bluuebunny/crossref_metadata_2025 huggingface dataset:
Increasing Early Cardiac Screening in an Inpatient Psychiatric Setting Using the KardiaMobile 6 Lead Device
Authors: Pierscionek Tomasz , Urban Gavin , Loubser Ignatius
Published: July 2023

Aims

The Royal College of Psychiatrists' core standards include a comprehensive physical health review as a vital part of an inpatient admission.

To determine whether using the KardiaMobile 6 lead (KM6L) device on an inpatient psychiatric ward would increase:

a.

the percentage of patients who receive an ECG during an inpatient stay

b.

the percentage of patients who receive an ECG within 24 hours of admission

Methods

The KM6L device provides a 6 lead ECG recording within 30 seconds. It enables ECGs to be performed more efficiently and less intrusively than a 12 lead ECG machine.

The study aimed to offer all patients (101) admitted to an acute inpatient ward (July 2022 – Jan 2023) an ECG using the KM6L device, unless reporting chest pain, having significant cardiac history, or doctor otherwise concerned – in that event a 12L ECG would be done instead.

The percentage of patients receiving an ECG during an inpatient stay and the percentage who received an ECG within 24 hours of admission were compared on the same ward when using:

a.

the KM6L device between July 2022 and Jan 2023; and

b.

a 12L ECG between July 2021 and July 2022

QT intervals were calculated manually as the automatic feature is still in development

Results

Between July 2021 – July 2022, using a 12L ECG:

•

217 patients admitted

•

142 (65.4%) had a 12L ECG during their inpatient stay. Of these, 83 were done within 24 hours of admission (58.5%). Overall, 83/217 (38.2%) of patients had an ECG within 24 hours of admission.

Between July 2022 – Jan 2023, when KM6L device available on ward:

•

101 patients admitted

•

66* (65.3%) had an ECG during their inpatient stay. Of these, 46 were done within 24 hours of admission (69.7%). Overall, 46/101 (45.6%) of patients had an ECG within 24 hours of admission

*Note: 15/66 patients had a 12L ECG as available clinician did not know how to operate KM6L device

Conclusion

KM6L, despite being easier to use and less intrusive, did not increase the percentage of patients who received an ECG during an inpatient stay. However, there was a notable increase in the percentage of ECGs performed within 24 hours of admission. KM6L offers a cost and time saving alternative for obtaining ECGs; earlier cardiac screening may also reduce risk.

Future work will consider further training of healthcare professionals in how to use the KM6L device and expand its use across healthcare settings.
A Quality Improvement Project: Improving the Presentation of Assessments Within a Liaison Psychiatry Department
Authors: Jain Shivali , Maalouf Natalie , Hassanally Khalil , Rashwany Raman , Faldu Asha , Amin Krishna
Published: July 2023

Aims

This Quality Improvement Project (QIP) was undertaken within a Liaison Psychiatry (LP) department at a district general hospital in North West London. The current service model has LP nurses and junior doctors providing first contact with patients, and subsequently discussing assessments with the team psychiatrists. A need for effective communication when presenting clinical cases has emerged given high rates of staff turnover. The aims of this QIP were; (1) To assess the quality of presentations within the multidisciplinary team (2) to deliver a targeted teaching session focused on frameworks for assessment presentation and (3) to evaluate the effectiveness of the intervention.

Methods

The ‘SBAR: Situation, Background, Assessment, Recommendation’ communication tool already used widely within healthcare was adapted for LP by an MDT including doctors, senior nurses and pharmacist.

A survey was designed with MDT input to collect data about the content of presentations using adapted Likert scales, a quantitative global score and qualitative data highlighting areas for improvement. Over two weeks, senior team members completed surveys for every patient discussion.

A targeted teaching session was delivered on the adapted LP SBAR including: presenting complaint, current medical issues, referral question, psychiatric background, mental state examination, delirium/cognitive screening, risk assessment, impression and management plan. The session included breakout groups with clinical vignettes to practice presenting. All team members filled in a pre- and post-intervention surveys rating their confidence in presenting assessments and received copies of teaching materials.

Data were collected over a 2-week period post-intervention using the same methodology as pre-intervention. Post-intervention data were presented to the MDT and feedback was sought for improvement in the next cycle.

Results

Pre-intervention data (n=30) indicated a risk assessment, impression and plan were often missed from presentations.

Following targeted teaching, team members felt more confident presenting assessments, formulating impressions, and management plans. Post-intervention data (n=22) showed an improvement in inclusion of all key information covered in the LP SBAR except management plans. The percentage of presentations with a global score ≥7 increased from 41% to 57%.

Conclusion

This ‘Plan, Do, Study, Act’ cycle has modestly improved the quality of assessment presentations within LP and has identified a critical need for communication tools within LP. We will perform another cycle in February 2023 given the high turnover of staff and continue to seek feedback from the MDT on the effectiveness of this targeted teaching session to continue to improve the presentation of assessments in LP.
Improving Screening and Standardising Interventions for Patients With Above Normal Body Mass Index (BMI) Admitted to a Male Psychiatric Intensive Care Unit (PICU): A Quality Improvement Project
Authors: Holmes Ariadne , Rashid Sheween , Zabrzycki Domenic , Satisha Shantala
Published: July 2023

Aims/hypothesis

1.

To increase the proportion of patients having their BMI documented on admission to the PICU.

2.

To improve rates of standardised interventions when abnormalities in BMI found.

Among patients admitted to PICU, there is lack of consistency in monitoring of BMI and in offering interventions for those with abnormal BMI. We expect an improvement in both the parameter with the quality improvement project. Background: Service users admitted to PICU have severe mental health illnesses, and are known to have several high risk cardiometabolic parameters including excessive weight. In addition, they are often treated with medications known to cause weight gain. Without effective management, this is likely to cause increased morbidity and mortality

Methods

Initial baseline data were collected by reviewing patient notes.

We then tested interventions to improve weight and BMI screening process on the PICU. We used the Plan-Do-Study-Act (PDSA) methodology over 2 cycles. In the first cycle, we engaged the nursing staff to improve screening on admission, including training to overcome the glitch in the electronic form that prevented automatic BMI calculation. In the second cycle, we introduced a protocol to ensure consistent interventions were offered to patients with abnormal BMI. The interventions offered were referral to dietician, referral to PICU gym instructor and MDT discussion about lifestyle changes and medication to manage weight.

Data were collected after each PDSA cycle to monitor change.

Results

Baseline: 47% of PICU patients had their BMIs recorded on admission. 69% of those patients that met the overweight criteria were offered an intervention.

After the first PDSA cycle, 91% of patients had their BMIs recorded. 71% of those patients that met the overweight criteria were offered an intervention.

After the second PDSA cycle, all the consenting patients had their BMIs recorded. 100% of those patients that met the overweight criteria were offered all the interventions in the protocol but not all agreed to engage with the interventions.

Conclusion

As a result of this quality improvement project there has been an improvement in screening for BMI on admission to PICU and in the standardised interventions offered to those with high BMI. The next steps will be to implement this across the other wards and to improve patients’ engagement with the interventions.
Improving the Screening and Diagnosis of Delirium for Older adult Patients Admitted to Hillingdon Hospital
Authors: Selladurai Abiram , Habib Mirette , Alston Duncan
Published: July 2023

Aims

The aim was for 80% of adults aged over 65 years to be screened for delirium at the point of admission to hospital.

Methods

We implemented multiple interventions including:

•

Teaching sessions for doctors, nursing staff and healthcare assistants on delirium.

•

Designed a new proforma using a more specific tool for screening delirium (4AT)

•

Making the clerking proforma and delirium screening tool more user friendly

Results

Results have shown statistically significant improvement in the detection of delirium with a sample in October 2022 showing 68% of older adults admitted to Hillingdon Hospital having been appropriately screened for delirium.

Conclusion

Current results suggest significant improvements with our interventions, however further progress is still required to reach our aims with regular data collection being paramount.
Trans and Non-Binary Healthcare QIP: Improving GPST Knowledge and Confidence
Authors: Vieira Mariana , Barry Olivia , Shaw Fiona
Published: July 2023

Aims

Trans and non-binary people present with condition-specific health needs. General Practitioners (GPs) face increased demand to care for this population. The Royal College of General Practitioners note that “the gaps in education, guidance and training for GPs around treating gender dysphoria… and managing broader trans health issues… needs to be urgently addressed.” We are an interdisciplinary team using QI methodology to assess current self-reported knowledge and confidence amongst GP Specialty Trainees in the North-West of England (NWGPSTs) and deliver interventions targeting problem areas.

Methods

Following engagement with Health Education England North-West, a preliminary questionnaire was distributed to all NWGPSTs to assess baseline knowledge and confidence regarding gender-diverse peoples' healthcare.

Results were used to design a teaching session covering basic language and concepts; history and physical exam; gender affirming therapies; psychiatric, medical, and sexual health.

Teaching was delivered in a pilot scheme at four NWGPST training locations. Data were gathered before and after each session, with 3 additional questions to assess the quality of teaching and open-text feedback.

Results

In the preliminary questionnaire (n=150) the most common answer was the lowest amount of knowledge, confidence, or training (1 out of 6) for 11 out of 17 questions. Most reported no training during medical school or GP training programmes. Lack of knowledge in gender affirming therapies, fertility preservation, legal framework and referral pathways were identified.

Using a Likert scale (1 to 5), comparison between pre (n=61) and post-teaching (n=49) questionnaires showed improvement in knowledge in all areas (CI 95%). Overall knowledge improved with a mean of 1.05 (95% CI 0.72–1.38). Teaching quality feedback achieved a total mean score of 4.18. Open-text feedback was overwhelmingly positive about teaching material, enthusiasm of presenters, and contained useful suggestions for improvement.

Conclusion

Baseline knowledge of trans and non-binary healthcare is generally very low. A brief educational intervention made a statistically significant improvement to self-reported knowledge and confidence.

We have adapted the teaching based on participant feedback and with involvement from Experts by Experience and Experts by Training. We have enriched teaching with video submissions from Experts by Experience. We have continued to engage with stakeholders, including partners at The LGBT Foundation and Indigo (GP-based Manchester gender service). To grow further, we have trained a faculty of 10 GPSTs to provide teaching, with 11 sessions now delivered to over 300 GPSTs and 5 sessions upcoming. We are planning a nationwide virtual training day.
Introducing an Equality, Diversity and Inclusion (EDI) Champion to Address Unconscious Bias Within the Clinical Intake Meeting Selection Process in a Community Psychotherapy Adolescent Department
Authors: Simione Silvia , Dean Andrew , Habel Sheva
Published: July 2023

Aims

It is widely recognised that the performance of the health care system falls far short of its potential on a wide range of quality indicators, particularly for racial and ethnic minorities and other disadvantaged groups. Within the Adolescent and Young Adult Service, data from the clinical intake meeting have been previously collected and stratified, identifying disparity conditions and populations based on gender (accepted females to males ratio = 7:1); ethnicity (low proportion of Black/Asian/Mixed background represented within the service); age (vast majority of accepted being in their 17s); disability (low proportion of disabled seen). Primary aim for this project was to evaluate whether the introduction of an EDI champion plus an EDI discussion within the intake clinical meeting could improve our department performance in terms of Equality, Diversity and Inclusion (EDI) quality indicators comparing to historical data.

Methods

A comprehensive Excel spreadsheet has been designed. All new referrals from November 22 till January 23 were included (N=29). Data collection included: non identifiable patients details, gender, date of birth, occupation, ethnicity, language, disability, outcome of the meeting, details of outcome, reason if outcome being negative. A further column on EDI comments.

Results

Following the introduction of the EDI champion for this cohort of patients, a decreased percentage of females (73.9% vs 69.2%) and increased percentage of transgender males (4.3% vs 15.4%) were offered an assessment. In terms of ethnicity, the number of Black/Asians/Mixed rejected for an assessment decreased. Respectively, 36.4% vs 11.1% (chi-square = 4.14, p-value = 0.47); 18.2% vs 11.1% (chi-square = 0.08, p-value ≈ 0 being statistically significant); 18.2% vs 0% (chi-square = 2.47, p-value = 0.26). An increased number of White people were rejected for an assessment which was also statistically significant (27.3% vs 66.7%; chi-square=1.96, p-value ≈ 0). Reasons for rejection have been recorded. More age groups (19, 20, 22 years old) were more widely represented in the new cohort of patients.

Conclusion

The introduction of an EDI champion and an EDI discussion, within the clinic intake meeting selection process, seems a valuable instrument to tailor intervention for disparity groups (e.g. ethnicity), assessing both quality and disparities at the same time aiming for a Culturally Competent Quality Improvement within the service. This findings can be easily applied to other departments and implemented more broadly.
Medical Emergency Drills: An Essential Component of Inpatient Psychiatric Care
Authors: Stammeijer Roelof Joe , Boyle Ainslie , Khalid Osman
Published: July 2023

Aims

At Farmfield Hospital, medical emergency drills are conducted monthly, as well as at all other Elysium Healthcare sites. Managing medical emergencies is an expected component of inpatient care, though without regular practice of Immediate Life Support (ILS) skills they can degrade rapidly. We propose that medical emergency drills should be considered an essential component of inpatient care, and explore how we have used them to create targeted teaching and to build skills after significant events.

Methods

We reviewed all medical emergency drills at Farmfield Hospital over the previous 12 months, looking through standardised event reports and feedback on quality and timing of response. We explore and compare qualitative feedback from involved staff members, and detail methods by which medical emergency drills can be used to create targeted teaching and training where skill gaps are noted.

Results

Staff fed back that these drills are key to building their confidence in managing medical emergencies. Core reports include that without these drills, for some staff the only regular practice would be at annual ILS recertification, and reports that they would feel considerably less confident to manage medical emergencies without regular practice and feedback. We use a case study exploring human factors and leadership skills being highlighted in one emergency drill as needing improvement, and how through targeted training and reassessment through subsequent drills we improved this skill gap and enabled staff to become more confident leaders in emergency situations as measured by direct feedback and assessment in subsequent drills.

Conclusion

Medical emergency drills are not currently standard practice across psychiatric inpatient services, and this creates several challenges. While ILS recertification is annual, these are perishable skills, and without regular practice confidence falls rapidly. Moreover, specific skill gaps such as leadership or even technical competencies such as familiarity with specific emergency equipment may go unnoticed until needed in a live medical emergency call. Organising these drills does not require a significant time investment, and we have found the increase in quality of response and staff confidence in managing emergencies makes these drills an essential part of our standard practice. We propose a simple structure for drill design and assessment as part of an ongoing Quality Improvement architecture.
Expeditious multipronged Interventions strike down Geriatric Memory Clinic No Shows in the Department of Geriatrics -a Value Enhancing Initiative via Memory Outreach Program and Telephone Triaging
Authors: Hamad Hanadi Al , Chandran Mani , Manikoth Pravija Talapan , Refaee Mahmoud , Orabbi Marwa El , Hussein Zakia , Gad-Elseed Mashrig , Ramadan Nabila , Babu Parvathy Chandra , Moldez Mancha Maraeh Angela
Published: July 2023

Aims/background

One of the biggest challenges faced by the healthcare sector is devising ways of tackling No shows in the Clinics. Patients are classed as no-shows when they fail to attend scheduled appointments without prior notification to the Health Care Provider. Some factors contributing to clinic No shows amongst frail Older Adults include lack of transportation and non-availability of family members to bring them to the clinic. Along with this, forgetfulness and poor insight into their condition also can contribute to No shows. Memory clinics in Rumailah Hospital under Hamad Medical Corporation in Qatar are the leading specialized multidisciplinary clinics that carry out an assessment, diagnosis, and management of people presenting with Memory Concerns.

Implementation of Quality Improvement projects to tackle the No shows in the Geriatric Memory Clinics in Rumailah Hospital under Hamad Medical Corporation in the State of Qatar.

Methods

Various process improvement initiative based on LEAN methodology got implemented from January 2022 to reshape the service and reduce No shows

1.

Initial nurse triage contacts with the patients or their family members to identify any inappropriate referrals are signposted to the right service and offer appointments for the appropriate referrals at a date and time convenient for them

2.

Telephone triage by the Physician and Case manager of new cases offered a clinic appointment and conduct a brief assessment to agrees risk and order investigations prior to the initial appointment . Patient's requesting rescheduling and cancellations are dealt with immediately. In addition, any new slots which becomes available during this process are offered to other patients and their appointments are brought forward

3.

Nurses contact with the patient caregiver of the person with Dementia and remind them of the appointment a day before the appointment.

4.

Geriatric Memory Outreach Service to carry out home visits for patients who are unable to attend clinic appointments because of frailty, significant cognitive impairment, and mobility issues.

Results

The No shows rates were as follows

2019 -26%.

2020 -13% (COVID-19 impact).

2021 -13%

Intervention was implemented in January 2022 and No Show reduced to 9% in 2022. This indirectly reduced the waiting time (from referral to Consultation) from three months to 5 weeks.

Conclusion

Innovative alternative Outpatient Service delivery balances the elimination of No Shows with enhanced outcomes by continuously improving all the workflow process
Quality Improvement Project: Increasing the Proportion of Inpatients Being Re-Offered and Receiving Baseline Physical Investigations
Authors: Thompson Bethany
Published: July 2023

Aims

The Greater Manchester Mental Health trust standard on admitting patients states that “The patient will receive a comprehensive mental health & physical health assessment (including electrocardiogram (ECG) and routine admission bloods) commenced within 4 hours of admission”. It was observed that patients commonly do not receive admission blood tests or ECG. It was also identified that there is no current system for keeping track of those who have not received admission investigations or any guidance on re-offering them. The aims were therefore to: 1) Increase the proportion of patients being re-offered baseline physical investigations (blood tests and an ECG) after not receiving them on admission. 2) Increase the total proportion of patients receiving baseline physical investigations

Methods

The patients included were any male inpatients (n=41) across two wards between 23/05/22 and 17/06/22.

A list was created of all the patients who had not received admission investigations. Each patient had their notes searched to find out whether they had undergone blood tests and an ECG on admission. If they had not, their notes were searched to see if there was any evidence of them having been reoffered and/or done later. As patients were admitted, they were added to the list if they had not received admission investigations.

The list was taken to ward reviews with the intention of prompting a reoffer of investigations to the appropriate patients. Following the creation of the list, it was reviewed and updated weekly. After 4 weeks, percentages were calculated to determine if there had been an improvement in the proportion of patients being reoffered/receiving baseline investigations.

Results

85.14% patients did not receive admission bloods. 83.79% did not receive admission ECG.

Prior to the introduction of the list, 90% of patients who did not have admission bloods were reoffered. 55.77% patients had baseline (admission or on reoffer) bloods taken. 85.72% patients who did not have admission ECG were reoffered. 78.85% patients had a baseline ECG.

During the 4 weeks following the introduction of the list, 97.5% patients who did not have admission bloods were reoffered. After 4 weeks, 85.14% of all patients had baseline bloods taken. 95% patients who did not have an ECG were reoffered. After 4 weeks, 86.49% of all had a baseline ECG.

Conclusion

Following the introduction of the list, the proportion of patients being reoffered baseline blood tests and ECGs increased.

The proportion of patients receiving baseline blood tests and an ECG also increased.
Improving the Assessment and Management of Acute Alcohol Withdrawal on General and Older Adult Mental Health Inpatient Wards – Baseline Data and Proposed Interventions
Authors: Pope Emma , Turner Charlotte , George James , Soe Myo Min , Westwood Lucy , Nguyen Jenny , Hopwood Beth
Published: July 2023

Aims

The management of alcohol withdrawal has become a national focus amongst psychiatry with recent POMH-UK audit data suggesting many aspects for improvement, whilst alcohol competencies have been reintroduced into the core training curriculum. The first part of this project was to evaluate the current standards of assessing and managing alcohol withdrawal on acute inpatient wards within Livewell South West and to survey doctors’ confidence levels in this area.

Methods

All admissions to the acute adult and older adult inpatient wards at Livewell SW between March and July 2022 were included in the initial data collection. An audit tool was designed to evaluate the initial assessment of alcohol use, the withdrawal risk and subsequent management. Guidance was provided to the authors assessing the records.

A survey to all doctors was conducted during a CPD session about this project which assessed confidence levels in the assessment and management of alcohol withdrawal.

Results

On initiation of this project, it was noted there was no trust guideline or policy to manage those presenting with possible alcohol withdrawal symptoms.

120 patient admissions were assessed against the audit tool. Half of these (53%) had alcohol intake documented on admission.

11 patients (9%) were found to be at risk of alcohol withdrawal symptoms (n.b 46% too little data). 5 (45%) of these were identified promptly and 4 (36%) were given thiamine (1 parental, 3 oral). Only 4 out of the 11 (36%) were prescribed benzodiazepines, these 4 patients were also considered for referral to alcohol services. Relapse medications were not considered for any patients. No significant incidents were noted.

Generally, trainee doctors feel confident in recognising and managing alcohol withdrawal in acute hospital settings but have difficulties on psychiatric inpatient wards. A major reason stated for this was the difficulty distinguishing between psychiatric and alcohol withdrawal symptoms and also concerns surrounding prescribing benzodiazepines

Conclusion

This project identified a need for a trust policy which has subsequently been developed and is currently being ratified.

The initial baseline results show poor assessment of alcohol use and low confidence amongst doctors in assessing and managing alcohol withdrawal in this population. Several interventions have been identified that could be trialled to improve these results. Further training has been given to junior doctors involved in initial assessment and other interventions planned include posters, electronic prompts, nursing survey and education. Furthermore, patient focus groups are planned to understand patients’ perspective and help guide further training.
Blood Tests in Psychiatric Patients-Evaluation and Improving the Process
Authors: Usman Mehr , Afloarei Daniel
Published: July 2023

Aims/background

The aim of this project is to assess which specific laboratory tests where being requested to psychiatric patients in our trust prior to developing a new local guideline to help standardise the blood testing to improve quality of patient care and reduce wastage in NHS due to inappropriate blood tests. It also assessed financial implication of unnecessary blood tests.

There are several reasons for the purpose of blood tests:

•

To identify medical conditions that might be causing or contributing to a psychiatric presentation

•

Provide baseline for safer initiation of psychotropic medication that can cause adverse effects

•

To screen for medical problems who are less likely to attend primary care. Requesting blood tests is a clinical responsibility .Currently there is no formal guidance on which specific lab tests should be ordered for psychiatric patients and was felt a new local guideline was essential to rationalise blood testing

Methods

A survey was circulated to all wards and community mental health teams within our trust to get a clear insight about current practice.

The survey questions included:

•

Place of work?

•

What is included in routine blood tests list?

•

Who created and approved the blood list?

•

Where is the blood list kept?

•

When was it reviewed?

Results

Results showed

•

Significant variation in blood test requesting within our trust emphasising need for standardization using evidence based methods.

•

Unnecessary repetition of blood tests like thyroid function and vitamin D levels against guidelines

•

Unwarranted blood test request when clinically not indicated like including Troponin and Creatine kinase in routine tests. The results were shared to all staff through meetings.

Conclusion

Recommendations were drawn to improve optimisation of resource use, communication between health professionals and the need for standardisation in requesting blood tests.
Re-Audit of Physical Examination and Blood Tests Completed Within 24 Hours of Admission to Psychiatric Ward
Authors: Wilson Kirstin
Published: July 2023

Aims

To establish if the creation of a checklist of examination and investigations required within 24 hours of admission to Psychiatric ward had improved practice and patient care.

Methods

This was a snapshot audit. On 7th August 2022 I carried out a retrospective review of the case notes & results on electronic recording system to ascertain which investigations had been completed for all current in-patients on Ward 4, Dr Gray's Hospital, Elgin. I noted how soon after admission these tests had been completed.

I compared these data with results from a previous audit in January 2022 which had highlighted failings in meeting the standards recommended by Royal College of Psychiatrists. The initial audit led to the creation of an Admission checklist to improve practice. The results from August 2022 demonstrated the impact of the checklist.

Results

On 7th August 2022, there were 18 inpatients in Ward 4. Duration of admission varied from 1 day to 1,259 days.

The 3 routine investigations of Physical Examination, ECG and Bloods were completed within 24 hours of admission much more reliably than the initial audit.

Bloods were completed in 100% of cases compared to 52.9% in January 2022. Physical Examination was completed in 94.4% compared to 76.4% in January 2022. ECG was also completed in 94.4% compared to 58.8% in previous audit.

Conclusion

There was a marked improvement in completion of examination, investigations and recording of the results since creation of a checklist. This could be due to increased awareness of the requirements aided by the visible prompt of the checklist on the ward.

Staff are recognizing that mental health cannot be viewed in isolation from physical health which improves the quality of care patients receive during admission. Any health needs can be identified early allowing time for referral if required.
Can Functional Visual Loss Occur in an Older Adult Patient With a History of Stroke: A Case Report
Authors: Aldweik Abdullah , Hussain Kholod Haj , Alhaj Hamid
Published: July 2023

Aims

Nonorganic visual loss, or functional blindness, is estimated to account for up to 5% of all presentations of blindness. This form of blindness can be ascribed to either a psychogenic aetiology or to malingering. Psychogenic blindness is often a manifestation of conversion disorder, in which a psychiatric condition impairs the normal physical functioning of the affected individual. This could lead to both motor and sensory defects, given that they are not better explained by an organic cause, which should be ruled out by investigations that prove an intact visual system. The individual would also commonly have an identifiable source of stress or trauma. Conversion disorders are less prevalent in older adults, and they may be missed where there are organic comorbidities.

Methods

A 67-year-old male with a recent history of stroke was diagnosed with a major depressive disorder, characterized by low mood, anhedonia, insomnia, fatigue, poor appetite, poor concentration, feelings of guilt, negative feelings about life, and hopelessness. Multiple social problems and family conflicts were identified as possible precipitating factors. Sertraline led to some good initial response, although it was later discontinued. A few months later, he developed severe depression with irritability and suicidal ideation, and he was repeatedly requesting euthanasia. At this point, there was a sudden loss of his vision. Following a thorough ophthalmology evaluation, neurological assessment, and investigations including MRI of the head, cortical blindness was ruled out. As a result, he was diagnosed with visual conversion disorder. After recommencing treatment for his depression with a psychotherapeutic approach as well as vortioxetine antidepressant medication, the visual loss resolved, and the issue has not recurred since then. There was also a significant improvement in his mood. He no longer feels suicidal and appears to be brighter and more socially interactive.

Results

Uncertainty regarding aetiology might initially arise if the patient has a history of trauma or a pathological condition that could cause blindness, such as diabetic retinopathy or stroke, both of which would have been differential diagnoses in the patient in this case had they not been debunked by further investigations, which included neuro-ophthalmic assessments and radiographic studies. The patient's improvement with antidepressants and counselling further supports the diagnosis of visual conversion disorder.

Conclusion

Functional blindness, which is an aspect of conversion disorder, may be a representation of how detrimental undiagnosed and untreated depression could be.
Regression in Down Syndrome. Case Study of a Young Adult With Down Syndrome Who Was Referred to Brent Community Learning Disability Service With ‘Unexplained’ Changes in Behaviour
Authors: Eggleston Evelina , Purandare Kiran
Published: July 2023

Aims

There has been growing interest in regression among adolescents and young adults with Down Syndrome. Regression can also be referred to Acute Regression, Down Syndrome Regression Disorder (DSRD), Down Syndrome Disintegrative disorder (DSDD) or Unexplained Regression in Down Syndrome (URDS) and these terms are sometimes used interchangeably. Characterised by reduction in expressive language, decreased functional skills and reduced psychomotor activity, regression can result in a significant change in the long-term needs of these individuals. Reporting this case, we wanted to highlight challenges in diagnosing, treating and supporting young people with regression in Down Syndrome.

Methods

This is Case Study of a young adult with Down Syndrome presenting with symptoms of mood disorder, apathy, new-onset vocal tics and ritualistic behaviours and profound loss of expressive language - both verbal and sign language.

Results

Diagnosis included ruling out physical causes for regression. The management remains largely symptomatic and aims to address as many as possible bio-psycho-social aspects of the concerning presentation.

Conclusion

Multitude of interventions and external events made it difficult to see what intervention was the most useful. Despite initial positive response to medication and behavioural strategies, a long term prognosis remains uncertain.
Emotional Lability Secondary to Androgen Deprivation Therapy for Prostate Cancer: A Case Report
Authors: Keenan Mary , Rafiq Atiqa
Published: July 2023

Aims

Prostate cancer accounts for more than a quarter (27%) of male cancer cases, making it the most common form of cancer in UK males. Androgen deprivation therapy (ADT) is the mainstay of treatment for prostate cancer. Its aim is to reduce the level of androgens which stimulate cancer cell growth, in turn reducing prostate cancer symptom burden over longer periods. Although the clinical benefits of androgen deprivation therapy have been well documented, the physical, and in particular psychological, side effects of this treatment are lesser reported and can be debilitating.

Methods

We present the case of an 84 year old male referred to Old Age Psychiatry outpatients for a one year history of low mood and tearfulness with no response to two antidepressant trials. The patient was receiving six-monthly injections of Decapeptyl (Triptorelin), a hormone therapy for prostate cancer. The patient's main presenting complaint was of bouts of tearfulness that were difficult to control and often mood incongruent. He reported low energy and reduced motivation; however other biological depressive symptoms were not endorsed.

Results

Depression and marked emotional lability have been reported by men who receive ADT for prostate cancer. This can be a cause of confusion or shame for patients, subsequently impacting interpersonal relationships and social functioning. Other side effects of ADT can lead to further negative psychological effects, including weight gain, gynaecomastia and genital shrinkage. It is possible that the side effects of this treatment are poorly recognized by clinicians initiating and managing it.

Conclusion

In conclusion, patients commencing ADT should be informed of the possibility of psychological side effects and encouraged to report any symptoms that arise. It is important for urologists, psychiatrists and GPs to be mindful of the possible link between this treatment and new onset mood and emotional symptoms in patients.
A Young Girl in Distress
Authors: Khan Rummana
Published: July 2023

Aims

The purpose of sharing this case is to bring attention to the complexities in implementing legal framework for children and adolescents as well as the serious shortages of in-patient adolescent psychiatric beds, which can adversely affect the mental health of young people.

Methods

A young girl with a diagnosis of Depressive Disorder and Disordered Eating was treated by community mental health team for two years. She took an overdose and was admitted to a private NHS funded in-patient adolescent psychiatric unit, where she was placed on Section 2 of Mental Health Act. After two months she was transferred to an out of area psychiatric bed. While on home leave she took another overdose and needed admission in High Dependency Unit. When medically fit she was moved back to psychiatric unit. After two months she was moved to a local in-patient unit. Due to dietary restriction she was commenced on nasogastric feed. At that point the local psychiatric unit could not provide the support she needed and she was transferred to another in-patient adolescent unit in the region. After being an in-patient for 18 months when her condition improved a discharge planning meeting took place. She was still on nasogastric feed and sometimes had to be restrained. The local and regional in-patient and crisis consultants suggested that she should be discharged under Community Treatment Order. The community consultant took legal advice. The legal advice was that the provision of nasogastric feeding in the community without young person's consent would be likely to be unlawful and a violation of her Article 3 rights under the European Convention of Human Rights. Such restraint would be likely to amount to an unlawful deprivation of liberty and a breach of her Article 5 rights under the European Convention of Human Rights.

Results

It is deeply concerning that she had to be moved between four in-patient units during one episode of in-patient admission due to lack of appropriate bed availability. Due to her age and complexities in the case, legal advice had to be taken because the consultants involved failed to agree on the appropriate application of legal framework.

Conclusion

This case clearly highlights the need to address the issue of adolescent in-patient psychiatric bed shortages as well as the importance of educational programmes aimed at improving the knowledge and skills of professionals on the application of legal framework in children and adolescents.
A Case of Urticaria One Month After Initiating Fluoxetine
Authors: Muzenda Muredzwa Adelina , Grimwade Lucy
Published: July 2023

Aims

According to NICE guidelines, fluoxetine is a first-line antidepressant for the management of depression in children and adolescents. There has been little discussion on urticaria occurring after 4 weeks on fluoxetine. Urticaria is defined as an itchy skin lesion "with localised oedema and is surrounded by redness which is also known as a wheal and flare phenomenon". In most urticarial scenarios, the trigger which is usually an allergen leads to an increase in levels of histamine among other chemicals into the skin.

Methods

We present the case of a 16-year-old young person with no previous history of skin conditions, who developed urticaria 4 weeks after starting fluoxetine for depressive disorder. No other trigger could be identified. On discontinuing fluoxetine, the rash gradually declined over time and completely resolved ten days later. On further enquiry, the patient reported eating at least one chocolate bar a day. He did admit to receiving a large amount of chocolate just before the rash began and hence was possibly eating more than his usual amount at the time. Furthermore, the rash occurred at the point when steady-state levels of fluoxetine were believed to have just been reached.

Results

Adverse effects of medication have always been a challenging part of managing patients. Although rash that develops acutely after starting fluoxetine has been published so far, literature on rash that develops after 4 weeks on treatment is limited. Cederberg et al (2004) and Gahir (2021) described the association of SSRIs (fluoxetine and sertraline) and chocolate (which contains serotonin) leading to an itchy hive-like rash. In these cases, discontinuation of the SSRI and use of antihistamine led to a resolution of symptoms.

We report a case who developed urticaria 30 days on fluoxetine without any other identifiable triggers. Aspects of this case to support a possible rash caused by chocolate-fluoxetine interaction include the rash occurring when the patient was consuming chocolate (quantities possibly increased immediately prior to the onset of rash), rash occurring when steady-state levels of fluoxetine had just been reached, no other identifiable trigger to explain the rash in the history and the slow resolution of the rash which can be explained by the long half-life of fluoxetine.

Conclusion

This report highlights the importance of being mindful of this rare dermatological side effect of fluoxetine despite it occurring weeks after initiation. Patients should also be made aware of this possible side effect and its association with consuming chocolate.
Rapid Cycling Bipolar Affective Disorder After COVID-19 Infection Accompanied With Neurological Symptoms
Authors: Raoof Abdul , Aboelenien Shaimaa , Elagawany Adel , Nurlu Derya
Published: July 2023

Aims

This case highlights an atypical presentation of a patient with known history of Bipolar Affective Disorder who experienced rapid mood changes and atypical neurological symptoms after he was tested positive for COVID-19.

Methods

Here we present a 63 years old male patient who was an inpatient in low secure forensic unit and has a history of Bipolar Affective Disorder. Patient reported that he started to experience COVID-19 symptoms and was tested positive on 12th April 2020. It was observed that patient experienced low mood, flat effect, anhedonia and decreased appetite for more than a month after he was tested positive. According to his medical records, he experienced significant mood changes suggesting major depression and manic/hypomanic episodes, 4 times to be specific, over 6 months period after having diagnosed with COVID-19 which is correlated with diagnostic guidelines for Rapid cycling Bipolar Disorder. Patient was observed to experience 1 major depressive episode over period of 6 months before his COVID-19 diagnosis. He also reported experiencing neurological symptoms such as tremor, numbness and unsteadiness on one leg. Although it was found that his lithium level was above therapeutic range at the beginning of these symptoms, even after successful reduction of Lithium dose, patient continued to experience these symptoms for another month. There were no gross abnormalities in physical examination and his blood results were not significant. In addition to Electroencephalogram (EEG); Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) were conducted and the results were all insignificant. During this time, he was fairly compliant with his medications. Additionally, his mood was stabilised only partially with the medications he was taking. He did not have any other major environmental, psychological or physical changes that might explain his rapid mood cycling.

Results

Authors considered various different causes for this patient's fluctuating mood. One confounding factor that was considered was blood lithium levels. However, that was proven to be irrelevant since patient continued to experience mood changes and neurological symptoms with therapeutic lithium levels. Also no other organic reasons were found that could explain his neurological symptoms.

Conclusion

Although, authors consider that longer observation period and other confounding factors could affect findings, they cannot confidently reject the impact of COVID-19 infection on patients with enduring mental illness and recommend further research which could lead to more comprehensive guidelines
Psychosis Prompts Detection of Early Stage Angioimmunoblastic T-Cell Lymphoma
Authors: Ong Li Anne , Mok Tabitha
Published: July 2023

Aims

Angioimmunoblastic T-cell lymphoma (AITL) is a rare (2%) and aggressive form of Non-Hodgkin lymphoma, with poor prognosis and median overall survival under 3 years. Most patients with AITL present at an advanced stage (3 or 4). Neuropsychiatric manifestations of lymphoma, though rare, have been reported as associated symptoms. We present a case of successfully treated Stage 2 AITL, whose rare presentation, of florid affective and atypical psychotic phenomena without neurological deficit, eluded clinical detection of AITL for months.

Methods

A 58 year-old gentleman with a history of Major Depressive Disorder, presented to hospital with a second episode of generalised tonic clonic seizure, following 4 months of manic disorganised behaviour and multimodal hallucinations.

Atypical psychotic features (preserved insight, multimodal hallucinations resistant to high dose anti-psychotics) and new systemic symptoms prompted suspicion of underlying organic pathology. CT Thorax Abdomen and Pelvis uncovered enlarged bilateral common iliac and external iliac lymph nodes, and small sub-centimetre retroperitoneal nodes. Eventually, Stage 2 Angioimmunoblastic T-cell lymphoma (Pattern 1 & 2), with concomitant psychosis with atypical features, was diagnosed.

Olanzapine 10mg ON and 2.5mg OD PRN, Sodium Valproate EPILIM CHRONO 300mg BD and Diazepam 10mg ON were continued over 6 rounds of chemotherapy and autologous stem cell transplant. The patient remains in remission.

Results

Neuropsychiatric manifestations of lymphoma are rare and usually associated with Central Nervous system (CNS) lymphoma. Here, we observe Stage 2 AITL (without CNS involvement), can present with neuropsychiatric symptoms in the absence of neurological deficits.

We found the combination of Olanzapine, Sodium Valproate and Diazepam to be effective in managing secondary neuropsychiatric symptoms.

Limbic Encephalitis is an important consideration for similar cases despite this patient not meeting the qualifying criteria (unremarkable neuroimaging and EEG).

This case highlights the importance of a thorough history, documenting and understanding the patient's psychopathology (both reported and observed), and differentiating atypical psychotic features which raise suspicions for underlying organic pathology.

Conclusion

This case is an an eye-opener for psychiatric and non-psychiatric clinicians. It reminds us to remain vigilant in such florid psychiatric presentations and highlights the importance of thorough organic workup and psychiatric medications that may be used to successfully address psychosis secondary to lymphoma.

We hope to contribute to the increasing awareness and broadening literature of psychiatric disturbance as initial manifestations of malignant illnesses, and the association between psychiatric manifestations and the rare form of lymphoma, AITL.