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Kassam AS, Karalis P, Aydinian T, Panjwani A, Martinez G, Whiteman A, Daas M, Cunningham EA. Racial disparities with PRN medication usage in inpatient psychiatric treatment. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2024; 10:46. [PMID: 38615056 PMCID: PMC11016118 DOI: 10.1038/s41537-024-00461-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/15/2024] [Indexed: 04/15/2024]
Abstract
Racial disparities in psychiatric diagnoses and treatment have significant public health implications, contributing to inequities in healthcare outcomes. We specifically examined racial disparities regarding pro re nata (PRN), or as needed, medications. Data from 14,616 encounters across 2019-2020 within Community Health Network's inpatient psychiatric setting in Indianapolis, Indiana were included in this study. Due to the demographic sample size, analyses were narrowed to Black and White patients. Primary outcomes included comparisons across race for all PRN administrations and PRN administrations of antipsychotics vs. non-antipsychotics. Logistic regression was used to examine associations between race and PRN administrations by medication category, including all antipsychotics vs. non-antipsychotics overall, hydroxyzine, and lorazepam, independently. Significant differences in the percentage of administrations between Black and White patients were observed. Black patients received more PRN medications overall (71.0%) compared to White patients (67.7%) (p < 0.01). Further, while 17.7% of Black patients were administered PRN antipsychotics, this was true for only 8.2% of White patients (p < 0.001). When comparing antipsychotic PRNs with non-antipsychotic, hydroxyzine, and lorazepam PRNs, independently, Black patients were 58% (OR 1.58, p < 0.001), 109% (OR 2.09, p < 0.001), and 32% (OR 1.32, p < 0.001), more likely to receive antipsychotic PRNs, respectively, than White patients, controlling for sex, age, length of stay, and psychotic disorder diagnosis. Our study identifies yet another area of medical care with significant racial disparities. In this analysis of PRN medications during psychiatric admission, we identified significant differences in medication utilization by race. This information provides a basis for further investigation of disparities in patient-centered data.
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Affiliation(s)
- Areef S Kassam
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA.
| | - Peter Karalis
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA
| | - Taline Aydinian
- Harvard Medical School, Department of Psychiatry, Boston, MA, USA
| | - Anita Panjwani
- Purdue University, Department of Nutrition Science, West Lafayette, IN, USA
- Center on Aging and the Life Course, Purdue University, West Lafayette, IN, USA
| | - Gabriel Martinez
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA
| | - Aaron Whiteman
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA
| | - Magdoline Daas
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA
| | - E Ann Cunningham
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA
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Azoury SC, Matros E. Top 25 Medications the Plastic and Reconstructive Surgery Trainee Should Know for an Emergency Medicine Department Consult. Plast Reconstr Surg 2024; 153:474e-489e. [PMID: 37141488 DOI: 10.1097/prs.0000000000010609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
SUMMARY Plastic surgery trainees are often called to render care in the emergency department (eg, for established patients, trauma, burns). Broad-based knowledge in pharmacotherapeutics during these encounters is critical. This includes an understanding of pain medications, anxiolytics, local anesthetics, antibiotics, anticoagulants, antidotes, and more to ensure optimal patient care. The purpose of this report is to describe 25 frequently used and other important medications that plastic surgery trainees should know for an adult emergency department encounter.
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Affiliation(s)
- Saïd C Azoury
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Evan Matros
- Division of Plastic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
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Mills J. The Use of Benzodiazepines in Individuals with Bipolar Disorder: A Look at Recent Literature. Issues Ment Health Nurs 2023; 44:1171-1173. [PMID: 38015821 DOI: 10.1080/01612840.2023.2279004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Affiliation(s)
- Jeremy Mills
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
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Marks Y, Demler TL, Matecki C. Impact of the Medication Shortages on Psychiatric Patients: Exploring the Consequences of Lorazepam Injection Scarcity. INNOVATIONS IN CLINICAL NEUROSCIENCE 2023; 20:23-28. [PMID: 38193102 PMCID: PMC10773607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Objective This study reviewed the cases of 13 patients in a psychiatric hospital during the 2022 lorazepam injection shortage in the United States (US). The objective was to determine if there were any patterns to the management of the medication shortage of an essential psychiatric medication at a psychiatric hospital. Methods A retrospective review of eligible patients who had an order for lorazepam injection prescribed as needed (PRN) between July and October 2022 were divided into, and compared between, two groups: those who had orders permitting continued PRN administration of the medication and those who were discontinued. Results No negative behavioral issues were seen in the patients who had their doses discontinued. Conclusion The absence of negative psychiatric consequences suggests that either nonpharmacotherapeutic interventions were alternatively stabilizing or that the standing PRN orders for lorazepam injection were not needed for these patients. A proactive emergency management plan to address critical medication shortages has become an increasingly necessary contingency and would have been appropriate for use during this national shortage.
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Affiliation(s)
- Yael Marks
- All authors are with Department of Pharmacy Practice, State University of New York at Buffalo, School of Pharmacy and Pharmaceutical Sciences in Buffalo, New York
| | - Tammie Lee Demler
- All authors are with Department of Pharmacy Practice, State University of New York at Buffalo, School of Pharmacy and Pharmaceutical Sciences in Buffalo, New York
- Dr. Demler is additionally with Department of Pharmacy, New York State Office of Mental Health in Buffalo, New York; and Department of Psychiatry, State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences in Buffalo, New York
| | - Chloe Matecki
- All authors are with Department of Pharmacy Practice, State University of New York at Buffalo, School of Pharmacy and Pharmaceutical Sciences in Buffalo, New York
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Wang HJ, Kusumo RW, Kiss A, Tennen G, Marotta G, Viaje S, Lanctôt KL. Characterizing PRN Use of Psychotropic Medications for Acute Agitation in Canadian Long-Term Care Residents with Dementia Before and During COVID-19. J Alzheimers Dis Rep 2023; 7:575-587. [PMID: 37313488 PMCID: PMC10259051 DOI: 10.3233/adr-230009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/15/2023] [Indexed: 06/15/2023] Open
Abstract
Background Agitation is a disabling neuropsychiatric symptom of dementia. Pro re nata (PRN) injections of psychotropics can be administered for severe acute agitation, but little is known about the frequency of their actual use. Objective Characterize actual use of injectable PRN psychotropics for severe acute agitation in Canadian long-term care (LTC) residents with dementia and compare use before and during the COVID-19 pandemic. Methods Residents from two Canadian LTC facilities with orders for PRN haloperidol, olanzapine, or lorazepam between January 1, 2018- May 1, 2019 (i.e., pre-COVID-19) and January 1, 2020- May 1, 2021 (i.e., COVID-19) were identified. Electronic medical records were reviewed to document PRN injections of psychotropic medications and collect data on reason and demographic characteristics. Descriptive statistics were used to characterize frequency, dose, and indications of use, and multivariate regression models were used to compare use between time periods. Results Of the 250 residents, 45 of 103 (44%) people in the pre-COVID-19 period and 85 of 147 (58%) people in the COVID-19 period with standing orders for PRN psychotropics received ≥1 injections. Haloperidol was the most frequently used agent in both time periods (74% (155/209 injections) pre-COVID-19; 81% (323/398 injections) during COVID-19). Residents in the COVID-19 period were almost two times more likely to receive injections compared with those in the pre-COVID-19 period (odds ratio = 1.96; 95% CI = 1.15-3.34; p = 0.01). Conclusion Our results suggest that use of PRN injections increased in LTC during the pandemic and contribute to the mounting evidence that agitation worsened during that time.
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Affiliation(s)
- Hui Jue Wang
- Neuropsychopharmacology Research Group, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Raphael W. Kusumo
- Neuropsychopharmacology Research Group, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Alex Kiss
- Department of Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Gayla Tennen
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Giovanni Marotta
- Neuropsychopharmacology Research Group, Sunnybrook Research Institute, Toronto, ON, Canada
- Division of Geriatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Villa Colombo Homes for the Aged Inc, North York, ON, Canada
| | - Shirley Viaje
- Villa Colombo Homes for the Aged Inc, North York, ON, Canada
| | - Krista L. Lanctôt
- Neuropsychopharmacology Research Group, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON Canada
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Sandoval S, Goyal A, Frawley J, Gappy R, Chen NW, Crowe RP, Swor R. Prehospital Use of Ketamine versus Benzodiazepines for Sedation among Pediatric Patients with Behavioral Emergencies. PREHOSP EMERG CARE 2023; 27:908-914. [PMID: 36629484 DOI: 10.1080/10903127.2022.2163326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Ketamine is an emerging alternative sedation agent for prehospital management of agitation, yet research is limited regarding its use for children. Our objective was to compare the effectiveness and safety of ketamine and benzodiazepines when used for emergent prehospital sedation of pediatric patients with behavioral emergencies. METHODS We performed a retrospective review of 9-1-1 EMS records from the 2019-2020 ESO Data Collaborative research datasets. We included patients ≤18 years of age who received ketamine or benzodiazepines for EMS primary and secondary impressions indicating behavioral conditions. We excluded patients with first Glasgow Coma Scale (GCS) scores ≤8, those receiving ketamine or benzodiazepines prior to EMS arrival, those receiving both ketamine and benzodiazepines, and interfacility transfers. Effectiveness outcomes included general clinician assessment of improvement, decrease in GCS, and administration of a subsequent sedative. Safety outcomes included mortality; advanced airway placement; ventilatory assistance without advanced airway placement; or marked sedation (GCS ≤8). Chi-square and t-tests were used to compare the ketamine and benzodiazepines groups. RESULTS Of 57,970 pediatric patients with behavioral complaints and GCS scores >8, 1,539 received ketamine (13.3%, n = 205) or a benzodiazepine (86.7%, n = 1,334). Most patients were ≥12 years old (89.2%, n = 1,372), predominantly Caucasian (48.3%, n = 744), and were equally distributed by sex (49.7% male, n = 765). First treatment with ketamine was associated with a greater likelihood of improvement (88.8% vs 70.5%, p < 0.001) and a greater average GCS reduction compared to treatment with benzodiazepines (-2.5 [SD:4.0] vs -0.3 [SD:1.7], p < 0.001). Fewer patients who received ketamine received subsequent medication compared to those who received benzodiazepines (12.2% vs 27.0%, p < 0.001). Marked sedation was more frequent with ketamine than benzodiazepines (28.8% vs 2.9%, p < 0.001). Provision of ventilatory support (1.5% vs 0.5%, p = 0.14) and advanced airway placement (1.0% vs 0.2%, p = 0.09) were similar between ketamine and benzodiazepine groups. No prehospital deaths were reported. CONCLUSION In this pediatric cohort, prehospital sedation with ketamine was associated with greater patient improvement, less subsequent sedative administration, and greater sedation compared to benzodiazepines. Though we identified low rates of adverse events in both groups, ketamine was associated with more instances of marked sedation, which bears further study.
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Affiliation(s)
- Sariely Sandoval
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Ashima Goyal
- Division of Pediatric Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - John Frawley
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Revelle Gappy
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | - Nai-Wei Chen
- Division of Informatics and Biostatistics, Beaumont Research Institute, Royal Oak, Michigan
| | | | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
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Searles Quick VB, Herbst ED, Kalapatapu RK. Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation. Front Psychiatry 2021; 12:750686. [PMID: 34950067 PMCID: PMC8688542 DOI: 10.3389/fpsyt.2021.750686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 11/10/2021] [Indexed: 11/28/2022] Open
Abstract
Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.
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Affiliation(s)
- Veronica B Searles Quick
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Ellen D Herbst
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Raj K Kalapatapu
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
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