Assessment and management of individuals consulting for a suicidal crisis: A European Delphi method-based consensus guidelines

INTRODUCTION

Managing patient with suicidal thoughts and behaviours presents significant challenges due to the scarcity of robust evidence and clear guidance. This study sought to develop a comprehensive set of practical guidelines for the assessment and management of suicidal crises.

MATERIALS AND METHODS

Utilizing the Delphi methodology, 80 suicide clinician and research experts agreed on a series of recommendations. The process involved two iterative rounds of surveys to assess agreement with drafted recommendations, inviting panellists to comment and vote, culminating in 43 consensus recommendations approved with at least 67% agreement. These consensus recommendations fall into three main categories: clinical assessment, immediate care, and long-term approaches.

RESULTS

The panel formulated 43 recommendations spanning suicidal crisis recognition to continuous long-term care. These guidelines underscore systematic proactive suicide risk screening, in-depth medical and toxicological assessment, and suicide risk appraisal considering personal, clinical factors and collateral information from family. The immediate care directives emphasize a secure environment, continuous risk surveillance, collaborative decision-making, including potential hospitalization, sensible pharmacological management, safety planning, and lethal means restriction counselling. Every discharge should be accompanied by prompt follow-up care incorporating proactive case management and multi-modal approach involving crisis lines, brief contact, and psychotherapeutic and pharmacological interventions.

CONCLUSIONS

This study generated comprehensive guidelines addressing care for individuals in suicidal crises, covering pre- to post-discharge care. These practical recommendations can guide clinicians in managing patients with suicidal thoughts and behaviours, improve patient safety, and ultimately contribute to the prevention of future suicidal crises.

Four-month incidence of suicidal thoughts and behaviors among healthcare workers after the first wave of the Spain COVID-19 pandemic

Healthcare workers (HCW) are at high risk for suicide, yet little is known about the onset of suicidal thoughts and behaviors (STB) in this important segment of the population in conjunction with the COVID-19 pandemic. We conducted a multicenter, prospective cohort study of Spanish HCW active during the COVID-9 pandemic. A total of n = 4809 HCW participated at baseline (May-September 2020; i.e., just after the first wave of the pandemic) and at a four-month follow-up assessment (October-December 2020) using web-based surveys. Logistic regression assessed the individual- and population-level associations of separate proximal (pandemic) risk factors with four-month STB incidence (i.e., 30-day STB among HCW negative for 30-day STB at baseline), each time adjusting for distal (pre-pandemic) factors. STB incidence was estimated at 4.2% (SE = 0.5; n = 1 suicide attempt). Adjusted for distal factors, proximal risk factors most strongly associated with STB incidence were various sources of interpersonal stress (scaled 0-4; odds ratio [OR] range = 1.23-1.57) followed by personal health-related stress and stress related to the health of loved ones (scaled 0-4; OR range 1.30-1.32), and the perceived lack of healthcare center preparedness (scaled 0-4; OR = 1.34). Population-attributable risk proportions for these proximal risk factors were in the range 45.3-57.6%. Other significant risk factors were financial stressors (OR range 1.26-1.81), isolation/quarantine due to COVID-19 (OR = 1.53) and having changed to a specific COVID-19 related work location (OR = 1.72). Among other interventions, our findings call for healthcare systems to implement adequate conflict communication and resolution strategies and to improve family-work balance embedded in organizational justice strategies.

Immediate and short-term efficacy of suicide-targeted interventions in suicidal individuals: A systematic review

OBJECTIVES

To address the extreme suicide risk period following a suicidal crisis, we aimed to assess the current evidence for specific healthcare system-based interventions on suicide-related outcomes within one-week or one-month in individuals with current suicidal ideation (SI) or a recent suicide attempt (SA).

METHODS

We performed a database (Medline, Academic Search Complete, PsycARTICLES, the Cochrane library, PubMed) and manual reference search for randomised controlled trials, published between March 2000 and March 2020. Antisuicidal efficacy was defined as SI, SA, or a closely related concept. Quality was assessed with the Cochrane Risk of Bias 2 tool for randomised trials.

RESULTS

Out of 34 trials, five reported ketamine or esketamine superiority over placebo in reducing SI in depressed subjects within one week, while five studies had negative findings. Single trials reported positive results for one-month antisuicidal efficacy of buprenorphine, paroxetine, a crisis response plan, and assertive case management. Most trials were underpowered and had moderate-to-high risk of bias.

CONCLUSIONS

Preliminary mixed evidence suggests the possible utility of several pharmacological (ketamine, esketamine paroxetine, and buprenorphine) and non-pharmacological (a crisis response plan, and assertive case management) interventions. Only the immediate efficacy of ketamine was supported by multiple studies, and replication is needed.

Translating big data to better treatment in bipolar disorder - a manifesto for coordinated action

Bipolar disorder (BD) is a major healthcare and socio-economic challenge. Despite its substantial burden on society, the research activity in BD is much smaller than its economic impact appears to demand. There is a consensus that the accurate identification of the underlying pathophysiology for BD is fundamental to realize major health benefits through better treatment and preventive regimens. However, to achieve these goals requires coordinated action and innovative approaches to boost the discovery of the neurobiological underpinnings of BD, and rapid translation of research findings into development and testing of better and more specific treatments. To this end, we here propose that only a large-scale coordinated action can be successful in integrating international big-data approaches with real-world clinical interventions. This could be achieved through the creation of a Global Bipolar Disorder Foundation, which could bring government, industry and philanthropy together in common cause. A global initiative for BD research would come at a highly opportune time given the seminal advances promised for our understanding of the genetic and brain basis of the disease and the obvious areas of unmet clinical need. Such an endeavour would embrace the principles of open science and see the strong involvement of user groups and integration of dissemination and public involvement with the research programs. We believe the time is right for a step change in our approach to understanding, treating and even preventing BD effectively.

Diltiazem inhibits human intestinal cytochrome P450 3A (CYP3A) activity in vivo without altering the expression of intestinal mRNA or protein

AIMS

To determine the effect of diltiazem on intestinal CYP3A activity and protein and mRNA expression in vivo in healthy subjects.

METHODS

Intestinal biopsies were obtained from ten healthy controls and from ten healthy subjects after receiving diltiazem 120 mg bid for 7 days. Intestinal CYP3A activity, CYP3A4 protein and mRNA concentrations were quantified in both groups. Intestinal CYP3A activity was determined by incubation of small bowel homogenate with midazolam (25 microM) and NADPH for 5 min and the rate of formation of 1'-hydroxymidazolam was quantified.

RESULTS

All subjects in the treatment group had detectable diltiazem concentration in the serum. While there was no significant difference in CYP3A4 protein and mRNA expression between the control and treatment groups, the formation of 1'-hydroxymidazolam (446 pmol min(-1) mg(-1) 6 (control) vs. 170 (CI 112, 228) pmol min(-1) mg(-1) 95% confidence interval (CI 269, 623) (diltiazem group)) was significantly reduced (P < 0.05).

CONCLUSION

Diltiazem decreased small bowel CYP3A activity by 62% as a result of irreversible inhibition with no corresponding change in intestinal CYP3A4 mRNA or protein concentrations.

[Midterm results of coronary bypass surgery exclusively with arterial revascularization]

INTRODUCTION AND OBJECTIVES

In recent years, the exclusive use of arterial grafts in coronary surgery has been the surgical option to achieve maximum survival and minimum recurrence of coronary events. The aim of this study was to analyze the surgical results and follow up of this approach.

PATIENTS AND METHODS

Over a period of six and a half years, 87 patients underwent coronary surgery using arterial grafts alone for revascularization. The mean age of the patients was 62 +/- 1 years with 78 men and 9 women; 22 patients (25%) were clinically unstable. The number of vessels affected per patient was 1.83 +/- 0.1, and the number of patients with one, two and three affected vessels, were 38 (44%), 26 (30%) and 23 (26%), respectively. The mean ejection fraction was 63 +/- 1.6. Emergency surgery was carried out in 13 cases (16%).

RESULTS

A total of 1.9 +/- 0.1 grafts were implanted per patient and complete revascularization was achieved in 65 cases (75%). The left mammary artery was used in 87 cases (100%), the right mammary artery in 31 (35.6%) and the radial artery in 20 cases (23%). Hospital mortality was 1.1% (one case). During the postoperative period, 3 patients (3.4%) presented myocardial infarction, 12 (13.8%) atrial fibrillation and there were 3 cases of sternal dehiscence.A total of 86 patients (98.9%) were followed over a mean period of 24.5 +/- 0.5 months. Survival, angina-free period and period free of any coronary event at 5 years were 97 +/- 0.05%, 89 +/- 0.1% and 87 +/- 0.1% respectively (mean +/- standard error, CI 95%). On multivariate analysis, the presence of peripheral vascular disease (p < 0.015) and the development of low cardiac output (p < 0.04) or atrial fibrillation (p < 0.04) during the postoperative period were predictive factors for the appearance of coronary events during follow-up.

CONCLUSIONS

Surgery exclusively with arterial grafts achieves good medium term results in relation to survival and time free of coronary events.

Aortic intramural hematoma during coronary angioplasty: insights into the pathogenesis of intramedial hemorrhage

We report a case of a 74-year-old woman who had an aortic intramural hematoma as a complication of percutaneous coronary angioplasty. Transesophageal echocardiography enabled the diagnosis of aortic intramural hematoma and was very useful in the patient's management and follow-up.

Effect of folate supplementation on DNA methylation of rectal mucosa in patients with colonic adenomas: correlation with nutrient intake

We have evaluated the effect of folate supplementation (5 mg/day) on global deoxyribonucleic acid (DNA) methylation status of the rectal mucosa of 20 patients with resected colonic adenomas in a prospective, controlled, cross-over study. Baseline values of DNA methylation were inversely correlated with caloric (P = 0.03) and fat intake (P = 0.05) and patients harbouring multiple polyps consumed significantly more calories (P = 0.0006), fat (P = 0.009) and carbohydrates (P = 0.009) as compared to patients having one single lesion. Folate supplementation resulted in a significant decrease of DNA hypomethylation in 7/20 patients (P = 0.05) which returned to previous values after placebo treatment. This effect was significantly correlated with number of polyps, with all the responders presenting one single lesion, whereas 8/13 of the non-responders had multiple ones (chi2 = 7.17, P = 0.007). In conclusion, folate supplementation may decrease degree of DNA hypomethylation, but only in patients with one single polyp. In those with multiple lesions, other nutritional factors such as caloric and fat intake, may be more determinant.

Extensive aneurysm of the aortic arch and descending aorta. Extra-anatomical reconstruction and exclusion of the aneurysmal sac

A new technique for repair of extensive aneurysm reaching from the ascending aorta to the diaphragm is presented. The operation consists of the reconstruction of the aortic arch and descending aorta and the exclusion of the aneurysmal sac in a single operation. Two successful cases are presented.

Annuloaortic ectasia and adult polycystic kidney. A frequent association

The association of annuloaortic ectasia and polycystic kidney in 18 consecutive patients who had intravenous pyelograms was 22 percent (4/18). Due to this high association rate, some type of work-up to study the kidney anatomy should be performed in every case of annuloaortic ectasia. For the same reasons, patients with adult polycystic kidney should have a careful cardiovascular evaluation.

Compound grafts of xenopericardium and Dacron fabric for repair or replacement of great vessels: a method to avoid interstitial and suture hole bleeding

Compound grafts constructed by wrapping pericardial xenografts around fabric grafts were used for replacement or repair of the great vessels. After cardiopulmonary bypass (CPB), bleeding through the compound graft is nil. Nine patients had the intrathoracic aorta replaced with a compound graft, and eight patients had patch repair of the ascending aorta or the right ventricular outflow tract. Bleeding in all patients was minimal because the nonporous nature of the xenopericardium avoids interstitial and suture hole hemorrhage until normal hemostasis is obtained.

Enlargement of the aortic annulus by resecting the commissure between the left and noncoronary cusps

Images