Lee A. Robinson

Rationale and design of the OPTIME CHF trial : Outcomes of a prospective trial of intravenous milrinone for exacerbations of chronic heart failure

BACKGROUND The optimal management of an acute exacerbation of chronic heart failure (CHF) is uncertain. There is little randomized evidence available to support the various treatment strategies for patients hospitalized with an exacerbation of CHF. Inotropic agents may produce beneficial hemodynamic effects, and although they are currently used in these patients, their effect on clinical response and impact on clinical outcome is unclear. We present a unique and simple study designed to determine whether a treatment strategy for CHF exacerbations that includes an intravenous agent with inotropic properties can reduce hospital length of stay and lead to improved patient outcome. METHODS The OPTIME CHF (Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure) trial is an ongoing multicenter, randomized, placebo-controlled trial of a treatment strategy for patients with acute exacerbations of CHF. The design of this study provides a novel approach to the evaluation of treatment strategies in the care of this population. The OPTIME CHF design uses early initiation of intravenous milrinone as both an adjunct to the best the medical therapy and to facilitate optimal dosing of standard oral therapy for heart failure. Patients with known systolic heart failure requiring hospital admission for a CHF exacerbation are randomly assigned within 48 hours of admission to receive a 48-hour infusion of either intravenous milrinone or placebo. The primary end point of this design is a reduction in the total hospital days for cardiovascular events within 60 days after therapy. Enrollment of 1000 patients began July 7, 1997, at 80 US centers and is projected to conclude in late 1999.

A Developmental Perspective for Promoting Theory of Mind

Social neuroscience research has resulted in changing views of the theory of mind (ToM) construct. Theory of mind is no longer viewed as a unitary construct, but rather as a multidimensional construct comprising cognitive and affective ToM and interpersonal and intrapersonal ToM, each of which has differing neurophysiological/neuroanatomical foundations and behavioral manifestations. Clinicians working with persons with social communication/pragmatic communication disorders should consider evaluating these dimensions of ToM and the cognitive, social–emotional, and language components underlying them. Then they might use this information to develop a ToM profile for each client so they are better able to implement specific intervention strategies to target the linguistic and cognitive/affective foundations for ToM development. In this article, we describe the characteristics of developmental stages of affective and cognitive and interpersonal and intrapersonal ToM and how to match intervention goals and strategies to those stages. Some activities and strategies have empirical support; others are based on what is known about typical development and patterns of impairment.

The Ability of Children with Specific Language Impairment to Participate in a Group Decision Task

This study examined the ability of 6 children with specific language impairment (SLI), ages 8:10 to 12:5 (years; months), to participate in a group negotiation task. Each child interacted with two peers to select toys that children their age would enjoy. Performance was compared to both chronological age-similar (CS)peers and language similar (LS)peers performing the same task. Analyses of the resulting interactions indicated that subjects with SLI produced significantly fewer utterances than the other children in the triad. Similar differences were not observed in the CS or LS triads. Additionally, significantly fewer utterances were addressed to the children with SLI than to the other children in their triad. CS and LS triads produced much more balanced interactions, with differences in the number of utterances addressed to each child failing to reach significance.

Sertraline-Associated Hyponatremia and Subsequent Tolerability of Bupropion in an Elderly Woman

To the Editor: Although hyponatremia is a well-described adverse effect of antidepressant therapy,1 few reports have examined which antidepressant agents are safe after a patient experiences selective serotonin reuptake inhibitor (SSRI)–associated hyponatremia. We describe a case of sertraline-associated hyponatremia and the subsequent tolerability of bupropion in an elderly woman. Case report. Ms A, an 87-year-old thin, hypertensive woman with a history of dementia and major depressive disorder (diagnosed before the onset of dementia), was transferred from an assisted living facility to a geriatric psychiatry ward in December 2009 for management of 3 weeks of worsening physical aggression, depressed mood, anxiety, insomnia, and suicidal ideation. The admission physical examination and laboratory studies were unremarkable (including a serum sodium value of 140 mEq/L). The patient was diagnosed with a major depressive episode (using DSM-IV criteria), and sertraline therapy was initiated at 50 mg by mouth daily, and trazodone 50 mg was administered on 2 nights at bedtime to manage insomnia. Haloperidol was also given at 0.25 mg by mouth in the morning and 0.5 mg by mouth at night to manage the aggressive behaviors. The patient was also prescribed enalapril 5 mg by mouth daily and levothyroxine 112 μg by mouth daily for management of chronic hypertension and hypothyroidism. Four days later, the patient demonstrated inability to sustain attention, hypoarousal, and worsened disorientation. Laboratory evaluation revealed a serum sodium level of 126 mEq/L and plasma osmolality of 272 mOsm/kg, thyrotropin level of 4.64 uIU/mL, and urine specific gravity of 1.002 and osmolality of 655 mOsm/kg. Additionally, the patient was found to have acute cystitis. The patient was euvolemic and demonstrated laboratory evidence consistent with the syndrome of inappropriate antidiuresis. Sertraline was discontinued, fluids were restricted, and antibiotic therapy was prescribed. Bupropion immediate release was initiated the next day at 75 mg by mouth daily and then increased the following day to 75 mg by mouth twice daily. The patients mental state improved, and electrolyte studies 6 days later revealed serum sodium and osmolality values of 135 mEq/L and 280 mOsm/kg, respectively. The suicidal ideation resolved and the other symptoms improved during the hospital course. The hyponatremia did not recur, and the patient was discharged to the assisted living facility. Jacob and Spinler1 reviewed all published material describing SSRI-associated hyponatremia and identified several patient characteristics (age greater than 65 years, woman, diuretic use, history of pneumonia, low body weight, low baseline sodium) commonly associated with development of hyponatremia. That review study was designed to identify patient characteristics associated with hyponatremia and did not address what agents may be safe for patients who experienced hyponatremia. During the initial clinical studies of bupropion, a norepinephrine and dopamine reuptake inhibitor, 1 group reported on a patient who experienced hyponatremia during imipramine monotherapy, then during bupropion monotherapy.2 Although 1 additional case described bupropion-associated hyponatremia,3 2 other case reports4,5 demonstrated the tolerability of bupropion in elderly patients who previously experienced antidepressant-associated hyponatremia. Our case is the third to demonstrate tolerability of bupropion in an elderly patient with SSRI-associated hyponatremia and suggests that bupropion may be a reasonable antidepressant choice for these patients.

Electroconvulsive therapy for the treatment of refractory mania.

We present the case of a patient with treatment-refractory mania. The patient had been tried on numerous medications, to which she either did not respond well or on which she developed severe side effects, However, the patient improved rapidly when treated with unilateral electropercussive therapy (ECT) following a court order. We outline the legal barriers that have been raised against the use of ECT in patients with mania, who often refuse treatment, and the irony that ECT can be safer than medications for some patients. ECT is underutilized in mania but deserves more frequent consideration. (Journal of Psychiatric Practice. 2011;17:61-66).

A Qualitative Study of Factors Affecting Morale in Psychiatry Residency Training.

ObjectiveResident morale is an important yet poorly understood aspect of the residency training experience. Despite implications for program quality, resident satisfaction, patient care, and recruitment, little is known about the variables influencing this complex phenomenon. This study sought to identify important factors affecting morale in psychiatry residency training.MethodsThe authors conducted four semi-structured focus groups at a moderately sized, urban, psychiatry residency program during the 2013–2014 academic year. They used qualitative data analysis techniques, including grounded theory and content analysis, to identify key themes affecting resident morale across training levels.ResultsTwenty-seven residents participated in the focus groups with equal distribution across post-graduate years (PGY) 1–4. Five major conceptual categories affecting resident morale emerged: Sense of Community, Individual Motivators, Clinical Work, Feeling Cared For, and Trust in the Administration.ConclusionsMorale is an important topic in residency education. The qualitative results suggest that factors related to a Sense of Community and Individual Motivators generally enhanced resident morale whereas factors related to a lack of Feeling Cared For and Trust in the Administration tended to contribute to lower morale. The authors describe the possible interventions to promote stronger program morale suggested by these findings.