Shamim H. Nejad

Insertion of Foreign Bodies (polyembolokoilamania): Underpinnings and Management Strategies

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Dr Unruh is an attending psychiatrist at McLean Hospital, Belmont, Massachusetts, and an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Nejad is an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts, an attending physician on the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and the director of the Burns and Trauma Psychiatric Consultation Service at Massachusetts General Hospital, Boston. Mr Stern is a research assistant in the Department of Psychiatry at Massachusetts General Hospital, Boston. Dr Stern is chief of the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and a professor of psychiatry at Harvard Medical School, Boston, Massachusetts.Dr Stern is an employee of the Academy of Psychosomatic Medicine, has served on the speakers board of Reed Elsevier, is a stock shareholder in WiFiMD (Tablet PC), and has received royalties from Mosby/Elsevier and McGraw Hill. Drs Unruh and Nejad and Mr Stern report no financial or other affiliations relevant to the subject of this article.

Clozapine use in HIV-infected schizophrenia patients: a case-based discussion and review.

Background Schizophrenia is a common neuropsychiatric disorder that is associated with an increased risk for HIV infection. Because schizophrenia may affect the ability of HIV-infected patients to adhere to their antiretroviral regimen, optimal management of their mental illness is a high priority in such individuals. However, 20% to 30% of patients with schizophrenia are refractory to first-line antipsychotics. Objective Given the frequency of comorbid HIV infection and schizophrenia, the authors investigated the potential role of clozapine, with the idea that this medication may be considered for use in this particular patient population. Method The authors present histories of clozapine treatment in two patients with schizophrenia and comorbid HIV illness. The use of clozapine in this population, along with potential pharmacodynamic and pharmacokinetic drug interactions are discussed. Results Management and information regarding the use of clozapine in patients with schizophrenia and comorbid HIV illness are presented. Discussion Clozapine can be used successfully in HIV-infected individuals, with control of viral replication an achievable goal, particularly for those patients in whom there is some external oversight of medication adherence. A multidisciplinary approach must be adopted, with the consultation psychiatrist providing the best possible control of psychiatric problems so that infectious-disease doctors can achieve the goal of HIV replication control.

Current approaches to the recognition and treatment of alcohol withdrawal and delirium tremens: "old wine in new bottles" or "new wine in old bottles".

Have you ever wondered how much alcohol a person has to drink (and for how long) before he or she risks developing a withdrawal syndrome after sudden abstinence? Have you ever wondered which methods are best to diagnose and quantify the severity of alcohol withdrawal? Have you been uncertain about which strategies can best manage alcohol withdrawal? If you have, then the following discussion and review of the literature should serve as a stimulus to enhance your understanding of the problem and to create effective solutions.

The Assessment and Management of Agitation and Delirium in the General Hospital

The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry. Dr Stern is chief of the Psychiatric Consultation Service at MGH and is a professor of psychiatry at Harvard Medical School (HMS); Drs Celano and Gross are clinical fellows in psychiatry at HMS and fellows in adult psychiatry at MGH and McLean Hospital; Dr Huffman is director of Inpatient Psychiatry Services at MGH; Drs Freudenreich, Kontos, and Nejad are attending physicians on the Psychiatric Consultation Service at MGH; Ms Repper-DeLisi is a psychiatric nurse clinician on the Nursing Consultation Service at MGH; Dr Thompson is director of the Medical Intensive Care Unit at MGH and an associate professor of medicine at HMS. Dr Stern is an employee of the Academy of Psychosomatic Medicine; has served on the speakers board of Reed Elsevier; is a stock shareholder in WiFiMed (Tablet MD); and has received royalties from Mosby/Elsevier and McGraw Hill. Dr Freudenreich has served as a consultant to Beacon Health Strategies and has received grant/research support from Pfizer and honoraria from Reed Medical Education. Drs Celano, Gross, Huffman, Kontos, Nejad, and Thompson and Ms Repper-DeLisi report no financial or other affiliations relevant to the subject of this article.

An approach to symptoms at the interface of medicine and psychiatry: pain, insomnia, weight loss and anorexia, fatigue and forgetfulness, and sexual dysfunction.

Primary care physicians commonly deal with patients who present with a somatic complaint for which no clear organic etiology can be found. This article discusses how a psychiatrist thinks about somatic symptoms (eg, pain, insomnia, weight loss and loss of appetite, fatigue and forgetfulness, sexual dysfunction) in a patient who might have depression. The management of a patient in whom no satisfactory medical or psychiatric diagnosis can be made is also reviewed briefly.

Simulation-Based Training for Residents in the Management of Acute Agitation: A Cluster Randomized Controlled Trial

ObjectiveSimulations are used extensively in medicine to train clinicians to manage high-risk situations. However, to our knowledge, no studies have determined whether this is an effective means of teaching residents to manage acutely agitated patients. This study aimed to determine whether simulation-based training in the management of acute agitation improves resident knowledge and performance, as compared to didactic-based instruction.MethodsFollowing a standard lecture on the management of agitated patients, first-year psychiatry residents were randomized (in clusters of three to four residents) to either the intervention (n = 15) or control arm (n = 11). Residents in the intervention arm then received simulation-based training on the management of acute agitation using a scenario with an agitated standardized patient. Those in the control arm received simulation-based training on a clinical topic unrelated to the management of agitation using a scenario with a non-agitated standardized patient who had suffered a fall. Baseline confidence and knowledge were assessed using pre-intervention self-assessment questionnaires and open-ended clinical case vignettes. Efficacy of the intervention as a teaching tool was assessed with post-intervention open-ended clinical case vignettes and videotaped simulation-based assessment, using a different scenario of an agitated standardized patient.ResultsResidents who received the agitation simulation-based training showed significantly greater improvement in knowledge (intervention = 3.0 vs. control = 0.3, p = 0.007, Cohen’s d = 1.2) and performance (intervention = 39.6 vs control = 32.5, p = 0.001, Cohen’s d = 1.6). Change in self-perceived confidence did not differ significantly between groups.ConclusionsIn this study, simulation-based training appeared to be more effective at teaching knowledge and skills necessary for the management of acutely agitated patients, as compared to didactic-based instruction alone. Subjective evaluations of confidence in these skills did not improve significantly compared to controls, corroborating the need for using objective outcome measures when assessing simulation-based training.

Interactive home telehealth and burns: A pilot study

OBJECTIVE The objective of this study is to review our experience incorporating Interactive Home Telehealth (IHT) visits into follow-up burn care. METHODS A retrospective review of all burn patients participating in IHT encounters over the course of 15 months was performed. Connections were established through secure video conferencing and call-routing software. Patients connected with a personal computer or tablet and providers connected with a desktop computer with a high-definition web camera. In some cases, high-definition digital images were emailed to the provider prior to the virtual consultation. For each patient, the following was collected: (1) patient and injury demographics (diagnosis, prognosis, and clinical management), (2) total number of encounters, (3) service for each encounter (burn, psychiatry, and rehabilitation), (4) length of visit, including travel distance and time saved and, (5) complications, including re-admissions and connectivity issues. RESULTS 52 virtual encounters were performed with 31 patients during the first year of the pilot project from March 2015 to June 2016. Mean age of the participant was 44 years (range 18-83 years). Mean total burn surface area of the participant was 12% (range 1-80%). Average roundtrip travel distance saved was 188 miles (range 4-822 miles). Average round trip travel time saved was 201min (range 20-564min). There were no unplanned re-admissions and no complications. Five connectivity issues were reported, none of which prevented completion of the visit. CONCLUSIONS Interactive Home Telehealth is a safe and feasible modality for delivering follow-up care to burn patients. Burn care providers benefit from the potential to improve outpatient clinic utilization. Patients benefit from improved access to multiple members of their specialized burn care team, as well as cost-reductions for patient travel expenses. Future studies are needed to ensure patient and provider satisfaction and to further validate the significance, cost-effectiveness and safety.

Clinical Case Vignettes: A Promising Tool to Assess Competence in the Management of Agitation.

ObjectiveWhile standardized patients (SPs) remain the gold standard for assessing clinical competence in a standardized setting, clinical case vignettes that allow free-text, open-ended written responses are more resource- and time-efficient assessment tools. It remains unknown, however, whether this is a valid method for assessing competence in the management of agitation.MethodsTwenty-six psychiatry residents partook in a randomized controlled study evaluating a simulation-based teaching intervention on the management of agitated patients. Competence in the management of agitation was assessed using three separate modalities: simulation with SPs, open-ended clinical vignettes, and self-report questionnaires.ResultsPerformance on clinical vignettes correlated significantly with SP-based assessments (r = 0.59, p = 0.002); self-report questionnaires that assessed one’s own ability to manage agitation did not correlate with SP-based assessments (r = −0.06, p = 0.77).ConclusionsStandardized clinical vignettes may be a simple, time-efficient, and valid tool for assessing residents’ competence in the management of agitation.

Intentional Self-inflicted Burn Injuries: Review of the Literature

BACKGROUND Intentional self-inflicted burn injuries are a rare occurrence in the United States, but they represent a considerable portion of all burn injuries in the developing world. Compared to nonintentional burns, patients with intentional self-inflicted burns have increased rates of higher total body surface area involvement and associated complications, including overall mortality. METHODS We present 2 representative cases and review the available literature on the topic of self-inflicted burns. We review epidemiologic, social, and cultural factors of importance, and also provide an overview of most common psychiatric pathologies encountered in patients with self-inflicted burns. RESULTS The patient demographics and motivation for intentional self-inflicted burn injuries differ considerably across the world. Although self-immolation is commonly associated with women experiencing domestic stress in the developing world, most cases of self-immolation in higher-income countries are males. Psychiatric pathologies, including primary mood and thought disorders and substance use, play a significant component in latter cases, while most patients in the developing world lack any premorbid psychiatric diagnosis, or carry diagnosis of adjustment disorder. CONCLUSIONS Nonlethal self-burns present a distinct subset of intentional self-burn injuries, often occurring in the context of significant personality pathology, or with potential secondary gain.

Updates in Psychosomatic Medicine: 2014

BACKGROUND The amount of literature published annually related to psychosomatic medicine is vast; this poses a challenge for practitioners to keep up-to-date in all but a small area of expertise. OBJECTIVES To introduce how a group process using volunteer experts can be harnessed to provide clinicians with a manageable selection of important publications in psychosomatic medicine, organized by specialty area, for 2014. METHODS We used quarterly annotated abstracts selected by experts from the Academy of Psychosomatic Medicine and the European Association of Psychosomatic Medicine in 15 subspecialties to create a list of important articles. RESULTS In 2014, subspecialty experts selected 88 articles of interest for practitioners of psychosomatic medicine. For this review, 14 articles were chosen. CONCLUSIONS A group process can be used to whittle down the vast literature in psychosomatic medicine and compile a list of important articles for individual practitioners. Such an approach is consistent with the idea of physicians as lifelong learners and educators.