There’s No Place Like Home: A Multidisciplinary Approach to Holistically Manage Addiction and Intravenous Drug Use Related Infections Requiring Intravenous Antibiotics

Lead presenter: Alisha Agrawai, MD

The opioid epidemic has resulted in increasing intravenous drug use (IVDU) related infections. Patients who inject substances intravenously have traditionally been excluded from outpatient IV antibiotic therapy programs due to safety concerns leading to prolonged hospitalizations, Against Medical Advice (AMA) discharges, and readmissions.

This study looks at outcomes from the implementation of a multidisciplinary team at Dartmouth-Hitchcock Medical Center for patients admitted with IVDU-related infections requiring long-term IV antibiotic therapy.

The results demonstrate that addiction was addressed in a higher percentage of admissions after multidisciplinary intervention was implemented. Although there was no difference in AMA discharge rates, and there was an increase in readmission rates post-intervention, results show that more patients were discharged on outpatient IV antibiotic therapy with an overall decrease in average length of stay.

“These findings are promising given that we know starting buprenorphine in-hospital and linking patients to outpatient MOUD [Medications for Opium Use Disorder] is more effective at retaining patients in treatment than compared to detoxification and referral,” say the presenters. “In addition, by safely increasing access to OPAT [Outpatient Parenteral Antimicrobial Therapy] for patients with IVDU, we can decrease lengths of hospital stay and, in turn, allow patients to return to their lives, reducing both institutional and patient costs.”

Dr. Marcangelo: “Managing opioid use disorder in the context of the worsening opioid crisis is becoming a larger and larger part of the work of inpatient C-L psychiatrists. This poster will provide evidence that a multidisciplinary approach can improve certain outcomes and give meeting attendees a roadmap to thinking about how to construct or modify their own service. Clinical innovations are a key part of the poster session and this is an example of the kind of work that will be showcased this year.”

Hormone Therapy in Gender Dysphoria with Concurrent Mental Health Diagnoses: National Data

Lead presenter: Mckenzee Chiam, BS

The three authors of this paper are (from left): Mckenzee Chiam, BS; Katharine Dalke, MD, MBE; and Andrew Francis, MD, PhD.

The prevalence of patients identifying as transgender is increasing. Transgender populations have increased rates of psychiatric diagnoses, but gender-affirming hormonal therapy (HT) can improve their mental health and quality of life.

This study investigated psychiatric comorbidities in gender dysphoria (GD) and the association of HT and GD across age and lifetime rates of psychiatric diagnoses.

Data indicates a minority of patients (10-20%) with GD receive HT. Overall, GD patients with most of the queried lifetime psychiatric comorbidities show similar overall rates of HT, except for those aged <18 with bipolar disorder. Some psychiatric comorbidities affect use or access to HT among younger GD patients.

Dr. Marcangelo: “This abstract utilizes a national database to increase knowledge of the prevalence of hormone therapy in people with gender dysphoria and how it relates to psychiatric conditions. One key finding is the overall high prevalence of psychiatric disorders among people with gender dysphoria. Given other work that has shown benefit for psychiatric conditions in people with gender dysphoria who receive hormone therapy, this poster highlights the disparities that exist for people seeking treatment and how that represents a missed opportunity to address psychiatric comorbidities.”

A Case of Disseminated Near Histoplasmosis presenting with Rapidly Progressive Cognitive Impairment: Case Report and Review of Psychiatric Symptoms in Fungal Infections

Lead presenter: Andrew Coulter, MD

Disseminated histoplasmosis is a rare complication of exposure to H. capsulatum, a common fungus endemic to the Midwestern states. Most patients who develop disseminated histoplasmosis are immunosuppressed, but there are several reports where the condition has developed in immunocompetent individuals. Patients may present with fever, fatigue, falls, cerebellar signs, confusion, or encephalopathy, among other physical signs.

“Given the variety of seemingly unrelated and diffuse symptoms, it often is misdiagnosed and treatment is delayed,” say the presenters, who give a case history example.

“Fungal infections can present insidiously and initial symptoms can be nonspecific. Patients with new onset psychiatric syndromes, as well as illness progressions that do not match known phenomenology, should be evaluated for occult infection. In addition, patients with emotional or cognitive symptoms with new-onset neurological symptoms should receive further evaluation.”

Collaboration with infectious diseases is recommended given their expertise in determining risk of exposure, appropriate testing, and management. “C-L psychiatrists should thoroughly evaluate cases of new-onset psychiatric syndromes for reversible causes, including fungal infection, even in immunocompetent individuals,” say the presenters.

Dr. Marcangelo: “Case reports provide key information about rare or unusual presentations and the annual poster session is a great opportunity for attendees to discuss diagnostic approaches and management. This case, of a patient with rapid cognitive decline who is found to have disseminated histoplasmosis, describes the clinical course and management clearly. One of the key roles of C-L psychiatrists is to recognize medical conditions presenting with behavioral symptoms and this case is an excellent example.”

Treatment Options for Catatonia in Cancer: Case Series and Literature Review

Lead presenter: Elizabeth Hale, MD

Catatonia is a syndrome of neuropsychiatric symptoms seen in mood and psychotic disorders, as well as medically complex individuals. Few studies have examined catatonia occurring in individuals with cancer; case reports have primarily focused on autoimmune encephalitis and paraneoplastic syndromes.

“To our knowledge, no clear cases of individuals developing catatonia without positive paraneoplastic causes or autoimmune markers have been reported,” say the presenters.

They describe two individuals without prior psychiatric history who developed catatonia after cancer diagnosis and aim to provide the C-L psychiatrist with management strategies in this population.

“Identifying treatment options, including pharmacotherapy and ECT, for catatonia in individuals with cancer can help lead to improvement in symptoms and overall prognosis,” they say.

Dr. Marcangelo: “This poster brings together two areas of abiding interest for the Academy—psycho-oncology and evaluation and management of catatonia. The cases presented here are encountered in practice, albeit rarely, and the presenters will expand on the cases with a review of the literature. Posters such as these provide guidance about best practices for relatively unusual presentations and add value for attendees looking to sharpen their clinical skills.”

Single-Agent Bupropion Overdose Presenting as Serotonin Syndrome: A Case Report and Literature Review

Lead presenter: Nadia Cacodcar, MD

Bupropion is a dopamine norepinephrine reuptake inhibitor (DNRI) felt to work in the mesocorticolimbic pathway. Overdose generally causes tachycardia, tremor, hallucinations, seizures, and agitation.

Although not directly serotonergic, bupropion has indirect effects on serotonergic neurons through inducing increased norepinephrine release in the raphe nucleus and locus coeruleus. Theoretically, this could cause symptoms more consistent with serotonin toxicity than simply dopamine and norepinephrine toxicity. 

Here, the presenters show the case of a man who overdosed on bupropion with signs of serotonin syndrome.

“There is little literature on single agent bupropion overdose resulting in serotonin syndrome,” say the presenters. “As bupropion is known by most psychiatrists as a pure DNRI to both augment serotonin reuptake inhibitors and use in individuals who have side-effects from serotonin, it is uncommon to consider that bupropion itself could cause serotonin toxicity in overdose.  Psychiatrists need to be aware of this rare but possible complication in single agent overdose.”

Dr. Marcangelo: “This case adds to a small literature that reports serotonin syndrome in patients who have bupropion toxicity. The case is well documented and allows the authors to link to the other cases that have been reported in terms of phenomenology and treatment. Discussion of complex psychopharmacology and toxicity is an essential part of the meeting, and posters such as this allow attendees to grapple with challenging problems.”

Piloting a Standardized Documentation Protocol for Observational Sitters on Non-Psychiatric Units

Lead presenter: Audrey Chen, MD

One-to-one observation sitters are often utilized with delirious or behavioral crisis patients and may be a valuable source of clinical information. However, because there is no standardized job description or training for sitters, formal standardized documentation is lacking and much information is lost.

Data for this IRB-approved study is currently being collected. It pilots a standardized documentation template for sitters observing patients on non-psychiatric units. The presenters aim to evaluate feasibility and also hypothesize that, if successful, satisfaction among sitters providing data for medical decision-making will increase.

“Sitters represent an underutilized source of behavioral information for C-L psychiatrists with the potential to impact medical decision-making and ultimately patient outcomes,” say the presenters. “This study will provide practical information on the perceived utility and satisfaction of standardized sitter observations relative to feasibility, and thus inform future efforts in the development of standardized education and training protocols for observation sitters.”

Dr. Marcangelo: “One of the key differences between inpatient psychiatric services and consultation services is the quality of observational information that the psychiatric team receives. While inpatient staff are trained to watch for key signs and symptoms that can inform the team about the patient’s response to treatment, consultation teams often face a dearth of primary information. This study aims to standardized the documentation that observers in the hospital complete in order to improve the quality of information being fed forward. It is an intriguing and possibly low-cost way to understand patient’s presentations better and maybe even get people discharged more easily. This poster should provide guidance to attendees as to how they can improve their hospital’s internal communication.”

Methadone Dosing for Opioid Use Disorder in the Setting of Infective Endocarditis and QTc Prolongation

Lead presenter: Dustin Todaro, PhD, MD

Injection drug use-associated infective endocarditis (IDU-IE) among patients with opioid use disorder (OUD) is associated with significant morbidity and mortality. Methadone is an effective treatment for OUD but carries a risk of QTc prolongation and torsades de pointes. Currently, limited data exists to guide methadone titration for concurrent OUD and QTc prolongation in the setting of surgically managed IDU-IE.

Guidelines for treatment of IDU-IE endorse surgery if medically indicated and incorporating addiction treatment. Many patients strongly prefer to start or continue methadone postoperatively. “Patients undergoing surgical management of IDU-IE may be at risk for QTc prolongation,” say the presenters. “It is important to use accurate correction formulas to assess QTc prolongation, which may reveal QTc ranges within normal limits.”

The presenters describe methadone dosing for three patients with IDU-IE complicated by QTc prolongation. The case series provides anecdotal observations to guide high-risk methadone titration in patients with IDU-IE while generating questions for future systematic evaluation.

Dr. Marcangelo: “The use of methadone to manage patients with opioid use disorder has become standard of care while they are in the hospital. This abstract looks at a series of patients with QTc prolongation and describes how methadone was titrated safely using appropriate correction factors. Given that methadone is known to prolong QTc this provides important clinical guidance for a high-risk patient population. Their efforts appear to have been successful because while the patients did not have great outcomes, they did not suffer consequences related to the QTc interval. This poster will help to further disseminate this life-saving intervention and hopefully lead to wider adoption of safe methadone use.”

Building Community Capacity: The Development of a TBI Behavioral Health ECHO

Lead presenter: Jennifer Erickson, DO

Traumatic brain injury (TBI) is a significant cause of disability. TBI increases the risk and complexity of multiple behavioral health conditions. Successful TBI recovery can largely depend on access to, and engagement in, behavioral health treatment.

“Unfortunately, treatment of post-TBI symptoms often falls to community providers who have little support and are under-prepared to manage these complexities,” say the presenters. “We created the first program that leveraged the ECHO (Extension for Community Healthcare Outcomes) model to deliver an educational curriculum and support by experienced TBI experts to community providers who treat persons with TBI.”

The poster reviews literature for ECHO programs in special populations, the program development, community engagement, and the characteristics of the first group to complete the curriculum.

ECHO programs have supported multiple complicated medical and psychiatric populations. This is the first program to help patients with post-TBI behavioral health symptoms.

“C-L psychiatrists have increased opportunities and responsibility to contribute to the population health of communities,” say the presenters. “The TBI-Behavioral Health ECHO Program is a model for how C-L psychiatrists can approach developing and delivering this much-needed community support for complex patient populations.”

Dr. Marcangelo: “Traumatic brain injury (TBI) is a common problem on consultation services and the follow-up care for these patients is often fragmented. This poster discusses a program that was developed by experts to do community outreach around the care of post-TBI patients after they leave the hospital. By sharing the elements of their program, including how it was designed, how it was shared, and the impact, the presenters provide a blueprint for other consultation groups to develop their own post-discharge programs for patients with complex conditions. Just as important as the program’s successes will be learning about the places where it didn’t go smoothly—something that the poster session really facilitates through discussion and engagement.”

A Change of Heart: Psychiatric Considerations in the First Porcine to Human Cardiac Xenotransplantation

Lead presenter: Nithya Cherukuru, MD

Xenotransplantation has been regarded as a solution to the limited number of human organs available for the exceeding amount of people who need them. However, there is little guidance available regarding the selection and management of appropriate candidates.

The presenters report the first human recipient of a cardiac xenotransplantation, and the involvement of C-L psychiatrists during the process.   

“Without a formal, multidisciplinary team to evaluate and develop care plans for future xenotransplantation recipients, the difficulties that arose in this case are very likely to recur with new and unforeseeable variations,” say the presenters. “As xenotransplantation continues to be developed, unanticipated difficulties are a certainty, and prospective, proactive involvement of psychiatric services will be necessary.”

Dr. Marcangelo: “One of the fastest-moving frontiers in organ transplantation is xenotransplantation. This poster provides a case report of the first human recipient of a porcine heart and raises a number of ethical and clinical concerns about the care of the patient. As new technologies are developed, C-L Psychiatry will surely be asked to participate to determine a patient’s capacity and suitability for new procedures. The poster will centralize the importance of a multidisciplinary approach in transplant to protect patients and ensure equity. This poster is also an example of a major medical news story coming to the conference with information from those involved in the patient’s care. This should allow attendees to dispel myths and learn about the actual facts of the case.”

Lead presenter: Grace Masters, MD

Mood and anxiety disorders, including bipolar disorder (BD), affect 20% of perinatal individuals. This period carries a high risk of new-onset or exacerbation of BD. Recommendations suggest obstetric clinicians screen for BD during the perinatal period, especially prior to initiating pharmacotherapy—“yet this is often challenging,” say the presenters.

Perinatal Psychiatry Access Programs have emerged across the US to help obstetric professionals meet the needs of perinatal individuals with mental health conditions.

This study aimed to elicit obstetric professional perspectives on barriers and facilitators to managing BD in perinatal patients, and show how such programs may help or hinder these processes.

The presenters conclude: “Perinatal Psychiatry Access Programs may be a useful tool to facilitate obstetric professionals in bridging gaps in mental health care for perinatal patients with BD.”

Dr. Marcangelo: “This poster reviews the impact of a Perinatal Psychiatry Access Program on the care that women with bipolar disorder receive. It is an elaboration on collaborative care programs in that it empowers obstetrical professionals to manage patients with bipolar disorder without the psychiatrist being directly involved. Participants who had completed the program screened more often for bipolar disorder but still felt they needed more information about the ongoing management of patients. Discussion around how programs such as this are designed and implemented can help attendees extend the work of other programs to their own. This poster also allows one of the discipline’s key subspecialties, women’s mental health, to play a prominent role at the meeting. ACLP is the premiere venue for learning about subspecialized consultative care.”