bluuebunny/crossref_metadata_2025_split huggingface dataset:
An audit of lithium prescribing practices in an old age psychiatry service highlighting renal impairment in this cohort
Authors: Valentine Leia , Cannon John , Marmion Siobhan , Corcoran Michelle , Cryan Marguerite , McCarthy Geraldine , Dolan Catherine 
Published: June 2021

AimsTo compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West of Ireland among adults aged 65 years and over with best practice guidelines.MethodReview of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary (2019) and Maudsley Prescribing Guidelines (2018). Data were collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past one year.ResultAt the time of the audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n = 9) had a depression diagnosis, 44% (n = 8) had bipolar affective disorder (BPAD) and 6% (n = 1) had schizoaffective disorder.78% (n = 14) of patients were on track to meet, or had already met, the NICE standard of 3-monthly serum lithium level. Lithium levels were checked on average 4.5 times in past one year, average lithium level was 0.61mmol/L across the group and 39% (n = 7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).83% (n = 15) of patients met the NICE standards of 3 monthly renal tests, thyroid function test was performed in 89% (n = 16) and at least one serum calcium level was documented in 63% (n = 15). Taking into consideration most recent blood test results, 100% (n = 18) had abnormal renal function, 78% (n = 7) had abnormal thyroid function and 60% (n = 9) had abnormal serum calcium.Half (n = 9) were initiated on lithium by POA service and of these, 56% (n = 5) had documented renal impairment prior to initiation. Of patients on long term lithium therapy at time of referral (n = 9), almost half (n = 4) had a documented history of lithium toxicity.ConclusionThe results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function, half had abnormal calcium and two fifths had abnormal thyroid function. This is an important finding given the associations between those admitted to hospital with COVID-19 and comorbid kidney disease and increased risk of inpatient death.Our findings highlight the need for three monthly renal function monitoring in older adults prescribed lithium given the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.
A review of required monitoring and management of physical health parameters in patients being treated with clozapine
Authors: Ward Louisa , Marriott Charlotte , Glass Giles , Negm Mariam , Porter Hannah 
Published: June 2021

AimsTo review available standards for physical health monitoring in people taking clozapine To audit current practice against standards To identify changes in practice and facilitate a re-audit to assess impact of any changesMethodStandard: CG178 Psychosis and Schizophrenia in Adults: Prevention and Management – NICE, February 2014Target:100%Exceptions: NoneSample: The original audit included all 58 patients from the Worcester clozapine clinic, as per October 2018. The re-audit reviewed a random sample of all patients attending the clozapine clinics in Worcester, Kidderminster and Redditch, as part of Worcestershire Health and Care NHS Trust, as per October 2019. A total of 66 patients were selected.Data Source: Carenotes and ICEResultAreas of good practice:Monitoring of HbA1c and FBC remains goodThere has been an improvement in monitoring alcohol use, substance misuse and side effectsAreas requiring improvement:There continues to be limited recording of respiratory rateThere has been a decline in recording temperature, BMI and concomitant therapiesPotential reasoning for missing data includes:Staff not knowing the monitoring requirements, which is more likely to be an issue when staff members running the clinics change frequentlyMonitoring being completed but not documentedPatients’ refusal of monitoringData being recorded in alternative locations including general practice, without communication between servicesPatients moving between teams or having inpatient stays may disrupt monitoring regimeConclusionLIMITATIONSThis audit assumes all patients involved to be on a stable dose of clozapine with routine monitoringSome patients may have been transferred between teams or inpatients during the period of data collectionThere is no scope to record when patients refuse monitoringWe may not have access to all notes such as those from general practice for data collectionRECOMMENDATIONSInduction programme for junior doctors to include education on clozapine monitoringTraining for staff involved in clozapine clinics to ensure better understanding of monitoring requirementsProcurement of ECG machines for each site and relevant training for nursing and medical staffCollaboration with GPs for shared dataRe-audit in 1 year
Tics induced by promethazine in an adolescent: a case report
Authors: Akinsiku Fiyinfoluwa 
Published: June 2021

ObjectiveThe objective of this report is to highlight the finding of a movement disorder caused by promethazine in a 16-year-old female and to alert other clinicians to a high index of suspicion of possible movement disorders in young people on promethazine.Case reportI discuss a 16-year-old female (who presented to medics at 15) with low mood, lack of motivation, self-consciousness – at 15, she was over 6 feet tall and weighed 81.2 kg. She also self-harmed by cutting her thigh with razor along with poor sleep, anxiety, and panic attacks. She took an overdose of paracetamol and ibuprofen and a strip of vitamin D and irritable bowel tablets she found at home.A clinical impression of moderate depression with anxiety and panic attacks and possible emerging emotionally unstable personality traits was made and she had begun psychological sessions with the therapist before referral to the medics. Fluoxetine 20 mg OD increased to 40 mg and Circadin 2 mg ON was commenced. Fluoxetine was later tapered off and Circadin stopped. Sertraline 100 mg OD increased to 200 mg was commenced and Promethazine 25 mg ON to improve sleep.Within a month of commencement of promethazine, a sudden onset of extension of neck, blowing through lips and a high-pitched sound occurred whilst experiencing a panic attack and hyperventilating. She also stuttered and had difficulty in speaking, and her vision would go blurry. She initially refused to come off promethazine as it had helped her sleep. An impression of a tic disorder characterised by motor and vocal tics was made. There had been no recent infections or previous history or family history of tics. However, at this point, sertraline had helped with her motivation and she was able to come off promethazine and her sleep was improved by practising sleep hygiene with an accompanied cessation of tics.DiscussionYoung person is currently on 150 mg of Sertraline.The rationale behind reporting this case is that previous studies have pointed at SSRIs, as causes of tics disorders, but promethazine is one that does a good job in improving sleep and has a side effects of movement disorder.ConclusionPromethazine is one medication that can cause movement disorder and a high index of suspicion coupled with a prompt cessation of medication will reduce patient's distress and improve the therapeutic relationship between health professional and young person.Written informed consent from patient and guardian was got.Author declares that there is no conflicting interest, financial or otherwise.
Off-licence use of clozapine in patients with emotionally unstable personality disorder: a case series analysis
Authors: Hyland Declan , Walmsley Alex , Simpson Victoria 
Published: June 2021

ObjectiveThis retrospective case series followed emotionally unstable personality disorder (EUPD) patients following initiation of clozapine on an off-licence basis, aiming to examine tolerance by determining side effect prevalence and treatment cessation frequency, as well as examining efficacy, by investigating number of hospital re-admissions and symptom control.Case reportThis case series captured the experiences of 11 EUPD patients under the care of Mersey Care NHS Foundation Trust, all of whom had, at some time in the past five years, been initiated on clozapine. All patients were white British females, with a median age of 31. The median daily dose of clozapine was 300 mg. Most patients had significant psychiatric comorbidities, as well as illicit substance and / or alcohol misuse.Whilst prescribed clozapine, patients were only admitted to hospital once on average and this was commonly for clozapine re-titration. Whilst in hospital, rates of self-harm were low, but ligaturing and suicide attempts showed higher prevalence. Patients still demonstrated self-harming behaviour out of hospital leading to A and E presentations. In the community, contacts with the police were minimal, with only two patients undergoing Section 136 assessments or arrests.All patients reported side effects from clozapine - usually hypersalivation, over-sedation and constipation. All 11 patients experienced sinus tachycardia. Eight patients temporarily ceased taking clozapine at some point. In three patients, discontinuation of clozapine was as a result of intolerable side effects. Three patients experienced neutropenia, which subsequently resolved. Only two patients had a body mass index within healthy range.DiscussionDespite patients reporting clozapine to provide symptomatic benefit for their EUPD, and improved their engagement with mental health services, prevalence of self-harm and of A and E presentations remained high, indicating the importance of community support and concomitant psychotherapeutic treatment. Patients with more robust community support showed greater adherence to clozapine.High prevalence of side effects and obesity in these patients, in addition to risk of developing neutropenia, highlights the importance of rigorous monitoring after initiating clozapine. It is reassuring that, despite development of neutropenia in some patients, this recovered quickly, and clozapine treatment could resume.ConclusionClozapine may be an effective pharmacological treatment for enabling EUPD patients to engage more therapeutically with services. Clozapine may be of greater benefit to those with more stable, less chaotic lives. Although diminished, patients still show self-harming behaviour and need for A and E admissions and re-hospitalisation. Side effects of clozapine are common and regular monitoring is required.
A haven for an extremely disturbed young person
Authors: Khan Rummana 
Published: June 2021

ObjectiveThe reason to share this case is to high light the lack of resources in mental health services which can delay the provision of appropriate care and this can have negative impact on child health outcomes.BackgroundA 10-year-old boy was referred to CAMHS. He presented with extremely challenging behaviours. After first appointment with CAMHS he attacked his father and nurses. He had to be restrained multiple times. He started to use wooden chair as a weapon, threatened to harm others and threatened to urinate on staff. He tried to kill him-self by ligature. Mental health act assessment was completed and when a decision was reached that detention under the mental health act was appropriate, no appropriate bed was available. He was admitted under Section II of MHA to paediatric ward where he remained for one week (with 2:1 CAMHS support). Then he was transferred to an inpatient CAMHS unit which was commissioned for children over 12 years of age. At a later date mental health tribunal panel upheld the section. After few days he was transferred to an age appropriate in-patient mental health bed. He stayed there for roughly 6 months and was discharged with a diagnosis of ADHD and Autistic Spectrum Disorder. There was a long delay in discharge, until appropriate specialist residential placement could be identified and he was transferred there. He is well settled now in the placement.Case reportLegal advice was later taken on this case. MHA 1983, Human Rights Act, Children Act 1989, Criminal Law Act 1967 and Code of Practice 2015 were considered and it was agreed that it was appropriate to use MHA 1983. There was discussion whether the Children Act could be relied on instead, but in view of the fact that repeated restrain was required, he was in seclusion and possibility of need for rapid tranquilization post admission the decision was made to use the mental health act.ConclusionThis case has highlighted a significant problem and calls for an urgent action to increase the number of inpatient age appropriate mental health beds and number of appropriate residential placements nationally. It has also been identified that application of legal frame work in children and adolescents can be a challenge and there is a need for targeted educational programmes for professionals on the use of legal frame work in children and adolescents.
Psychosis in youth in Singapore: a case series
Authors: Lim Pei Ling , Shirley Roselyne , Fong Pat 
Published: June 2021

ObjectiveIn this report, we present a case series of children with psychotic symptoms referred to a child consultation liaison psychiatric service within a tertiary paediatric hospital in Singapore. The purpose of this case series is to identify common symptoms at presentation, review the current practices in our hospital for investigation and treatment of first episode psychosis and short-term outcomes.Case reportWe identified 9 cases over a 1 year period, for which 7 were seen whilst admitted to hospital and 2 in the outpatient clinic. There were 6 females and 5 males ranging in age from 11 to 16 years old. The commonest symptoms on presentation were perceptual disturbance (88%) most commonly auditory hallucinations and altered behaviour (55%). Of the 7 children admitted to hospital, all were seen by the neurology team prior to the request for a psychiatric opinion. All admitted patients had blood and radiological investigations carried out. Most of the children were started on a short course of antipsychotic medication with the majority continuing to attend follow-up outpatient.DiscussionOnly 9 cases were identified in this case series over a 1 year period highlighting that psychosis is not a common presentation in the paediatric population. From the history alone, it can be challenging to distinguish between primary and secondary causes of psychosis. Acute onset of symptoms and the presence of other neurological signs should raise the suspicion of an underlying organic cause. Out of 9 cases, only 1 case was treated for a presumed organic aetiology, which is consistent with findings from other authors who only found underlying organic factors in 12.5% of cases.In this case series, we also noted that 45% of cases reported having symptoms for over 1 year before seeking help. This is also seen in the adult population in Singapore. Stigma, denial and lack of information about psychosis may all contribute to delay in seeking help. Although prolonged duration of untreated psychosis has been shown to be associated with poor long-term outcome, we found in our case series that even patients who reported a long duration of symptoms still responded well to medication.ConclusionThere is room for collaboration with our neurology colleagues in the approach towards children with first presentation of psychosis, both in terms of investigations and management. Identifying reasons for disengagement from psychiatric care is an area for further investigations to improve outcomes in our patients.
Provision of training for accommodation providers in the London Borough of Hackney – results of a scoping exercise and educational session pilot
Authors: Aldersey Kate , Ahmad Sheraz , Mason Sian 
Published: June 2021

AimsTo understand the level of training given to staff in providers of accommodation in the London Borough of Hackney across mental and physical health.MethodThe Urgent and Emergency Care Collaborative (Health Education England) put out a call for funding bids around a number of workforce priority areas. This included upskilling care home staff to reduce admissions. We considered care home staff as those working across supported living schemes, housing with care, residential and nursing homes. Some of these settings exclusively support people with mental health needs.We obtained a list of accommodation providers across the borough via the Local Authority. As a Community Rehabilitation team we work closely with many of the providers. We also co-facilitate the Hackney Mental Health Supported Accommodation panel and review all funded placements annually. We made contact via email and phonecall and arranged face to face meetings with 11 providers. We asked a standard set of questions about the organisation and training provision. We also asked them to identify gaps in training.ResultThe level of training provided to staff varies vastly across different settings. There was a predominance of e-learning for some providers. Most staff in mental health settings are support worker level which limits the level of training offered/received.Providers varied greatly in size of project and management structure and this directly impacts on access to training, often as a result of cost.Providers were able to identify training gaps and were keen to have additional training.Some common themes emerged – dual diagnosis, psychosis, medication – and some setting specific themes – dementia.Based on the gaps identified we provided training sessions to a total of ~40 staff across a number of settings. Content included mental health awareness, crisis signposting and medicines management. All sessions were well received with pre and post-training questionnaires demonstrating an improvement in knowledge and confidence.ConclusionThere is potential for knowledge sharing across accommodation settings and for stronger links between accommodation providers and healthcare providers. We plan to explore the possibility of quantitative data on the number of Emergency Department presentations from accommodation settings locally.
Black and minority ethnic groups and forensic mental health
Authors: Arya Donna , Connolly Charlotte , Yeoman Beth 
Published: June 2021

AimsTo review the existent literature base regarding Black and Minority Ethnic (BAME) groups care pathway into and experience of care and treatment within secure services. This includes any differences (between BAME and majority ethnic groups) in rates of sentencing, sectioning, length of stay, received treatment and use of restrictive practice. Our overarching aim is to highlight the severe lack of research in this area and the corresponding need for increased research to both consolidate and progress the existing evidence base in order to inform and improve culturally competent service provision.BackgroundResearch suggests that BAME groups have an increased risk of involuntary psychiatric care, longer-stays within services and higher rates of re-admission. Several explanations have been proposed for this observed disparity, however few of these proposed explanations have provided sufficient or consistent supporting evidence.MethodA review of both quantitative and qualitative research regarding BAME groups within secure services was conducted. Approximately twenty journal articles, literature reviews and meta-analysis published between 1988 and 2019 were included. The current study should be considered a snapshot and not reflective of the full extent of published literature on the subject. For inclusion, studies should have been conducted in either a forensic mental health setting or a prison and differentiate a minimum of two ethnic groupsConclusionResearch suggest that BAME individuals continue to experience an increased risk of involuntary psychiatric care, longer stays within secure services and higher rates of re-admission. Whilst many explanations for this disparity have been proposed, few have provided adequate supporting evidence. The ongoing lack of research within this field has led to a limited evidence base from which to inform culturally competent practice. The research which has been conducted has tended to produce inconsistent findings, in part due to the reliance on small scale studies with limited generalisability. Research within this area has been further complicated by varying definitions of culture and ethnicity across studies, leading to some suggestion that the issue of ethnic inequalities and pathways to care, has been misconceptualised. This highlights a critical need for increased research efforts to:Understand why BAME individuals are at increased risk of involuntary psychiatric care, and how this disproportionate risk can be addressedExplore potential disparities in the care and treatment of BAME individuals within services and how this might impact upon higher rates of re-admissionAscertain how best to improve culturally competent service provision.
Governance of Protecting Patients
Authors: Bhatt Sureshkumar 
Published: June 2021

AimsInvoluntary commitment is a legal process through which an individual with symptoms of severe mental illness is court-ordered into inpatient or outpatient treatment. These criteria vary between nations. The goal of this presentation is to compare the governance of protecting patients among different parts of the world.BackgroundUnderstanding the relevance of the judicial committeemen in psychiatry is an essential part of good psychiatric practice. A majority of patients who need inpatient psychiatric treatment fall into one of the following categories: dangerous to self, dangerous to others, or gravely disabled.In the United States, the Parens Patriate doctrine has had great application in the treatment of mentally ill persons, children, and other individuals who are legally incompetent to manage their affairs. The states, which act as parens patriae, can make decisions regarding mental health treatment. State law governs involuntary commitment, and procedures may vary among states.MethodOne of the essential duties of St. Tammany Parish Coroner Office, Louisiana, USA is Mental Health Service, From January 2017 to October 2019, 887 Order of Protective Custody (OPC), 17,838 Physician Emergency Certificates (PEC), and 13096 Coroner Emergency Certificates (CEC) were issued. These certificates allow legal authority to transport a patient to the nearest ER for assessment by physician and mental health providers.ResultPatients with active Physician Certificate are examined by a coroner according to patient's mental history and clinical presentation. Coroner Certificate helps the treatment facilty detail the patient for diagnosis and treatment for fifteen days.ConclusionSt. Tammany Parish Coroner Office is fulfilling its responsibility to provide proper mental health to psychiatric patients. It is necessary for each country/state/parish to have legal structure and provide proper care who are dangerous to self or others, or gravely disabled. The procedures of OPC, PEC, and CEC will be presented.