Self-Harm Before and Six Months After Obesity Surgery

PURPOSE

Previous research on obesity surgery (OS) showed that patients do not only experience weight loss but also improvements in certain mental health outcomes (e.g., depression) after OS. However, self-harm behaviors might increase after OS. Regarding self-harm, the literature is mostly limited to studies using data from hospital or emergency room charts. This longitudinal study examined self-reported self-harm behaviors and potential psychopathological correlates before and after OS.

MATERIALS AND METHODS

Pre-surgery patients (N = 220) filled out a set of questionnaires before and approximately six months after OS. Self-harm behaviors were captured with the Self-Harm Inventory. The assessments further included standardized instruments to measure symptoms of depression, anxiety, eating disorders, alcohol use, and suicidal ideations.

RESULTS

Any self-harm was reported by 24.6% before and by 25.0% after OS. No differences in the number of self-harm behaviors or prevalence of any self-harm before and after OS were found. Overall, 11.4% experienced self-harm behaviors at both times. A subset showed self-harm behaviors only before (13.2%) OS and another subset only after OS (13.6%). These two groups were about the same size. Self-harm behaviors showed strong associations with psychopathology after OS, especially with depression and suicidal ideation.

CONCLUSION

No increase in self-harm behaviors after OS emerged. Still, a subgroup showed self-harm behaviors after OS closely linked to further psychopathology. This mirrors the need to implement screening for self-harm before and after OS into OS care. Further studies with longer follow up periods are needed to extend these findings.

Comparison between a complete preconditioning programme and conventional conduct on behaviour, health and performance of young bulls from small cow-calf herds

Bovine respiratory diseases (BRDs) have major socioeconomic impacts in the beef sector. Antimicrobials have been traditionally used to prevent the development of BRDs upon arrival in fattening units. Currently, from a "One Health and One Welfare" perspective, alternative solutions are being investigated. Preconditioning programmes that aim at reducing stress and reinforcing immune functions have been proposed to decrease BRDs incidence. In this study, we assessed the effect of a preconditioning protocol set up in nine commercial beef herds on young bulls' behaviour, health, and performance. Preconditioned bulls (PREC) were weaned indoors 50 days before departure, and progressively fed a concentrate diet supplemented with vitamins and trace elements. They also received an anthelmintic treatment, and two doses of a trivalent vaccine against respiratory pathogens at 4-week intervals. In contrast, controls (CTRL) were kept on pasture with their dams with no vaccination or particular diets. All calves were transported together to a single sorting facility to be sorted by experimental groups, origins, and BW, forming new groups before dispatch to four fattening units. At arrival, CTRL were treated with anthelmintic drugs and received one injection of the same BRDs vaccine. No intervention was performed on PREC bulls. BRD-scores were 0.73 in PREC versus 0.07 in CTRL (P = 0.01) during the preconditioning period and 0.96 in PREC versus 0.54 in CTRL (P = 0.41) after 15 days in the fattening units. Morbidity estimates were 18% in PREC versus 1% in CTRL (P < 0.001) during the preconditioning period and 32% in PREC versus 19% (P = 0.07) in CTRL after 15 days in the fattening units. Poor housing conditions during preconditioning and a different aetiology could partly explain these results. At arrival to fattening, the average daily gain (ADG) was 1 605 g for PREC versus 1 140 g (P = 0.012) for CTRL. After fattening for 180 days, differences in BW, ADG, carcass weight and conformation were inconclusive. In Europe, preconditioning programmes including vaccination must be set up coherently with good husbandry practices and with a global adaptation of batch management of the beef sector otherwise, they may be less effective than expected.

Safety and tolerance of combination of monoamine oxidase inhibitors and direct dopamine agonists in adults and older adults with highly resistant depression

INTRODUCTION

Dopamine (DA) is likely to be involved in some depressive dimensions, such as anhedonia and amotivation, which account for a part of treatment-resistant forms. Monoamine oxidase inhibitors (MAOI) and direct D2 and D3 receptors agonists (D2/3r-dAG) are known to help, but we lack safety data about their combined usage. We report on safety and tolerance of the MAOI+D2r-dAG combination in a clinical series.

METHOD

All patients referred to our recourse center for depression between 2013 and 2021 were screened to select those who did receive the combo. Data were extracted from clinical files.

RESULTS

Sixteen patients of 60±17 years of age (8 women, 7 with age>65years, all suffered from treatment resistant depression, 7 with bipolar disorder) received the combo. There were no life-threatening adverse effects (AE). However, AE were reported by 14 patients (88%) most of which were mild and consisted of insomnia, nausea, nervousness, confusion, impulse control disorder and/or "sleep attacks". One patient presented a serious AE requiring a short hospitalization for confusion. Intolerance led to failure to introduce treatment in two patients (13%). The retrospective non-interventional design, the variety of molecules, and the modest sample size limited the scope of these results.

CONCLUSION

There was no life-threatening safety issue in combining MAOI and D2/3r-dAG, especially regarding cardiovascular side effects. The systematic screening of AE might account for their frequency, but these precluded the treatment in only two patients. Comparative studies are needed to assess the efficacy of this new combination.

Postoperative Dumping Syndrome, Health-Related Quality of Life, Anxiety, Depression, and Eating Disturbances: Results of a Longitudinal Obesity Surgery Study

INTRODUCTION

Given the lack of research on the relationship of post-surgery dumping syndrome and eating disturbances, the purpose of the present longitudinal study was to investigate whether dumping after obesity surgery is associated with pre-/postoperative eating disorder symptoms or addiction-like eating beyond the type of surgery, gender, health-realted quality of life (HRQoL) and anxiety/depressive symptoms.

METHODS

The study included 220 patients (76% women) before (t0) and 6 months after (t1) obesity surgery (sleeve gastrectomy [n = 152], Roux-en-Y gastric bypass [n = 53], omega loop gastric bypass [n = 15]). The Sigstad Dumping Score was used to assess post-surgery dumping syndrome. Participants further answered the Eating Disorder Examination Questionnaire (EDE-Q), Yale Food Addiction Scale 2.0 (YFAS 2.0), Short-Form Health Survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) at t0 and t1.

RESULTS

The point prevalence of symptoms suggestive of post-surgery dumping syndrome was 33%. Regression analyses indicate an association of dumping with surgical procedure (bypass), female gender, reduced HRQoL, more anxiety/depressive symptoms, and potentially with binge eating but not with eating disorder symptoms in general or with addiction-like eating.

CONCLUSION

The current study failed to show a close relationship between the presence of self-reported dumping syndrome and eating disorder symptoms or addiction-like eating following obesity surgery. Further studies with longer follow-up periods should make use of clinical interviews to assess psychosocial variables and of objective measures to diagnose dumping in addition to standardized self-ratings.

The experiences of doctorally prepared nurses and doctoral nursing students with being mentored in the Nurse-Lead programme: A focus group study

AIM

to explore experiences of being mentored and the contribution of the mentoring to leadership and professional development of doctorally prepared nurses and doctoral nursing students participating in the Nurse-Lead programme.

BACKGROUND

Mentoring is considered important for career development of academic nurses. Doctorally prepared nurses need a wide range of professional competences to develop sustainable careers. Therefore, they may benefit from a larger network of mentors, outside their own organization, to support their professional development. Therefore, a web-based leadership and mentoring programme was developed - the Nurse Lead programme.

DESIGN

A descriptive study with semi-structured focus groups.

METHOD

Three focus groups were conducted during an on-site programme meeting in 2019 with twenty-one doctorally prepared nurses and doctoral nursing students. The interview guide included questions about mentoring relationships and meaning of mentoring for leadership and professional development. The interviews were thematically analysed.

RESULTS

Five themes were identified: "Preferred characteristics of mentors", "Developing trusting relationships", "Engagement of the mentors", "Becoming a proficient researcher and team leader" and "Becoming an empowered and confident professional".

CONCLUSION

Mentoring supported the leadership and professional development of doctorally prepared nurses and doctoral nursing students. Participants were engaged in rewarding mentoring trajectories. The results indicate that a similar approach could be followed when developing mentoring programmes in the future.

141 THE INTENSE PROJECT: IMPROVING DEMENTIA CARE THROUGH SIMULATION OF SELF-EXPERIENCE

Background

The EC is concerned about the growing shortage of experienced health and social care professionals to care for people with dementia. Although specialized dementia education programs have begun to appear in recent years, a lack of consistency and adequate level of knowledge of dementia to anticipate the required treatment remains across Europe. The Improving demeNtia care Through Self-Experience (INTENSE) project supports the creation of skills improvement paths for professionals across Europe that incorporate and promote successful self-experience methodologies and practices to increase knowledge and understanding of the lived experience of dementia (e.g., Virtual Dementia Tours, role plays and practices of theatre workshops).

Methods

A systematic review of self-experience tools, training and interventions was conducted. Participatory stakeholder workshops were then held in Ireland, Italy, Germany and the Netherlands to explore ways in which self-experience could be used to better understand the experience of the person with dementia and how the simulation of self-experience could be incorporated into existing (or new) training programmes. Workshop discussions were transcribed and thematically analysed along with workshop outputs to develop the INTenSE toolkit and supporting platform.

Results

An INTenSE toolkit was developed containing interactive no-tech, low-tech and high-tech approaches to simulating self-experience. Training scenarios, facilitation approaches and sustainability plans were designed and a prototype of the INTenSE Platform (website to house and support use of the toolkit) was developed. Beta versions of each will be presented.

Conclusion

INTenSE has illustrated how participatory research can strengthen cooperation and exchange of experiences between organizations working in the field of dementia care; improve social awareness of the ability of self-experience to improve dementia care; promote the integration of self-experience practices in the training of health and social care professional; and highlight the potential for self-experience simulation to be incorporated into carer training and dementia awareness education, subject to the provision of appropriate supports.

189 IMPROVING DEMENTIA CARE THROUGH SELF-EXPERIENCE; CO-DESIGNING A SIMULATION-BASED DEMENTIA EDUCATION TOOLKIT

Background

Although specialised dementia education programmes have begun to appear in recent years, they lack consistency. Knowledge gaps persist, which results in a professional workforce who can struggle to anticipate the care needs of people with dementia. Self-experience or simulation practices (e.g., roleplays, virtual reality, sensory tools) are established teaching methods that can provide learning opportunities to experience aspects of illness. These innovative learning approaches can positively impact empathy, understanding, and quality of care; however, they are rarely implemented in specialised care for people with dementia. The Improving demeNtia care Through Self-Experience (INTENSE) project has co-designed a dementia simulation toolkit to educate, equip, and train professionals to better support people with dementia.

Methods

As part of the Erasmus+ INTenSE project, a series of three participatory, online workshops were conducted with people with dementia, informal caregivers, and dementia-care professionals in Ireland, Italy, Germany, and the Netherlands. The first explored the co-design of training scenarios using simulation tools to demonstrate the lived experience of dementia. The second involved the co-design of an online training platform. The third examined the sustainable implementation of INTenSE into practice. All workshops were inductively coded and analysed thematically.

Results

Recommended training scenarios demonstrate daily activities and environments that impact people with dementia using a combination of existing and newly developed simulation tools. Four themes arose from workshop discussions: 1) representation of dementia, 2) daily challenges that impact people with dementia, 3) applying a person-centred approach, and 4) implementing self-experience training. Together these were used to develop facilitation guides to support the implementation of the INTenSE simulation toolkit into practice.

Conclusion

These findings demonstrate the potential of simulating self-experience across a range of everyday scenarios as a means to increase professionals' empathy and understanding of the lived experience of dementia. Recommendations have been developed that support the use of self-experience tools in practice.

[Anticholinergic scales: Use in psychiatry and update of the anticholinergic impregnation scale]

Anticholinergic properties are well known to prescribers, notably in mental health, as a therapeutic strategy for i.e. extrapyramidal syndrome but also as a source of numerous adverse side effects. Herein, we propose a narrative literature review describing: (i) cholinergic pharmacology and anticholinergic properties; (ii) the importance of anticholinergic therapeutic properties in psychiatry; (iii) the existing anticholinergic drug scales and their usage limitations in Psychiatry and; last (iv) an update to the anticholinergic drug impregnation scale, designed for the French psychiatry practice. The anticholinergic side effects can appear both in the peripheral level (dry mouth, constipation, etc.) and in the central level (especially as cognitive deficits). Many of the so called « anticholinergic » drugs are in fact entirely or mostly antimuscarinic and act essentially as parasympathetic system antagonists. Overall, anticholinergic/antimuscarinic side effects are usually attributed to psychotropic medications: to certain antipsychotics, notably classical neuroleptics such as phenothiazine and also to tricyclic antidepressants. In practice, the impact of anticholinergic toxicity treatments is often highlighted due to their excessively prolonged use in patients on antipsychotics. Interestingly, these antipsychotic treatments are better known for their anticholinergic side effects, especially cognitive ones, with an early onset specially in elder patients and/or in the case of polymedication. In order to evaluate anticholinergic side effects, metrics known as anticholinergic burden scales were created in the last few decades. Nowadays, 13 different scales are documented and accepted by the international academic community, but only three of them are commonly used: the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden Scale (ACB). All of them are based on a similar principle, consisting of grading treatments individually, and they are normally scored from 0 - no presence of side effects - to 3 - anticholinergic effects considered to be strong or very strong. Using these scales enables the calculation of the so-called "anticholinergic burden", which corresponds to the cumulative effect of using multiple medications with anticholinergic properties simultaneously. The application of anticholinergic scales to patients with psychiatric disorders has revealed that schizophrenic patients seem to be especially sensitive to anticholinergic cognitive side effects, while elder and depressed patients were more likely to show symptoms of dementia when exposed to higher anticholinergic burden. Unfortunately, these tools appear to have a low parallel reliability, and so they might induce large differences when assessing side effects predictability. In addition, the capacity of these scales to predict central adverse effects is limited due to the fact they poorly or do not differentiate, the ability of treatments to cross the blood-brain barrier. Finally, one last limitation on the validity of these scales is prescription posology is not accounted for side effects considered to be dose dependent. Recently, the MARANTE (Muscarinic Acetylcholine Receptor ANTagonist Exposure) scale has incorporated an anticholinergic burden weighting by posology. Nevertheless, this new model can be criticized, due to the limited number of medications included and due to testing a limited number of potency ranges and dosages for each treatment. Herein, we propose an update to the Anticholinergic Impregnation Scale, developed specifically for the French Psychiatry practice. The scale validation was based on an evaluation of the prescriptions correcting anticholinergic peripheral side effects (constipation, xerostomia and xeropthalmia). This indirect evaluation allowed us to show patients with an anticholinergic impregnation score higher than 5 received significantly more treatments for constipation and xerostomia. This strategy bypasses the bias of a cognitive evaluation in patients with severe mental health disorders. Moreover, the relevance of a tool developed specifically for French psychiatry is justified by the fact that some highly prescribed treatments for mental illness in France (cyamemazine and tropatemine) are strong anticholinergics, and also by the fact they are rarely included in the existing anticholinergic scales. This update of the original scale, published in 2017, includes information whether prescribed drugs cross the blood-brain barrier and thus makes possible a more accurate assessment when evaluating anticholinergic central side effects. Finally, the anticholinergic impregnation scale will soon be integrated into a prescription help software, which is currently being developed to take into consideration dose dependent adverse effects.

Psychotropics and COVID-19: An analysis of safety and prophylaxis

The use of psychotropics during the COVID-19 pandemic has raised two questions, in order of importance: first, what changes should be made to pharmacological treatments prescribed to mental health patients? Secondly, are there any positive side effects of these substances against SARS-CoV-2? Our aim was to analyze usage safety of psychotropics during COVID-19; therefore, herein, we have studied: (i) the risk of symptomatic complications of COVID-19 associated with the use of these drugs, notably central nervous system activity depression, QTc interval enlargement and infectious and thromboembolic complications; (ii) the risk of mistaking the iatrogenic impact of psychotropics with COVID-19 symptoms, causing diagnostic error. Moreover, we provided a summary of the different information available today for these risks, categorized by mental health disorder, for the following: schizophrenia, bipolar disorder, anxiety disorder, ADHD, sleep disorders and suicidal risk. The matter of psychoactive substance use during the pandemic is also analyzed in this paper, and guideline websites and publications for psychotropic treatments in the context of COVID-19 are referenced during the text, so that changes on those guidelines and eventual interaction between psychotropics and COVID-19 treatment medication can be reported and studied. Finally, we also provide a literature review of the latest known antiviral properties of psychotropics against SARS-CoV-2 as complementary information.

Patients with atherosclerotic peripheral arterial disease have a high risk of lung cancer: Systematic review and meta-analysis of literature

PURPOSE

Lung cancer and atherosclerosis share common risk factors. Literature data suggest that the prevalence of lung malignancy in patients with peripheral arterial disease (PAD) is higher than in the general population. Our goal was to determine, through a systematic literature review, the prevalence of lung cancer in patients with PAD.

METHODS

We consulted available publications in the Cochrane library, MEDLINE, PUBMED, EMBASE, and ClinicalTrials.gov. We included all articles, written in English or French, published between 1990 and 2020 reporting the prevalence of lung cancer in patients with PAD (atherosclerotic aortic aneurysm or peripheral occlusive diseases). Patients with coronary artery disease, cardiac valvulopathy or carotid stenosis were not included. We did not include case reports. We performed a critical analysis of each article. Data were collected from two independent readers. A fixed effect model meta-analysis allowed to estimate a summary prevalence rate.

RESULTS

We identified 303 articles, and selected 19 articles according to selection criteria. A total of 16849 patients were included (mean age 68.3 years, 75.1% of males). Aortic aneurysms were found in 29% of patients and atherosclerotic occlusive disease in 66% of patients. Lung cancer was identified in 538 patients, representing a prevalence of 3%.

DISCUSSION

Lung cancer is found in 3% of patients with atherosclerotic PAD. This prevalence is higher than that found in lung cancer screening programs performed in the general population of smokers and former smokers. These patients should be screened for lung cancer. Their selection may dramatically increase the benefit of lung cancer screening.

Progressive clinical case-based multiple-choice questions: An innovative way to evaluate and rank undergraduate medical students

INTRODUCTION

In France, at the end of the sixth year of medical studies, students take a national ranking examination including progressive clinical case-based multiple-choice questions (MCQs). We aimed to evaluate the ability of these MCQs for testing higher-order thinking more than knowledge recall, and to identify their characteristics associated with success and discrimination.

METHODS

We analysed the 72 progressive clinical cases taken by the students in the years 2016-2019, through an online platform.

RESULTS

A total of 72 progressive clinical cases (18 for each of the 4 studied years), corresponding to 1059 questions, were analysed. Most of the clinical cases (n=43, 60%) had 15 questions. Clinical questions represented 89% of all questions, whereas basic sciences questions accounted for 9%. The most frequent medical subspecialties were internal medicine (n=90, 8%) and infectious diseases (n=88, 8%). The most frequent question types concerned therapeutics (26%), exams (19%), diagnosis (14%), and semiology (13%). Level 2 questions ("understand and apply") accounted for 59% of all questions according to the Bloom's taxonomy. The level of Bloom's taxonomy significantly changed over time with a decreasing number of level 1 questions ("remember") (P=0.04). We also analysed the results of the students among 853 questions of training ECNi. Success and discrimination significantly decreased when the number of correct answers increased (P<0.0001 both). The success, discrimination, mean score, and mean number of discrepancies did not differ according to the diagnosis, exam, imaging, semiology, or therapeutic type of questions.

CONCLUSION

Progressive clinical case-based MCQs represent an innovative way to evaluate undergraduate students.

[Psychopharmacotherapeutic guidelines : a challenge during health crisis]

The construction of pharmacological guidelines is a complex endeavor, and this is all the truer amidst a health crisis such as the current SARS-CoV-2 pandemic. In psychiatric settings, guidelines have to consider the handling of other drugs (i.e., psychotropic medications), that have been suggested as potentially prophylactic for COVID-19. These dialectics are discussed here, and the methodological foundations used for the elaboration of guidelines are put forward.

[Challenges for psychotropics in the context of the SARS-Cov-2 pandemic]

French recommendations have been proposed for psychotropics use and possible adaptations during the SARS-CoV-2 epidemic. Between uncertainties linked to the lack of data and speculations about possible benefits of psychotropics against the coronavirus, we propose here elements allowing to base the pharmacotherapeutic decisions potentially useful in Covid+ patients with psychiatric disorders.

[Informations on psychotropics and their adaptations for patients suffering from mental disorders in France during the SARS-CoV-2 epidemic]

The 2019-20 coronavirus pandemic (SARS-CoV-2; severe acute respiratory syndrome coronavirus 2) has dramatic consequences on populations in terms of morbidity and mortality and in social terms, the general confinement of almost half of the world's population being a situation unprecedented in history, which is difficult today to measure the impact at the individual and collective levels. More specifically, it affects people with various risk factors, which are more frequent in patients suffering from psychiatric disorders. Psychiatrists need to know: (i) how to identify, the risks associated with the prescription of psychotropic drugs and which can prove to be counterproductive in their association with COVID-19 (coronavirus disease 2019), (ii) how to assess in terms of benefit/risk ratio, the implication of any hasty and brutal modification on psychotropic drugs that can induce confusion for a differential diagnosis with the evolution of COVID-19. We carried out a review of the literature aimed at assessing the specific benefit/risk ratio of psychotropic treatments in patients suffering from COVID-19. Clinically, symptoms suggestive of COVID-19 (fever, cough, dyspnea, digestive signs) can be caused by various psychotropic drugs and require vigilance to avoid false negatives and false positives. In infected patients, psychotropic drugs should be used with caution, especially in the elderly, considering the pulmonary risk. Lithium and Clozapine, which are the reference drugs in bipolar disorder and resistant schizophrenia, warrant specific attention. For these two treatments the possibility of a reduction in the dosage - in case of minimal infectious signs and in a situation, which does not allow rapid control - should ideally be considered taking into account the clinical response (even biological; plasma concentrations) observed in the face of previous dose reductions. Tobacco is well identified for its effects as an inducer of CYP1A2 enzyme. In a COVID+ patient, the consequences of an abrupt cessation of smoking, particularly related with the appearance of respiratory symptoms (cough, dyspnea), must therefore be anticipated for patients receiving psychotropics metabolized by CYP1A2. Plasma concentrations of these drugs are expected to decrease and can be related to an increase risk of relapse. The symptomatic treatments used in COVID-19 have frequent interactions with the most used psychotropics. If there is no curative treatment for infection to SARS-CoV-2, the interactions of the various molecules currently tested with several classes of psychotropic drugs (antidepressants, antipsychotics) are important to consider because of the risk of changes in cardiac conduction. Specific knowledge on COVID-19 remains poor today, but we must recommend rigor in this context in the use of psychotropic drugs, to avoid adding, in patients suffering from psychiatric disorders, potentially vulnerable in the epidemic context, an iatrogenic risk or loss of efficiency.