Methadone Withdrawal-Induced Psychosis: A Case Report

Methadone is a synthetic full µ-opioid receptor agonist and N-methyl-D-aspartate antagonist given to patients who have recently stopped using illicit opioids or are tapering off chronic opioid pain medication. Maintenance treatment with methadone is today the most widespread and effective way to treat opiate addiction, which achieves abstinence, decreases morbidity and mortality, improves quality of life, and reduces crime genesis, among other benefits. It is also approved by the Food and Drug Administration for treating moderate-to-severe pain that remains unresponsive to nonopioid medications. Patients sometimes abruptly discontinue the medication for several reasons and sometimes suffer distressing but non-life-threatening withdrawal symptoms. More common withdrawal symptoms include anxiety, agitation, rhinorrhea, nausea, and vomiting, like other opioid agonist medications. Psychosis has been reported in some rare cases of methadone withdrawal. However, more research is required because, although psychotic symptoms have been described in different case reports after the reduction or withdrawal of methadone, they have not been sufficient. This case report contributes to the literature on rare manifestations of psychosis in patients who abruptly discontinue the use of methadone.

Psychosis as a Manifestation of Focal Impaired Awareness Seizure in a Geriatric Patient

Focal impaired awareness seizures (FIAS), previously known as complex partial seizures, refer to focal seizures that start in one hemisphere of the brain and are associated with an impairment in consciousness. FIAS of temporal lobe origin most often present with psychopathology, such as behavioral and affective symptoms. It has a bimodal age distribution peaking at the extremes of life. Geriatric presentations can often be subtle and go unnoticed asides from a few symptoms, such as confusion and memory lapses. Here, we present a unique case of a geriatric patient with FIAS presenting as transient psychosis.

Rebound Catatonia Associated With Injectable Paliperidone

Paliperidone is an atypical antipsychotic medication commonly used to treat schizophrenia, schizoaffective disorder, and bipolar disorder. It is a metabolite of risperidone and has a similar mechanism of action, primarily blocking dopamine 2 receptors (D2 receptors) in the brain. Paliperidone has various adverse effects, including extrapyramidal symptoms, weight gain, and metabolic disturbances. Catatonia is rare but severe side effects can occur in the context of an underlying psychiatric, neurologic, or general medical condition. Paradoxically, antipsychotics for treating schizophrenia or bipolar spectrum disorders can precipitate or worsen catatonic symptoms. The report suggests that 17-19% of all cases diagnosed as catatonia due to other medical conditions are medication-induced. Catatonia is a neuropsychiatric syndrome that presents as a cluster of psychomotor signs and symptoms resulting in movement and behavior aberrations. Various symptoms, including mutism, stupor, rigidity, and abnormal movements, characterize catatonia. Catatonia is a potentially life-threatening condition requiring prompt recognition and management. Here, we present a case of a patient with catatonia associated with long-acting injectable paliperidone intramuscular therapy in a patient with schizophrenia.

Lithium-Induced Sialorrhea

Lithium is a mood stabilizer frequently used in psychiatry to treat bipolar disorder. Because lithium has a narrow therapeutic index, it requires frequent monitoring for its toxicity. Lithium toxicity requires monitoring of serum lithium and clinical assessment by clinicians. Sialorrhea, also known as excessive drooling, hypersalivation, or ptyalism, is common among psychiatric patients. Sialorrhea, an infrequent and embarrassing side effect of lithium, has been reported at varying serum levels, either at subtherapeutic or in the normal range. Here, we present the case of a patient with sialorrhea associated with oral lithium therapy at the subtherapeutic serum level.

Implementation of a telehealth-enhanced home visiting programme for families of young children

INTRODUCTION

Health systems are applying innovative solutions, such as telehealth and home visiting, to reduce unnecessary healthcare utilization, including emergency department (ED) visits. A large paediatric healthcare system implemented a telehealth-enhanced home visiting programme as an extension of primary care services. The purpose of this paper is three-fold: (1) Examine the process of implementation and the intermediate clinical outcomes; (2) Evaluate patient experiences and acceptability of the programme post-implementation; (3) Identify system, clinic and patient factors influencing implementation of the home visiting programme.

METHODS

Implementation of the telehealth-enhanced home visiting programme occurred from July 2018 to March 2019. Longitudinal electronic health records (EHR) and surveys were triangulated with qualitative data to evaluate the preliminary effectiveness, feasibility, and acceptability of the programme.

RESULTS

Of the 948 eligible families, clinical care staff referred 38% of families to the home visiting programme and 49 families (5%) completed the 12-week home visiting programme. Necessary ED utilization significantly increased post-implementation compared with pre-implementation. Families were overall highly satisfied with the programme and its content. Several factors influenced implementation including outer setting (i.e. patient needs and external policy), inner setting (e.g. poor leadership engagement, fully integrated network, and high tension for change), and individual characteristics (e.g. high self-efficacy).

CONCLUSIONS

Once families were enrolled, the programme was fairly successful in addressing patient outcomes. The programme and visit process was highly regarded by families and the unlicensed healthcare professionals. Future programme recommendations, such as small programmatic changes and major improvements in the clinic, should be implemented before widespread dissemination.

Objective Evaluation of a Simulation Course for Residents in the Pediatric Emergency Medicine Department: Breaking Bad News

INTRODUCTION

Breaking bad news (BBN), especially in the pediatric emergency medicine department, requires significant skill and delicacy due to the acute context of a busy emergency department (ED) and the lack of prior rapport with the patients and families. Pediatric literature on breaking bad news has mostly focused on pediatric oncology and pediatric critical care, with limited literature focused on pediatric emergency medicine. Review of the literature also reveals that most existing studies solely assess the learners' self-ratings of efficacy and comfort, and far fewer studies objectively evaluate learners' actual performance using simulation. Our objectives for this study was to use an objective assessment tool to assess residents' breaking bad news skills, pre- and post-simulation training, specifically in the setting of a pediatric emergency medicine department.

METHODS

34 residents were evaluated on their performance in breaking bad news via videotaped simulation encounters before and after teaching intervention. The "Modified Breaking Bad News Assessment Scale" (mBAS) was used as the assessment tool. A paired t-test analysis was conducted to examine the mean difference in pre- and post-simulation scores in each of the five mBAS domains.

RESULTS

Breaking bad news performance score improves one to two weeks post-intervention, and was statistically significant in three of five domains.

CONCLUSION

Our study shows that breaking bad news is a teachable skill that can be improved by simulated education in the pediatric emergency medicine department. This study demonstrates the utility of simulation course in improving breaking bad news skills in the pediatric emergency medicine department. Future work in developing focused simulation curriculums is important to improve provider communication skills and patient-physician relationships.

Stroke-like syndrome in a middle aged Nigerian woman with metastatic brain cancer

BACKGROUND

Metastatic brain cancer constitutes about 24 to 25 % of brain tumours worldwide and in Nigeria it constitutes about 40% of brain tumors. The clinical presentation of metastatic tumors may be atypical.

OBJECTIVE

To present a middle aged Nigerian woman with a metastatic brain cancer who had a stroke-like syndrome.

METHODS

The patient was a 47-year old woman who presented with a two-week history of progressive weakness of the right upper and lower limbs, associated with headache, blurring of vision and slurring of speech. There was a history of weight loss but no history of cough or evening pyrexia. She was not a known hypertensive or diabetic patient though, there were positive history of diabetes mellitus in her father and elder senior brother. Her other systemic review and past medical history were not contributory.

RESULTS

Examination revealed a woman with expressive dysphasia and right spastic hemiparesis. Her pulse, blood pressure and heart sounds were normal. There was no carotid bruit. Imaging studies showed metastases in the brain, liver, chest, cervical lymph nodes and bone marrow. Cervical lymph node histology showed metastatic adenocarcinoma. She was managed with chemotherapy, steroids and other supportive therapy but she died on the 40th day of admission due to disease progression and aspiration pneumonitis.

CONCLUSION

Metastatic brain cancer may manifest atypically. Physicians should screen any patient with stroke without any apparent risk factors for possibilities of underlying metastatic brain cancer.

Immunoprotective factors in breast milk and sera of mother-infant pairs

We analysed breast milk and serum samples from 33 healthy Nigerian mother-infant pairs for concentrations of IgG, IgM, IgA, C3, C4 and lysozyme. We found that the mean IgG and IgM concentrations in maternal sera were three to four times higher than the levels in infant sera, and five to ten times higher than in breast milk. The IgA and lysozyme concentrations in breast milk were, however, slightly higher than the levels in infant sera, suggesting an active localized synthesis of these factors in the mammary gland. While 54.5% of the milk samples lacked measurable concentrations of IgM by radial immunodiffusion, IgA was consistently present in all the milk samples. The mean C3 concentration in maternal sera was 164 mg/100 ml, compared to 145 mg/100 ml and 11.5 mg/100 ml in infant sera and breast milk respectively. The C4 concentration was also considerably lower in breast milk than in maternal and infant sera.