Psychiatrists should investigate their patients less

Summary Psychiatrists often order investigations such as blood tests, neuroimaging and electroencephalograms for their patients. Rationales include ruling out ‘organic’ causes of psychiatric presentations, providing baseline parameters before starting psychotropic medications, and screening for general cardiometabolic health. Hospital protocols often recommend an extensive panel of blood tests on admission to a psychiatric ward. In this Against the Stream article, we argue that many of these investigations are at best useless and at worst harmful: the yield of positive findings that change clinical management is extremely low; special investigations are a poor substitute for a targeted history and examination; and incidental findings may cause anxiety and further unwarranted investigation. Cognitive and cultural reasons why over-investigation continues are discussed. We conclude by encouraging a more targeted approach guided by a thorough bedside clinical assessment.

Can using the functional resonance analysis method, as an intervention, improve patient safety in hospitals?: a stepped wedge design protocol

Background Healthcare professionals are sometimes forced to adjust their work to varying conditions leading to discrepancies between hospital protocols and daily practice. We will examine the discrepancies between protocols, ‘Work As Imagined’ (WAI), and daily practice ‘Work As Done’ (WAD) to determine whether these adjustments are deliberate or accidental. The discrepancies between WAI and WAD can be visualised using the Functional Resonance Analysis Method (FRAM). FRAM will be applied to three patient safety themes: risk screening of the frail older patients; the administration of high-risk medication; and performing medication reconciliation at discharge. Methods A stepped wedge design will be used to collect data over 16 months. The FRAM intervention consists of constructing WAI and WAD models by analysing hospital protocols and interviewing healthcare professionals, and a meeting with healthcare professionals in each ward to discuss the discrepancies between WAI and WAD. Safety indicators will be collected to monitor compliance rates. Additionally, the potential differences in resilience levels among nurses before and after the FRAM intervention will be measured using the Employee Resilience Scale (EmpRes) questionnaire. Lastly, we will monitor whether gaining insight into differences between WAI and WAD has led to behavioural and organisational change. Discussion This article will assess whether using FRAM to reveal possible discrepancies between hospital protocols (WAI) and daily practice (WAD) will improve compliance with safety indicators and employee resilience, and whether these insights will lead to behavioural and organisational change. Trial registration Netherlands Trial Register NL8778; https://www.trialregister.nl/trial/8778. Registered 16 July 2020. Retrospectively registered.

Peri conceptional association of the triad of hyperhomocsteinemia, hypothyroidism and impaired carbohydrate metabolism with recurrent pregnancy loss

Background: Recurrent pregnancy loss is a cause of great concern to the affected couple as well as the treating physician. We evaluated the periconceptional association of the triad of hyperhomocystienemia, hypothyroidism, and impaired carbohydrate metabolism with RPL and to identify the potential risk factors for RPL which are probably nutritional.Methods: Seven hundred ninety-six consecutive pregnancies with two or more abortions referring to our Infertility clinic were selected to be studied in a descriptive, prospective observational study in 2012-2014. All the pregnant women were subjected to routine blood tests/ examination/ imaging as per hospital protocols. All underwent TSH, FT4, GTT 75 gm (fasting and 2 h postprandial) as per routine antenatal workup. Additionally, fasting plasma homocysteine, antinuclear antibody, anti phospholipid antibody, anti- thyroid peroxidase antibody tests were performed for patients with RPL. All the patients were studied for the triad of hypothyroidism, hyperhomocysteinemia and impaired carbohydrate metabolism.Results: The incidence of RPL was found to be 5.65 %. Majority of women (51.1%) were in the age group 30-34 years. Majority of the women (55.6%) had 2 previous abortions. Majority of women (57.7%) had conceived normally. Majority of women (46.7%) had BMI<25. PCOS was reported in 28.9% women. HHcy, hypothyroidism and impaired carbohydrate metabolism was found in 78%, 73% and 73% women, respectively. The presence of two factors was reported in 60 to 65% women. 56% women reported the presence of the triad. About 7% of the patients underwent repeat abortion in second trimester of which 66.6% had the association of triad.Conclusions: Investigating these three factors in patients with RPL would help in early recognition, monitoring, and aggressive surveillance, which will help prevent obstetric complications. Simple nutritional correction may allow for better maternal and fetal programming and appropriate risk modulation.

Hospital-associated functional decline and possible interventions based on physical activity, a review of the literature

Hospital functional impairment is defined as the loss of the ability to perform at least one of the basic activities of daily living with respect to the baseline situation of the person (2 weeks before the onset of acute illness). Its prevalence has been increasing due to the demographic transition of the last few years, which has caused aging to become a challenge with great impact on the health of people, their families and the health system. One of the main consequences of the increase in hospitalizations in the elderly is hospital functional impairment. This condition has multiple consequences in the short, medium and long term, which include increased hospital stay, increased costs of care, increased morbidity and mortality, among others. One of the stages of hospital functional impairment, which corresponds to the functional decline during hospitalization, is modifiable; hence the importance of identification and timely management to intervene at risk patients. Among the interventions that are proposed to deal with this condition are specialized geriatric care, comprehensive management with a multidisciplinary team, nutritional support and physical activity. The latter has been shown to have beneficial effects on physical, cognitive and neuropsychiatric symptoms in the elderly; Therefore, it has been included in multiple hospital protocols as the main non-pharmacological intervention to reduce dependence and impact on functional hospital deterioration.The objective of this literature review is to describe the definition, epidemiology, risk factors, complications, factors associated with functional recovery and intervention programs described for the treatment. Additionally, describe the interventions that include physical activity in elderly patients hospitalized for acute pathologies and possible functional outcomes in this population.

Prospective practice survey of management of cetuximab-related skin reactions

Purpose Evidence-based guidelines on how to prevent or treat cetuximab-related skin reactions are lacking and multiple care and management strategies are used. The main purpose of the present study is to gain information about the different skincare products being used against skin reactions in metastatic colorectal cancer (mCRC) and recurrent/metastatic (R/M) or locally advanced (LA) squamous cell cancer of the head and neck (SCCHN) patients treated with cetuximab. Methods An open-label, prospective observational study conducted in the Netherlands. The occurrence of skin reactions and the care and management options taken were documented for 16 weeks, starting from the first administration of cetuximab. Results A total of 103 patients were included in 7 hospitals. 38 patients (37%) developed a grade ≥ 2 skin reaction. Eighty-six patients could be analysed for the primary endpoint (73.3% males, mean age 62.4 years, n = 44 LA SCCHN, n = 16 R/M SCCHN, n = 26 mCRC). The most frequently used skin products at some point during the observation period were moisturizing products (70%), systemic antibiotics (64%), topical antibiotics (58%), lipid-regenerating (28%) and other topical products (28%). The overall use of products gradually increased from baseline to week 6–10, reducing by week 16. Hospital protocols were the primary reason (> 50%) for choice of the skincare products and medications. Conclusion A variety of skin care products and antibiotics were commonly used. Only few patients developed severe cutaneous reactions. For patients, the occurrence of skin reactions did not influence their willingness to continue cetuximab therapy.

Midazolam, Etomidate, Propofol, Fentanyl, Ketamine, and Propofol/Ketamine for Procedural Sedation and Analgesia Among Adults in the Emergency Departments: A Systematic Review

: The current systematic review aimed at investigating different medications commonly used for procedural sedation and analgesia (PSA) in emergency departments (EDs) for adults. The articles related to the subject of interest were searched in five electronic databases, including Google Scholar, PubMed, Medline, Web of Science, Scopus, and Embase, up to 2019. The blinded, randomized, controlled, clinical trials comparing common PSA medications, including midazolam, etomidate, propofol, fentanyl, ketamine, and ketofol, among the adults undergoing PSA in EDs were included in the study. The search process resulted in the inclusion of 35 papers in the study. The main information, including clinical features, sedation duration, recovery time, and incidence of adverse events, was extracted from the selected studies. Based on the reviewed studies, various combinations of medications are used for PSA depending on the hospital protocols and policies; however, there is still controversy over the best choice. As the results of the retrieved articles indicated, propofol is the most common medication used for PSA in EDs due to the shorter time of induction, rapid recovery of consciousness, and fewer side effects. Etomidate and ketamine were also identified as other common sedatives applied for PSA.

Multisystem Inflammatory Syndrome in Children: Survey of Early Hospital Evaluation and Management

Background: In the absence of evidence-based therapies for Multisystem Inflammatory Syndrome in Children (MIS-C), we aimed to describe the similarities and differences in the evaluation and treatment of MIS-C at hospitals in the United States. Methods: We conducted a cross-sectional survey from June 16 to July 16, 2020 of U.S. pediatric hospitals regarding protocols for patients with MIS-C. Elements included hospital characteristics, clinical definition of MIS-C, evaluation, treatment, and follow-up. We summarized key findings and compared results from centers that had treated >5 patients vs. those that had treated <5 patients. Results: Forty centers of varying size and experience with MIS-C participated. About half (21/40) of centers required only 1 day of fever for MIS-C to be considered. In the evaluation of patients, there was often a tiered approach. Intravenous immunoglobulin was the most widely used medication to treat MIS-C (98% of centers). Corticosteroids were listed in 93% of protocols for primarily the moderate or severe cases. Aspirin was commonly used including for mild cases, whereas heparin or low molecular weight heparin were used primarily in severe cases. In severe cases, anakinra and vasopressors were frequently recommended. Nearly all centers (39/40) recommended follow up with cardiology. There were similar findings between centers that had treated >5 patients vs. those that had treated <5 patients. A supplement containing hospital protocols is provided. Conclusion: There are many similarities yet some key differences between hospital protocols for MIS-C. These findings can help healthcare providers learn from others regarding options for managing MIS-C patients.

Simple thrombin-based method for eliminating fibrinogen interference in serum protein electrophoresis of haemodialysed patients

Introduction: Serum samples of haemodialysed patients collected through vascular access devices, e.g. central venous catheter (CVC) can contain residual heparin, which can cause incomplete clotting and consequently fibrinogen interference in serum protein electrophoresis (SPE). We hypothesized that this problem may be overcome by addition of thrombin and aimed to find a simple thrombin-based method for fibrinogen interference removal. Materials and methods: Blood samples of 51 haemodialysed patients with CVC were drawn through catheter into Clot Activator Tube (CAT) and Rapid Serum Tube Thrombin (RST) vacutainers (Becton Dickinson, New Jersey, USA) following the routine hospital protocols and analysed with gel-electrophoresis (Sebia, Lisses, France). Samples were redrawn in the CAT tubes and re-analysed after being treated with thrombin using two methods: transferring CAT serum into RST vacutainer and treatment of CAT serum with fibrinogen reagent (Multifibren U, Siemens, Marburg, Germany). Results: Direct blood collection in RST proved to be slightly more efficient than CAT in removing the interfering band in beta fraction (CAT removed 6/51 and RST removed 12/51, P = 0.031). Transferring CAT serum into the RST vacutainer proved to be more efficient for subsequent removal of interfering band from CAT serum than the addition of fibrinogen reagent (39/45 vs. 0/45 samples with efficiently removed interfering band, P &lt; 0.001). Conclusion: Fibrinogen interference caused by incomplete clotting because of residual heparin can be overcome by addition of thrombin. Transferring CAT serum into the RST vacutainer was the most efficient method.