Preeti Sinha

Improving quality of prescriptions with clinical audit.

Sir, Prescription writing is one of the most important and basic skills that a doctor needs. Specifi c training and supervision in prescription should be emphasized during undergraduate and postgraduate teaching to minimize related errors.[1] These prescription errors may lead to adverse drug events. The study done to assess adverse drug events by Bates et al. found 28% of adverse drug events to be preventable in their study and concluded that 56% of those preventable adverse events occurred at the stage of ordering.[2] Evidence indicates that these adverse drug events are common in long-term psychiatric care units.[3] It may be applicable to other psychiatric settings, although related study has not been reported so far. The use of clinical audit for assessing the nature of prescription errors and establishing standards may be one viable solution for this problem. Clinical audit is shown to be benefi cial in many developed countries, especially in the UK, where it is commonly utilized. Often, recommendations from the audit cycle are not effectively implemented or are not pursued completely.[4] This can undermine the utility of clinical audit. A few reports on audit cycles of prescription related to psychiatry have been published in the past few years.[5-7] Even though there is a need for improvement in prescription patterns,[8] we are not aware of such a study conducted in India. This report describes our experience with a systematically conducted audit exercise on prescription orders written by postgraduate resident doctors in psychiatry.

Clinical utility and tolerability of transcranial direct current stimulation in mild cognitive impairment

BACKGROUND Neuromodulatory interventions like transcranial direct current stimulation (tDCS) is emerging as a potential therapeutic strategy to promote cognitive function in healthy and pathological aging. There is need for more studies evaluating the utility and tolerability of tDCS in Mild cognitive impairment (MCI). Since MCI is considered as the prodromal stage of dementia, it has emerged as the most important target for intervention in dementia. OBJECTIVE AND METHOD This study investigated the feasibility, tolerability and clinical utility of tDCS in patients with MCI. In this observational study that included 11 patients with MCI, tDCS with an intensity of 2mA and duration of 20minutes per day was administered for 5 consecutive days with anode over left dorsolateral prefrontal cortex (DLPFC) and cathode over right supra orbital region. Treatment outcome was measured using picture memory impairment test (PMIT) immediately and also 1 month after the 5th session of tDCS RESULTS: All the patients tolerated tDCS sessions without any significant adverse effects. Stimulation of left DLPFC with tDCS was noted to significantly improve the immediate and delayed recall performance of the patients in PMIT after five days of stimulation and most of the benefits were persistent at one month follow up. CONCLUSION This study findings suggests that tDCS is safe and potentially beneficial in combating cognitive deficits in patients with MCI and provides a framework for further studies with better methodology (randomized and sham controlled trial) to investigate the same.

Predictors of Effect of Atypical Antipsychotics on Speech.

Background: Most of the studies have looked into the effect of typical antipsychotics on speech secondary to tardive dyskinesia. Aims: This study was aimed to explore the factors predicting the effect of atypical antipsychotic medications on the production of speech. Materials and Methods: One hundred and forty patients on stable regimen of three or more months on risperidone (92), olanzapine (28), aripiprazole (14), and clozapine (6) were recruited for the study. Speech was assessed by maximum phonation duration task, s/z ratio, diadochokinetic task, acoustic analysis and Frenchay Dysarthria Assessment (FDA). Extrapyramidal symptoms (EPS) were assessed by Simpson Angus scale. Statistical Analysis: Spearman correlation analysis was carried out to find the association between speech parameters and continuous variables. Effect of EPS, duration and dose of antipsychotic treatment on speech parameters was compared using Mann-Whitney test. Results: The risperidone group differ from other antipsychotics groups significantly in s/z ratio (0.07), FDA-total (0.23) and FDA-reflex (0.25). People who took antipsychotic for more than 2 years had lower score of FDA-palate (P = 0.042), and FDA-respiratory (P = 0.04) and higher values in noise-harmonic ratio (P = 0.011) and maximum /fundamental frequency (MFF) for males (P = 0.02). Effect of EPS was seen on MFF for males (spearman correlation coefficient = 0.34) and on almost all sections of FDA (spearman correlation coefficients = -0.2 to -0.33). Conclusion: Both duration of use and propensity of atypical antipsychotics to cause EPS can influence the speech performance of the patients. This information can be useful, particularly in people with the requirement of high quality speech.

Evaluating the effect of risperidone on speech: A cross-sectional study.

Speech subsystems are susceptible to the effects of several factors including medications. The atypical antipsychotics can also adversely affect the speech because of its action on serotonin and dopamine neurotransmitters. The present study aims to analyze the speech characteristics associated with atypical antipsychotic risperidone. Speech of 92 patients on risperidone with or without trihexyphenidyl and/or clonazepam were compared with that of 31 persons who were not on any psychotropic medicines. Compared to control group, maximum phonation duration, sequential motion rate of diadochokinesia was reduced by about 3s and 1syllable/s respectively and s/z ratio was increased by 0.16 in patients with risperidone. Performance of larynx, lips and tongue sub-system and intelligibility of speech were also significantly reduced in risperidone group. Risperidone did impact the phonation and articulation sub-systems of speech mildly, which was independent of tardive dyskinesia and extrapyramidal symptoms. Randomized controlled prospective study looking into impact on speech and related effect on drug adherence, functioning and quality of life needs to be conducted with risperidone and other atypical antipsychotics.

A Meta-review of the Safety of Electroconvulsive Therapy in Pregnancy.

Background Four systematic reviews have examined the safety of electroconvulsive therapy (ECT) in pregnancy. These have varied widely in methods, findings, and conclusions. Methods We compared these reviews with regard to search strategy, study selection criteria, total number of studies identified, total number of patients included, findings related to safety and adverse events, and interpretation of results. Results The number of studies (number of cases) included in the reviews ranged from 16 (n = 300) to 67 (n = 169) with only one review stating reasons for exclusion of nonselected studies. We provide comparisons about how the reviews described patient characteristics, illness characteristics, ECT characteristics, confounder characteristics, and outcome characteristics; there was wide variation in these regards. We list adverse outcomes that were identified by some but not other reviews. We provide a detailed breakdown of the adverse maternal and fetal outcomes identified in each review. Finally, we examine how different reviews interpreted their findings; whereas some reviews provided reasons for ruling out ECT as an explanation for an adverse outcome, one review adopted the stance that all adverse outcomes were potentially ECT-related. Conclusions Our meta-review provides readers with comparative information on the strengths and limitations of the 4 systematic reviews, their findings, and their conclusions. It can assist with clinical decision making on the use of ECT in pregnancy by providing a more complete description of the available literature.

An exploratory study for bladder dysfunction in atypical antipsychotic-emergent urinary incontinence

Introduction: This is an exploratory study, which aimed to analyze urodynamic findings in patients who are on atypical antipsychotics and present with urinary incontinence (UI) in order to understand the mechanisms of antipsychotic-emergent UI. Patients and Methods: Eight patients (34 ± 7.6 years; five males and three females) diagnosed with schizophrenia or other psychotic disorders, who were on risperidone, olanzapine, or clozapine monotherapy and having UI were recruited. Urodynamic study was performed in all patients. Results: Six out of eight (75%) patients had abnormal urodynamic findings. Three of them had detrusor overactivity (DO) without detrusor-sphincter dyssynergia (DSD); two had DO with DSD; and one had hypoactive detrusor with nonrelaxing sphincter during void phase. The common urinary symptoms were urgency, enuresis, and straining to void urine. Significant postvoid residual urine was found in two patients. Conclusion: The evidence of bladder dysfunction in atypical antipsychotic-emergent UI is similar to that present in patients with neurological disorders. Urinary complaints in patients on antipsychotics thus need to be evaluated and managed systematically using the protocol followed for neurological conditions.

Two decades of an indigenously developed brief-pulse electroconvulsive therapy device: A review of research work from National Institute of Mental Health and Neurosciences

In 1993, a device to administer brief-pulse electroconvulsive therapy was indigenously developed through collaboration between the National Institution for Quality and Reliability and the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India. The additional feature of computerized recording of the electroencephalograph and electrocardiograph for both online and offline use had substantial clinical and research implications. Over the past two decades, this device has been used extensively in different academic and nonacademic settings. A considerable body of research with clinical and heuristic interest has also emanated using this device. In this paper, we present the development of this device and follow it up with a review of research conducted at NIMHANS that validate the features and potentials of this device.

CLINICAL PROFILE OF BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS IN ELDERLY WITH DEMENTIA

method. dT2Awas strongly correlated with Clinical Dementia Rating Scale “sum of boxes” (CDR-SB) in both studies, and dT2A exhibited a high Area Under the Receiver Operating Characteristic Curve (AUC) for the discrimination of Alzheimer’s Disease (AD) v. Normal Controls (NC) in both studies. As a demonstration of d’s indifference to its indicators, we modeled alternative homologs with fewer cognitive indicators. Homologs lacking any combination of Logical Memory II, Boston Naming and /or Animal Naming performed similarly to the full dT2A homolog. Conclusions: This is the twelfth d homolog validated to date. Regardless of its indicators, d correlates strongly with CDR-SB and accurately diagnoses dementia, across diagnoses and multiple cohorts. This implicates g as dementia’s essential cognitive impairment.

Predictors of Desire to Institutionalization in Dementia Caregivers From a Developing Country

Older adults with dementia have higher rates of institutionalization than those without dementia. Desire to institutionalization (DTI) is an important factor influencing the actual institutionalization but is less well studied. This cross-sectional study examines the DTI with the scale of same name developed by Morycz, in 1985, in a sample of 50 caregivers of patients with dementia in a tertiary clinical care setting in a developing country. Caregiver burden associated with personal strain (by factor analyzed Zarit Burden Interview scale), and stress perceived out of caregiving (by Perceived Stress Scale) predicted higher DTI. Besides, those who were married had lower DTI scores. The factors which didn’t affect DTI were total caregiver burden, family and social support, age of patient and caregiver, education of caregiver, severity and duration of dementia, and treatment duration. These results were different from those of developed country-based DTI studies and may indicate sociocultural differences.

Development of Ti – 6Al – 4V Wire Rods for Fastener Applications

Multipass forging in dies is used to obtain thin rods 4 mm in diameter from alloy Ti – 6Al – 4V. The properties exhibited by the alloy in this process are described and the possibilities of making fasteners from it are considered. The high strain produced by warm swaging makes it possible to fabricate high-strength fasteners without the expensive and labor-intensive operations of solution treatment and aging.