Findings

Recent data suggest that corticosteroids may negatively impact survival in glioma patients. In addition, corticosteroids should be incorporated as a standard criterion to assess a patient’s clinical and radiographic response to treatment.

Summary

Corticosteroids should be used judiciously in neuro-oncologic patients, given the potential deleterious effects on clinical outcome and patient survival. Anti-angiogenic agents, which lack these adverse effects, may be a reasonable alternative to corticosteroids.

     

Cancer Care Coordination: a Systematic Review and Meta-Analysis of Over 30 Years of Empirical Studies

Background

According to a landmark study by the Institute of Medicine, patients with cancer often receive poorly coordinated care in multiple settings from many providers. Lack of coordination is associated with poor symptom control, medical errors, and higher costs.

Purpose

The aims of this systematic review and meta-analysis were to (1) synthesize the findings of studies addressing cancer care coordination, (2) describe study outcomes across the cancer continuum, and (3) obtain a quantitative estimate of the effect of interventions in cancer care coordination on service system processes and patient health outcomes.

Methods

Of 1241 abstracts identified through MEDLINE, EMBASE, CINAHL, and the Cochrane Library, 52 studies met the inclusion criteria. Each study had US or Canadian participants, comparison or control groups, measures, times, samples, and/or interventions. Two researchers independently applied a standardized search strategy, coding scheme, and online coding program to each study. Eleven studies met the additional criteria for the meta-analysis; a random effects estimation model was used for data analysis.

Results

Cancer care coordination approaches led to improvements in 81 % of outcomes, including screening, measures of patient experience with care, and quality of end-of-life care. Across the continuum of cancer care, patient navigation was the most frequent care coordination intervention, followed by home telehealth; nurse case management was third in frequency. The meta-analysis of a subset of the reviewed studies showed that the odds of appropriate health care utilization in cancer care coordination interventions were almost twice (OR = 1.9, 95 % CI = 1.5–3.5) that of comparison interventions.

Conclusions

This review offers promising findings on the impact of cancer care coordination on increasing value and reducing healthcare costs in the USA.

     

Physician Power to Declare Death by Neurologic Criteria Threatened

Background

Three recent lawsuits that address declaration of brain death (BD) garnered significant media attention and threaten to limit physician power to declare BD.

Methods

We discuss these cases and their consequences including: the right to refuse an apnea test, accepted medical standards for declaration of BD, and the irreversibility of BD.

Results

These cases warrant discussion because they threaten to: limit physicians’ power to determine death; incite families to seek injunctions to continue organ support after BD; and force hospitals to dispense valuable resources to dead patients in lieu of patients with reparable illnesses or injuries.

Conclusions

Physicians, philosophers, religious officials, ethicists, and lawyers must work together to address these issues and educate both the public and medical community about BD.

     

Takotsubo Cardiomyopathy in Traumatic Brain Injury

Background

Takotsubo cardiomyopathy (TC) is a well-known complication after aneurysmal subarachnoid hemorrhage and has been rarely described in patients with traumatic brain injury (TBI).

Methods

Case report and review of literature.

Results

Here, we report a 73-year-old woman with mild traumatic brain injury (TBI) presenting in cardiogenic shock. Takotsubo cardiomyopathy (TC) was diagnosed by repeated echocardiography. Cardiovascular support by inotropic agents led to hemodynamic stabilization after initiation of levosimendan. Cardiac function fully recovered within 21 days. We performed an in-depth literature review and identified 16 reported patients with TBI and TC. Clinical course and characteristics are discussed in the context of our patient.

Conclusion

Takotsubo cardiomyopathy is under-recognized after TBI and may negatively impact outcome if left untreated.

     

Transsphenoidal meningoencephalocele associated with cleft lip and palate: challenges for diagnosis and surgical treatment

Purpose

The aim of this study was to highlight the challenges for early diagnosis and the difficulties observed in surgical treatment of patients with transsphenoidal meningoencephalocele associated with cleft lip and/or palate.

Method

We evaluated six male patients treated over the course of 4 years. Five patients presented encephalic herniation with nonfunctional brain tissue; one of these presented herniation of the pituitary gland and cerebral ventricles.

Results

All the patients received surgical treatment for the cleft lip and/or palate. Only one patient underwent repair of the meningoencephalocele, via nasal endoscopy. There were no postprocedural clinical or surgical complications.

Conclusion

The tendency is to avoid neurosurgery, opting for periodic follow-up with magnetic resonance imaging. In the presence of cleft palate, palatoplasty is essential to protect the meningoencephalocele.

     

Dementia Care at End of Life: Current Approaches

Purpose of Review

Dementia is a progressive and life-limiting condition that can be described in three stages: early, middle, and late. This article reviews current literature on late-stage dementia.

Recent Findings

Survival times may vary across dementia subtypes. Yet, the overall trajectory is characterized by progressive decline until death. Ideally, as people with dementia approach the end of life, care should focus on comfort, dignity, and quality of life. However, barriers prevent optimal end-of-life care in the final stages of dementia.

Summary

Improved and earlier advanced care planning for persons with dementia and their caregivers can help delineate goals of care and prepare for the inevitable complications of end-stage dementia. This allows for timely access to palliative and hospice care, which ultimately improves dementia end-of-life care.

     

Factors that influence access to mental health services in South-Eastern Europe

Introduction

Access to mental health (MH) services is unequal worldwide and changes are required in this respect.

Objectives

Our aim was to identify the delay to the first psychiatry consult and to understand patients’ characteristics and perspectives on the factors that may influence the delay, among a sample of participants from three Southeastern European Countries.

Materials and methods

The WHO Pathway Encounter Form questionnaire was applied in 400 patients “new cases” and a questionnaire on the factors influencing the access was administered to the same patients, as well as to their caretakers and MH providers.

Result and discussions

The average profile of the patient “new case” was: married female older than 40 years, with an average economic status and no MH history. The mean delay was up to 3 months and the most important factors that were influencing the delay were stigma and lack of knowledge regarding MH problems and available current treatments.

Conclusions

Future policies trying to improve the access to psychiatric care should focus on increasing awareness about MH problems in the general population.

     

A Self-Regulatory Intervention for Patients with Head and Neck Cancer: Pilot Randomized Trial

Background

Research is yet to investigate whether psychological interventions delivered early after diagnosis can benefit patients with head and neck cancer (HNC).

Purpose

The aim of this study was to investigate the effectiveness of a brief self-regulatory intervention (targeting illness perceptions and coping) at improving HNC patient health-related quality of life (HRQL).

Methods

A pilot randomized controlled trial was conducted, in which 64 patients were assigned to receive three sessions with a health psychologist in addition to standard care or standard care alone. Participants completed questionnaires assessing HRQL, general distress, and illness perceptions at baseline and again 3 and 6 months later.

Results

Compared to the control group, patients who received the intervention had increased treatment control perceptions at 3 months (p = .01), and increased social quality of life at 6 months (p = .01). The intervention was particularly helpful for patients exhibiting distress at baseline.

Conclusion

A brief psychological intervention following HNC diagnosis can improve patient perceptions of treatment and social quality of life over time. Such interventions could be targeted to patients who are distressed in order to confer the greatest benefit.

Trial Registration Number

12614000813684.

     

Coping strategies in caregivers of disorders of consciousness patients

Objective

The management of patients with disorders of consciousness (DOC) has raised several important ethical, social, and medical issues. It is also known that families and caregivers are subjected to physical and emotional load due to their assistance activity. The aim of this observational study was to compare distress and coping strategies used among caregivers of two kinds of DOC: vegetative state (VS) and minimally conscious state (MCS).

Methods

We have enrolled 80 caregivers (mean age 47.87?±?11–28 years) that were tested with self-administered measures of distress and coping to individuate which coping strategies were adopted by caregivers of DOC patients and to analyze how these have influenced the degree of distress.

Results

Data showed that the reaction to stress was different between two groups of caregivers (VS and MCS); moreover, it may vary according to the coping strategies used.

Conclusion

Results showed the importance to develop effective coping strategies aimed to reduce psychological distress and improving caregiver’s well-being.

     

A thoracic spinal bone giant cell tumor in a skeletally immature girl. A case report and literature review

Purpose

Giant cell tumors (GCT) are benign primary bone tumors, locally aggressive, affecting in long bones in young adults during the third decade. It is rare to experience this lesion in skeletally immature patients. GCT are related to a risk of local recurrence and malignant transformation.

Method

We report a rare case of a giant cell tumor of the thoracic spine in a skeletally immature girl presenting with a painful right scoliosis.

Results

MRI, CT scan, and bone scintigraphy were discordant and the percutaneous biopsy non-contributive.

Conclusion

A marginal “en bloc” resection was performed and revealed the GCT. Based on a literature review, the diagnosis and the surgical management of this case are discussed.

     

Serum anti-JCV antibody indexes in Japanese patients with multiple sclerosis: elevations along with fingolimod treatment duration

Background

The risk of developing progressive multifocal leukoencephalopathy in natalizumab-treated multiple sclerosis (MS) patients is related to serum anti-JCV antibody (JCVAb) index. However, the correlation of JCVAb index with other disease-modifying treatments (DMTs) is not well understood.

Objective

In this study, we investigated the JCVAb seropositivity rate/JCVAb indexes and its correlation with clinical profiles in Japanese MS patients, and the relationship between JCVAb indexes and DMTs.

Methods

JCVAb indexes were measured in 149 serum samples from 105 patients with MS. JCVAb indexes and seropositivity, and their correlation with age, sex, disease duration, Kurtzke expanded disability status scale and the duration of the DMTs were evaluated in each patient.

Results

JCVAb was positive in 73 of 105 MS patients. Within 40 fingolimod-treated patients, 27 were positive for JCVAb and JCVAb indexes were positively correlated with the duration of fingolimod treatment. No significant relation was found between JCVAb indexes and the duration of treatment for the other disease-modifying drugs.

Conclusion

JCVAb seropositivity was comparatively high in Japanese MS patients. Fingolimod treatment is likely to increase serum JCVAb index, possibly leading to the development of PML. Therefore, it is advised that JCVAb index should be serially monitored during fingolimod treatment to decrease PML risk.

     

Transition of Children with Neurological Disorders

Purpose of the Review

The goal of the article is to describe a systematic approach through core principles and steps for the transition of the patient with a neurological disorder to the adult model of care, to provide steps and principles to help receiving providers successfully integrate the patient into their practice, and to discuss cultural, systemic, and discipline-based barriers to transition.

Recent Finding

The literature has expanded rapidly. The recent publications help define the barriers to the process and are currently exploring the best methods to evaluate readiness, needs, barriers, and develop solutions for best practices. There is a consensus that there is a need for a systematic approach to transition and integration of the patient with a neurological disorder.

Summary

The transition of the child and youth with special health care needs (CYSHCN) is complex with multiple barriers. An important concept is that these patients, their families, and medical care providers all benefit from a coordinated and collaborative methodology.

     

Cholinergic urticaria: epidemiology,physiopathology, new categorization,and management

Purpose

The aim of this study was to review the evidence on the epidemiology, physiopathology, categorization, and management of cholinergic urticaria. We specifically focused on several subtypes of cholinergic urticaria and investigated the relationship between cholinergic urticaria and idiopathic anhidrosis.

Methods

Using an integrative approach, we reviewed publications addressing the epidemiology, clinical features, diagnostic approach, physiopathology, subtype classification, and therapeutic approach to cholinergic urticaria.

Results

Multiple mechanisms were found to contribute to the development of cholinergic urticaria. This disorder should be classified based on the pathogenesis and clinical characteristics of each subtype. Such a classification system would lead to better management of this resistant condition. In particular, sweating function should be given more attention when examining patients with cholinergic urticaria.

Conclusions

Because cholinergic urticaria is not a homogeneous disease, its subtype classification is essential for selection of the most suitable therapeutic method.

     

A typology of satisfaction with mental health services based on Andersen’s behavioral model

Objective

Patients with mental disorders (MDs) form a highly heterogeneous group, whose satisfaction with mental health services (MHS) may vary according to different variables. Identifying patient subgroups with similar levels of satisfaction may help identify variables that contribute to satisfaction or dissatisfaction with services. This study established a typology of patient satisfaction with MHS that revealed variables specific to each group.

Methods

The study included 325 patients with MDs across four health service networks offering integrated and diversified services. Data were collected using five standardized instruments, and participant medical records. A conceptual framework was developed, based on Andersen’s Behavioral Model, which integrates socio-demographic, clinical, needs-related and service use variables. Using cluster analysis, a typology of patient satisfaction was created.

Results

Analyses yielded four patient clusters: two where levels of satisfaction were relatively high and two with lower levels of satisfaction (range 3.74–4.37). Greater care continuity and higher income related to greater patient satisfaction; whereas co-occurring MDs and substance use disorders (SUD), as well as more numerous and severe needs, characterized dissatisfied patients who were frequent users of MHS.

Conclusions

Results highlight the need for continuity of care and adequate socio-economic conditions for increasing patient satisfaction with MHS. Lower levels of satisfaction among patients with common MDs and SUDs suggest the importance of addressing their specific needs to enhance satisfaction and MH recovery.

     

Die ambulante Betreuung von Patienten mit somatisch nicht erklärten Beschwerden

Background

The aim of this study was to compare the approach of general practitioners (GP) and outpatient specialists for psychiatry, neurology or psychosomatic medicine to patients with somatically unexplained complaints.

Methods

Qualitative interviews were conducted with general practitioners in Berlin and with outpatient specialists. Interviews were analyzed by qualitative content analysis.

Results

Both GPs and specialists rarely used structured diagnostic instruments. Guidelines are seen and used with reservation throughout the different specialties. Similar to the GPs, most of the specialists surveyed in this study had reservations against the necessity of a precise coding according to the International Classification of Diseases (ICD).

Conclusion

In outpatient care the concern for the individual patient is the connecting element between different medical specialties. This results in a differential diagnostic and therapeutic approach that is not automatically in line with guidelines. The development of common concepts in ambulatory care might help to meet the demands of this complex group of patients with somatically unexplained complaints.

     

Palliative Care Consultations in the Neuro-ICU: A Qualitative Study

Background

Integration of palliative care (PC) into the neurological intensive care unit (neuro-ICU) is increasingly recommended, but evidence regarding the best practice is lacking. We conducted a qualitative analysis exploring current practices and key themes of specialist PC consultations in patients admitted to a single neuro-ICU.

Methods

We retrospectively identified all patients who were admitted to the neuro-ICU for ≥24 h and received a PC consultation between January and August 2014. We reviewed PC consultation notes and neuro-ICU progress notes from the electronic health records of these patients. We performed content analysis on the PC notes.

Results

Twenty-five neuro-ICU patients (4 %) received a PC consultation over 8 months with the most prevalent reason of clarifying goals of care. The main distinctions between patients with and those without (n = 580) a PC consultation were ICU length of stay (median 8.2 vs. 2.8 days) and death in the neuro-ICU (56 % vs. 11 %). The most prevalent themes addressed in the PC consultation notes were (1) discussing prognosis, (2) eliciting patient and family values, (3) understanding medical options, and (4) identifying conflict.

Conclusions

PC consultations in the neuro-ICU emphasize family coping and decision-making by helping discuss prognosis and exploring patient and family values as well as their ability to understand the medical information. Several features suggest that earlier integration of PC into neuro-ICU care may enhance both coping and the decision-making process.

     

Aspiration of parafalcine empyemas with flexible scope

Purpose

Subdural empyemas are considered neurosurgical emergencies, and the parafalcine location is particularly insidious. We revised the experience of general surgeons who are used to manage chronic pleural purulent collections with video-assisted thoracoscopy.

Methods

With a similar technique, we successfully aspirated a parafalcine empyema using a flexible scope avoiding a more invasive craniotomy. A review of the treatment options of empyematous collections is also provided, focusing particularly on the hazardous parafalcine location.

Results

The management of subdural empyemas poses different decision-making problems compared to common brain abscesses, urging a more rapid and holistic surgical treatment with minimally invasive approach. Endoscopic aspiration of parafalcine empyema was followed by complete recovery in our patient.

Conclusions

Flexible endoscopy is a promising method to obtain complete pus removal even from loculated collections through a bur hole, avoiding large craniotomies and consequent potential complications.