Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation

Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.

Categorical Medicine: a mathematical embedding of clinical medicine with applications to headache medicine.

The practice of clinical medicine, diagnosing and treating patients appear to be very different from proving mathematical theorems. Since the 1950s, category theory has been introduced as a potentially unifying theory for disparate disciplines in mathematics. Our project investigates whether it is possible to convert disease classification and iatrogenic interventions, and therefore clinical medicine, axiomatically through the application of category theory. Here we propose two ways of unifying these two seemingly disparate areas of research by interpreting clinical medicine as a mathematical category. Our models allow the practice of medicine to be interpreted from an algebraic topological fashion, thereby opening up the possibility of modeling disease phenotypes/classifications and clinical decision making as topological spaces. We also show that medication intervention and disease classification are inherently linked. We applied the above model to headache medicine as a practical example of the approach. We anticipate that our formulations can be applied to any classifiable arenas of medicine, serving as a theoretical starting point for more sophisticated modeling of clinical medicine mathematically and therefore computationally.

An audit looking at the impact of poverty on referrals to child and adolescent mental health services

AimsRecently, there has been a greater focus on how mental health in young people (YP) can be improved. Up to 10% of YP in Scotland have a diagnosable mental health condition1 and half of all adults with mental ill-health have had symptoms from their mid-teens2. Poverty is an important factor associated with poorer mental well-being from an early age which worsens if left untreated3. The aim of this audit was to answer the question: Are more YP referred from the least deprived areas, and are they more likely to require medication intervention or high intensity (tier 4) care? The results of which could help identify possible avenues for intervention to help improve retention of those most at risk of negative outcomes.MethodNHS Grampian CAMHS provides service to Aberdeen City, Aberdeenshire, and Moray. Pre-collected data over 15 months from these areas were analysed using the Scottish Index of Multiple Deprivation (SIMD) deciles to distinguish any differences between referrals made. In addition, this audit evaluated the data to define any trends of deprivation linking YP to medication intervention or tier 4 care.ResultResults showed that more referrals were made for YP in low-ranking areas (3.19% of decile one compared to 1.74% of decile ten). The referrals were also more likely to be rejected based on the referral criteria, 33% in decile one versus 21% in decile ten. The increased rejection of referrals is most likely a reflection of the health inequalities faced by communities in more deprived areas. In terms of service provision, the patients from the most deprived areas are 3 times more like to require tier 4 care while the least deprived are 1.5 times more likely as compared to percentage of population. With regards to medication intervention patients from deciles one, five, six and seven have significantly higher numbers.ConclusionThis project set out to look at the current service provided by CAMHS and found that despite best efforts deprivation has had an impact on the acceptance of referrals. Going forward this data will be shared with multiagency stakeholders to develop service provisions, in particular the issues identified with the rejection of referrals in more deprived areas. Higher level of medication use in more deprived population is not unexpected but highlights the need to share the findings with a multiagency network.

Using radiofrequency ablation for the treatment of lower limb varicose veins

Lower limb chronic venous insufficiency is a commonly seen disease which accounted for 40.5% of people over the age of 50 years old with females having 4.25 higher prevalence compared with males [23]. The lesions could be observed in superficial, perforating, deep veins or all three venous systems in the lower extremities [2]. Superficial veins in particular could be classified in 3 groups: chronic venous insufficiency, varicose veins, and thrombophlebitis. The treatment options of lower limb chronic venous insufficiency in general and chronic venous insufficiency – varicose veins are grouped in two major categories: medication/intervention and surgery. Since 1980s-1990s, endovascular interventions for the treatment of superficial venous insufficiency – varicose veins were introduced and were the new advancement in the treatment of lower limb venous insufficiency disorders [3, 7, 11, 12, 16] .

Evaluation of Carer Strain and Carer Coping with Medications for People with Dementia after Discharge: Results from the SMS Dementia Study

This study reports carer strain and coping with medications for people with dementia with an unplanned admission to hospital, and it evaluates the impact of a safe medication intervention on carer coping and carer strain. This was a quasi-experimental pre/post-controlled trial that included a survey of carers about managing medications for people with dementia after discharge. For 88 carers who completed surveys, 33% were concerned about managing medications, and 40% reported difficulties with medication management, including resistive behaviours by people with dementia. Dose administration aids were used by 72% of carers; however, only 15% reported receiving a recent home medicines review by a community pharmacist. High carer strain was reported by 74% of carers. Carer comments described many issues that contributed to high carer stress, as well as their engagement in vigilant activities to maintain medication safety. Strategies that can contribute to carers managing medications and reducing their strain include an increased use of dose administration aids, increased provision of home medicines reviews, and increased education of health professionals to provide adequate support and education about managing medications.

T174. ANTIPSYCHOTICS AND THE MICROBIOME

Background Gut microbial diversity is influenced by many factors including aging and environmental factors and it has an important implication on various physiologic functions and disease processes. Studying microbial communities and its diversity may be used as a predictor or biomarker for disease development. Methods In-depth literature review was conducted of literature within the last 5 years via database search of Pubmed, PsycInfo, EMBASE, and Google Scholar with Boolean combinations of the following keywords: antipsychotics AND (microbiome OR “metabolic syndrome”), microbiome AND (gender OR aging). Results 2,360 articles were initially retrieved. 27 articles remained after excluding for non-English articles and relevance. Notable findings include that patients treated with both risperidone and olanzapine have less diverse microbiomes with a higher ratio of Firmicutes to Bacteroidetes. Additionally, patients treated with olanzapine have been shown to have increased actinobacteria and increased ratio of Firmicutes to Bacteroidetes. The ratio of Firmicutes to Bacteroidetes correlates directly to the extent of olanzapine induced weight gain. Patients concurrently treated with olanzapine and antibiotics not only stopped weight gain but also reversed it. This has been a target of potential medication intervention, specifically focused on antagonism of histamine-1 and -3 receptors which is speculated to inhibit the askewed Firmicutes to Bacteroidetes ratio. Similarly, the gender differences in relative microbiome levels of Bacteroidetes are suspected to correlate to the increased olanzapine induced weight gain seen in women versus men. Additionally, patients with schizophrenia who were treated with Bifidobacterium breve A1, a probiotic supplement, showed improvements in their affective, positive, and negative symptoms. Discussion There is a large paucity of research into the relationship between the microbiome and psychotropic medications. This dynamic should be further studied within multiple populations to better understand the gut biome’s effects on psychiatric disorders.

Recycling N-acetylcysteine: A review of evidence for adjunctive therapy in schizophrenia

IntroductionAll symptoms in schizophrenia may impact functioning. Although Food and Drug Administration-approved medications typically benefit positive symptoms, negative symptoms are generally refractory to medication interventions. N-acetylcysteine's (NAC) influence on glutamatergic neurotransmission has been established. An emerging body of research has attempted to correlate this action with reduction in symptom severity, evaluating response in positive, negative, and cognitive symptom domains.MethodsA literature review was performed to analyze available data on NAC intervention and improvement in the positive, negative, and cognitive symptom domains in patients with schizophrenia. Quality of evidence was systematically assessed to determine level of certainty in results.ResultsThree randomized controlled trials were identified. Across studies, negative symptoms decreased more with NAC compared to placebo; ranging between 11.9% and 24.1%. The assessment determined a low level of certainty regarding benefit of NAC on negative and cognitive symptoms and moderate certainty for NAC regarding findings of side effects and lack of benefit on positive symptoms.DiscussionConsistent reporting of benefit in negative symptoms is found across studies of NAC intervention. These improvements are notable for symptoms that have generally remained refractory to medication intervention. Inconsistent benefit was reported in positive and cognitive symptoms. GRADE (grading of recommendations assessment, development and evaluation) assessment of current evidence indicates a low certainty of benefit for negative symptoms with standard use of NAC in patients with schizophrenia. However, a trial of this low-risk intervention may be warranted in patients with resistant negative symptoms and subsequent impaired functioning despite appropriate antipsychotic therapy as they may experience additional benefit in this symptom domain.