Takuto Ishida

Incidence of Deep Vein Thrombosis in Restrained Psychiatric Patients

BACKGROUND Although physical restraint is still used in psychiatric inpatient settings, it sometimes causes serious side effects, including deep vein thrombosis (DVT) and resulting pulmonary embolism. OBJECTIVE The aim of this study was to investigate the incidence of the DVT in restrained patients who were receiving routine prophylaxis and to identify the risk factors of this condition. METHODS This study was conducted at Sakuragaoka Memorial Hospital, Japan from December 2008 to September 2010. Inpatients who were restrained during the study period were included. All restrained patients wore graduated compression stockings and were recommended to receive subcutaneous injection of unfractionated heparin during the period of restraint unless it was contraindicated. When plasma d-dimer level at the time of removal of restraint was ≥ 0.50μg/dL, the patients underwent a Doppler ultrasound scanning of their lower extremities to examine the presence of DVT. A multiple logistic regression model was used to examine the effects of demographic and clinical characteristics on the incidence of DVT. RESULTS A total of 181 patients (98 men; mean ± standard deviation age, 47.8 ± 17.0y) were included; DVT was detected in 21 patients (11.6%). A longer duration of restraint (odds ratio = 9.77, 95% confidence interval = 1.56-61.03, p = 0.015), excessive sedation (odds ratio = 4.90, 95% confidence interval = 1.33-18.02, p = 0.017), lower antipsychotic dosage (odds ratio = 0.05, 95% confidence interval = 0.005-0.57, p = 0.016), and recent medical hospitalization (odds ratio = 11.44, 95% confidence interval = 2.13-61.47, p = 0.004) were significantly associated with the incidence of DVT. CONCLUSION The incidence of DVT in restrained psychiatric patients was not low in spite of prophylaxis. These findings emphasize the importance of regular screening of and thorough assessments of DVT, especially in restrained psychiatric patients.

Incidence of deep vein thrombosis in catatonic patients: A chart review

Catatonia is a syndrome of motor and psychological disturbances, which is accompanied by blood stasis that increases the risk of deep vein thrombosis (DVT). The aim of this study was to examine the incidence of DVT in catatonic patients in comparison to that in non-catatonic physically restrained patients. We conducted a chart review of involuntarily hospitalized patients from 2010 to 2013 at Sakuragaoka Memorial Hospital in Japan. Routine screening of DVT has been conducted for catatonic patients and restrained patients in this hospital. Catatonic patients were identified based on descriptions of charts and sorted to two subtypes (i.e. retarded and excited forms). A Doppler ultrasound scanning was performed to examine the presence of DVT. The incidence of DVT was compared among retarded and excited catatonic patients and non-catatonic restrained patients. There were 79 catatonic patients, of whom 42 were retarded. The incidence of DVT was 25.3% (20/79) in the catatonic patients. The retarded catatonic patients demonstrated a significantly higher incidence rate than the restrained non-catatonic patients (35.7% [15/42] vs. 10.6% [31/272], adjusted OR, 4.47). The incidence of DVT in catatonic patients, especially in the retarded form, was considerably high, which suggests the importance of prophylaxis of DVT.

Plasma substance P level in patients with schizophrenia: a cross-sectional study.

Aspiration pneumonia is a serious health concern in older patients with schizophrenia. In this study, we examined clinical and demographic variables that could impact the plasma substance P level, which is a useful predictive biomarker of aspiration. Thirty‐four patients were included (mean age ± SD: 70.9 ± 10.8 years). A greater number of cigarettes/day and a higher antipsychotic dosage were found to be associated with a lower plasma substance P level, while age showed a trend‐level effect. This finding suggests the need for intensive observation for prevention of aspiration pneumonia in heavy smokers who are receiving a higher antipsychotic dose in this senior population.

Impacts of switching antidepressants after successful electroconvulsive therapy on the maintenance of clinical remission in patients with treatment-resistant depression: A chart review

Introduction: There is no consensus regarding whether a previously prescribed, that is, failed, antidepressant should be continued or switched after a successful electroconvulsive therapy (ECT) for the maintenance of clinical remission in patients with treatment-resistant depression (TRD). In this study, we conducted a chart review to examine impacts of the antidepressant switch after the successful ECT on 1-year outcome in patients with TRD. Materials and Methods: This retrospective chart review included inpatients with TRD (ie, those who failed to respond to adequate trials of 2 distinctly different classes of antidepressants) who showed clinical remission after ECT. Readmission rate and social functioning 6 months and 1 year after the successful ECT were compared between patients who experienced an antidepressant switch and those who continued prior regimen. Results: Twenty-eight patients (mean age, 59 years; 9 men) were followed-up for 1 year. The patients who changed antidepressants after ECT (n = 7) experienced a readmission significantly less frequent than the others (n = 21) in 1 year (0% vs 43%, P = 0.043). In addition, the former showed significantly better social contacts at 6 months (P = 0.022) and 1 year (P = 0.015). There were no significant differences in baseline characteristics between the 2 groups. Conclusions: The patients who experienced an antidepressant switch after ECT required a readmission less frequently in 1 year than those who were maintained with the same antidepressant. The findings of this preliminary study suggest that a switch to another antidepressant after successful ECT may be encouraged for the maintenance of clinical remission in patients with TRD.

Prophylactic use of heparin for deep vein thrombosis in restrained psychiatric patients: a chart review

OBJECTIVE Physical restraint sometimes causes deep vein thrombosis (DVT) and pulmonary embolism. Although unfractionated heparin (UFH) is used for the prophylaxis of DVT, its effectiveness remained unknown for restrained patients. METHOD We conducted a chart review of restrained inpatients at Sakuragaoka Memorial Hospital in Japan. Restrained patients received subcutaneous injection of UFH 5000 IU bid from December 2008 to September 2010 [heparin (+) period] while UFH was not used from December 2010 to September 2012 [heparin (-) period]. A Doppler ultrasound scanning was performed to examine the presence of DVT. The incidence of DVT was compared between the two periods by chi-square test. A multiple logistic regression model was used to examine effects of demographic and clinical characteristics on the incidence of DVT. RESULTS No significant difference was found in the incidence of DVT between the heparin (+) and (-) periods [11.8% (11/93) vs. 11.1% (13/117)]. Sedation [odds ratio (OR) = 3.78], physical comorbidities (OR = 6.29) and a longer duration of restraint (OR = 1.22) were associated with the incidence of DVT. CONCLUSION The use of UFH was not associated with any reduction in the incidence of DVT in restrained psychiatric patients.

A Possible Role of Takotsubo Cardiomyopathy in Ventricular Fibrillation During Delirium Tremens: A Case Report and Literature Review

Introduction Takotsubo cardiomyopathy is characterized by acute and transient apical ventricular dysfunction in the absence of significant obstructive coronary artery disease and is assumed to be caused by excessive catecholamines release. We report on a 57-year-old male who presented with Takotsubo cardiomyopathy during delirium tremens that resulted from alcoholism. Laboratory examination revealed hypokalemia and hypomagnesemia. ECG revealed marked QT prolongation and he developed ventricular fibrillation (Vf) after torsade de pointes (TdP), which was successfully treated with immediate defibrillation. Method We searched articles related to Takotsubo cardiomyopathy complicated with alcohol withdrawal using Embase and PubMed. Results There have been 11 case reports of Takotsubo cardiomyopathy associated with alcohol withdrawal thus far. Of these reports, 6 patients had symptoms consistent with delirium tremens, 1 patient with possibly delirium tremens, and 2 patients experienced withdrawal seizure. Of these 9 patients with severe alcohol withdrawal symptoms, 7 patients developed heart failure, 6 patients exhibited QT prolongation in ECG, and 1 patient suffered TdP and Vf. Conclusion The patients who suffered from delirium tremens complicated with Takotsubo cardiomyopathy may have a high risk of TdP and Vf because of QT prolongation due to Takotsubo cardiomyopathy and electrolyte disturbances associated with alcohol withdrawal. Considering high fatality of this condition, clinicians need to be on alert for Takotsubo cardiomyopathy as a possible complication of delirium tremens; serial 12-lead ECGs and TTEs should be performed appropriately in response to the abnormal findings. Systematic survey on the incidence of Takotsubo cardiomyopathy among patients with delirium tremens is warranted.

Chest compression-related fatal internal mammary artery injuries manifesting after venoarterial extracorporeal membrane oxygenation: a case series

BackgroundCardiopulmonary resuscitation-related bleeding, especially internal mammary artery injuries, can become life-threatening complications after initiating venoarterial extracorporeal membrane oxygenation owing to the frequent involvement of concomitant anticoagulant treatment, antiplatelet treatment, targeted temperature management, and bleeding coagulopathy. We report the cases of five patients who experienced this complication and discuss their management.Case presentationWe retrospectively evaluated five patients with cardiopulmonary resuscitation-related internal mammary artery injuries who were treated between February 2011 and February 2016 at our institution. All five patients were Asian men, aged 56 to 68-years old, who had received concomitant intravenously administered unfractionated heparin (3000 units) with antiplatelet therapy. Four patients received targeted temperature management. The injuries and hematomas were detected using contrast-enhanced computed tomography in all cases. Three patients were treated using transcatheter arterial embolization within 6 hours following cardiopulmonary arrest, and two were resuscitated and received appropriate treatment following early recognition of their injuries. Two patients died of hemorrhagic shock with delayed intervention. Four of the five patients had excessively prolonged activated partial thromboplastin times before their interventions.ConclusionsComputed tomography should be performed as soon as possible after the return of spontaneous circulation to identify injuries and consider appropriate treatments for patients who have experienced cardiac arrest. Delayed bleeding may develop after treating hypovolemic shock and relieving arterial spasms; therefore, transcatheter arterial embolization should be performed aggressively to prevent delayed bleeding even in the absence of extravasation. This approach may be superior to thoracotomy because it is less invasive, causes less bleeding, and can selectively stop arterial bleeding sooner. A 3000-unit intravenous bolus of unfractionated heparin may be redundant; heparin-free extracorporeal cardiopulmonary resuscitation may be a more appropriate alternative. Unfractionated heparin treatment can commence after the bleeding has stopped.

Administration of Eculizumab, a C5 Inhibitor, for the Treatment of Shiga-Toxin-Producing Escherichia coli Infection: A Case Report

Hemolytic-uremic syndrome (HUS), which is characterized by microvascular hemolytic anemia, consumption thrombocytopenia, and acute renal failure, is a complication of the Shiga-toxin-producing Escherichia coli (STEC) infection. We describe the case of a patient who, despite undergoing plasma exchange and renal replacement therapy for STEC-induced HUS, experienced poor improvement in platelet count, serum creatinine level, and serum lactate dehydrogenase level. The patient developed acute encephalopathy but recovered without permanent organ damage after eculizumab therapy. For severe HUS cases involving the central nervous system, early administration of eculizumab, which inhibits the abnormal activation of the complement activation pathway, may be effective.

Flunitrazepam overdose induces brilliant-blue gastric fluid

Dear Editor We report the case of a patient with flunitrazepam overdose who presented with brilliant blue-stained gastric fluid. A 37-year-old woman who had a history of borderline personality disorder was transported to our hospital with disturbance of consciousness by the emergency medical service. On arrival, the Glasgow Coma Scale score was 6/ 15 (eye 1, verbal 1, motor 4), and both pupils were approximately 3 mm in diameter and reactive to light. Her blood pressure was 104/76 mmHg, heart rate was 64 b.p.m., respiratory rate was 10 breaths/min, and oxygen saturation was 99% on 6 L of oxygen. She did not smell of alcohol, and had airway constriction. Endotracheal intubation was performed, and 100 mL blue-colored gastric fluid was aspirated after nasogastric intubation (Fig. 1). Laboratory results on arrival were as follows: serum sodium level, 141 mmol/L; serum calcium level, 9.0 mg/ dL; urea nitrogen level, 6.2 mg/dL; and blood glucose level, 119 mg/dL. Head computed tomography scan yielded normal findings. The emergency medical service informed us about her medical history, and empty pressthrough packages (32 tablets of 2 mg flunitrazepam, 52 tablets of 5 mg nitrazepam, and 87 tablets of 25 mg quetiapine) were found in her living room. Rapid urine toxicology screening test revealed positive results for benzodiazepines. She was diagnosed with the above drug overdoses, and admitted to our hospital. She was extubated 3 days post-admission, and discharged after a psychiatric examination without any sequelae. Our case highlighted the brilliant-blue gastric fluid due to flunitrazepam overdose. Flunitrazepam is a central nervous system depressant that belongs to the class of drugs known as benzodiazepines. While flunitrazepam produces sedative-hypnotic, anti-anxiety, and muscle relaxant effects, it is also used in combination with alcohol to produce an exaggerated intoxication, and misused to physically and psychologically incapacitate victims targeted for sexual assault. This drug has never been approved for medical use by the US Food and Drug Administration. In Japan, the white color of flunitrazepam (Silece; Eisai, Tokyo, Japan, and Rohypnol; Chugai, Tokyo, Japan: Basel, Switzerland) tablets has been changed to blue to prevent its use for criminal purposes by the Ministry of Health since July 1, 2015. Although intended to prevent crime, there are some medical merits. If we could not diagnose the cause of the altered consciousness, the blue-colored gastric fluid could signify a possible overdose; we could then anticipate the patient’s altered consciousness to resolve, knowing its half-life (10–30 h). We retrospectively evaluated the medical records of patients with drug overdose between July 2015 and July 2017 at our institution. Of the 90 patients identified, bluecolored gastric fluid was found in four patients. The diagnosis of flunitrazepam was confirmed with oral evidence in two patients; for one patient it was suspected based on the drug history, but there was no evidence from the medical history of the other patient. There are several limitations to making a diagnosis based on the blue-colored gastric fluid. First, Silece and Rohypnol expire 4 and 5 years, respectively, from the date of manufacture (both have been changed from

Asymptomatic Deep Vein Thrombosis in a Patient with Major Depressive Disorder

Pulmonary embolism is a serious, life-threatening condition and most commonly derives from deep vein thrombosis of the lower extremities. Once deep vein thrombosis (DVT) reaches a proximal vein (i.e., popliteal vein or higher), pulmonary embolism reportedly occurs in up to 50% of patients. Case Presentation. We report on an inpatient with major depressive disorder in a catatonic state in whom an asymptomatic proximal deep vein thrombosis of 11 × 70 mm was detected through routine screening, using doppler ultrasound scanning. Anticoagulant therapy was immediately started and continued for three months, which resulted in resolution of the deep vein thrombosis. Discussion. To our knowledge, this is the first description of asymptomatic proximal DVT that was detected in a psychiatric inpatient setting. In light of the reported causal relationship between DVT and pulmonary embolism, screening for DVT can be of high clinical value in patients with psychiatric disorders, especially when their physical activity is highly compromised.