Unmanageable Patient Research Articles

Pattern of outcome of management of bipolar-1 disorder in manic phase during hospital stay: a case series

Background: Most of the unmanageable patients of bipolar-1 disorder need hospital admission during manic episode. Pharmacological management is challenging because of severity of condition, presence of co-morbidity, need for poly-pharmacy, side effects of medication etc. The purpose of this article is to evaluate the treatment pattern of hospitalized bipolar-1 manic patients and effectiveness of drug combinations in controlling manic symptoms and reducing hospital stay. Methods: This is a case series on 7 admitted bipolar-1 manic patients, who were treated within last 6 months at Department of Psychiatry, BSMMU. Young Mania Rating Scale (Y-MRS) was applied just after admission and before discharge. All patients were given psycho-education and follow up plan. Results: Average hospital stay was around 30 days (maximum 73 days and minimum 7 days). Based on Y-MRS score, 2 cases were found to have severe symptom, other 5 cases were categorized as having moderate symptoms on admission. The score on discharge showed that all patients achieved remission from acute symptoms. Patient with first/second episode, younger age with no family history of mental illness tend to respond better with single agent (first/second generation antipsychotic) with less hospital stay. Patient with multiple episodes, history of non-compliance and positive family history were correlated to severe episode, need for polypharmacy and had prolonged hospital stay. Conclusion: Treatment of acute mania should be personalized in respect to several clinical criteria, which include manic symptoms, course specifiers and patient factors. BIRDEM Med J 2023; 13(2): 103-106

Oncologists and medical assistance in dying: where do we stand? Results of a national survey of Canadian oncologists.

In June 2016, when the Parliament of Canada passed Bill C-14, the country joined the small number of jurisdictions that have legalized medical assistance in dying (maid). Since legalization, nearly 7000 Canadians have received maid, most of whom (65%) had an underlying diagnosis of cancer. Although Bill C-14 specifies the need for government oversight and monitoring of maid, the government-collected data to date have tracked patient characteristics, rather than clinician encounters and beliefs. We aimed to understand the views of Canadian oncologists 2 years after the legalization of maid. We developed and administered an online survey to medical and radiation oncologists to understand their exposure to maid, self-perceived knowledge, willingness to participate, and perception of the role of oncologists in introducing maid as an end-of-life care option. We used complete sampling through the Canadian Association of Medical Oncologists and the Canadian Association of Radiation Oncology membership e-mail lists. The survey was sent to 691 physicians: 366 radiation oncologists and 325 medical oncologists. Data were collected during March-June 2018. Results are presented using descriptive statistics and univariate or multivariate analysis. The survey attracted 224 responses (response rate: 32.4%). Of the responding oncologists, 70% have been approached by patients requesting maid. Oncologists were of mixed confidence in their knowledge of the eligibility criteria. Oncologists were most willing to engage in maid with an assessment for eligibility, and yet most refer to specialized teams for assessments. In terms of introducing maid as an end-of-life option, slightly more than half the responding physicians (52.8%) would initiate a conversation about maid with a patient under certain circumstances, most commonly the absence of viable therapeutic options, coupled with unmanageable patient distress. In this first national survey of Canadian oncologists about maid, we found that most respondents encounter patient requests for maid, are confident in their knowledge about eligibility, and are willing to act as assessors of eligibility. Many oncologists believe that, under some circumstances, it is appropriate to present maid as a therapeutic option at the end of life. That finding warrants further deliberation by national or regional bodies for the development of consensus guidelines to ensure equitable access to maid for patients who wish to pursue it.

Oncologists and medical assistance in dying: Where do we stand?

64 Background: With the passage of Bill C-14 in June 2016, medical assistance in dying (MAiD) was formally enacted into Canadian law. Since then, approximately 2,000 patients have died with medical assistance across the country, with cancer being the most common qualifying condition. We aimed to understand the views of oncology providers (OPs) regarding MAiD. Methods: We designed and administered an online survey to Canadian OPs’ to assess experience with MAiD, self-perceived knowledge, willingness to participate, and perception of the role of OPs in introducing MAiD as an end-of-life care option. We used complete sampling via the Canadian Association of Medical Oncologists (CAMO) and the Canadian Association of Radiation Oncologists (CARO) membership email lists. The survey was sent to 366 Radiation Oncologists, and 325 Medical Oncologists. Data was collected from April-June 2018. Results were analyzed using descriptive statistics as well as univariate and multivariate analysis. Results: We received 224 responses (response rate 32.4%). 70% of OPs have been approached by patients requesting MAiD. OPs were confident in their knowledge of the eligibility criteria, and previous exposure to MAiD was associated with confidence in this domain (odds ratio [OR]=3.77, 95% CI=2.05-6.94, p value<0.001). OPs were most willing to engage in MAiD with an assessment for eligibility, yet most refer to specialized teams for assessments. A majority of physicians (52.8%) would initiate a conversation of MAiD with a patient under certain circumstances, most commonly the absence of viable therapeutic options, coupled with unmanageable patient distress. Conclusions: In this first national survey of Canadian OP’s regarding MAiD, we found that most OP’s encounter patient requests for MAiD, are confident in knowledge of eligibility, and are willing to act as assessors of eligibility. Many OP’s believe that it is appropriate to present MAiD as a therapeutic option at the end of life under some circumstances. This finding warrants further deliberation amongst national/regional bodies for the development of consensus guidelines in order to ensure equitable access to MAiD for patients who wish to pursue it.

One-stage percutaneous triple procedure for treatment of endoscopically unmanageable patients with malignant biliary obstruction and marked ascites

Background and study aimsTo assess the feasibility, safety and efficacy of one-stage percutaneous triple procedure including; ascites drainage, primary metallic biliary stenting, and tract embolisation with N-butyl 2-cyanoacrylate (NBCA), in treatment of patients with malignant biliary obstruction and marked ascites. Patients and methodsThis study involved 25 patients with malignant biliary obstruction and marked ascites (age range, 46–78y; mean age±SD, 65y±5) for whom endoscopic treatment failed or was unsuitable. Ascites drainage, percutaneous primary metallic biliary stenting, and tract embolisation with lipiodol/NBCA mixture were performed in a one-stage procedure. The mean±SD follow up period was 26±2weeks. ResultsThe technical and clinical success rates were 96% and 88% respectively. No procedure related deaths or major complications were observed. The reported minor complications included; moderate pain and vomiting during and after balloon dilation, postprocedural cholangitis, and bile leakage in 44%, 16%, and 8% of the patients respectively. Primary stent patency was achieved in 96%. The 30-days mortality was 8%. The stent obstruction occurred in 3 (13%) of the 23 patients who survived more than 30-days. ConclusionsPercutaneous drainage of ascites followed immediately by primary biliary stenting, together with tract embolisation with NBCA is technically feasible, safe, and effective alternative palliative treatment for endoscopically unmanageable patients with malignant biliary obstruction and marked ascites.

Severe prolonged gastroparesis after cytoreductive surgery in an advanced ovarian cancer patient

Number and type of complications after ovarian cancer surgery can vary greatly according to both the patient's characteristics, and the extension and type of surgery. Current literature lacks in mentioning specific gastrointestinal side effects, which could be evidenced during the early postoperative course of patients submitted to major gynecological oncologic surgery. A severe gastroparesis prolonged for 2 months after cytoreductive surgery in an advanced ovarian cancer patient was successfully treated with conservative multidrug therapy. Gastroparesis has to be enumerated as a rare but possible event after major gynecological oncologic surgery. A conservative management involving decompressive nasogastric tube, nutritional support, antiemetic drugs, prokinetic drugs is suggested, while surgical therapy is only recommended in a very small subset of unmanageable patients.

Multi-method assessment of access to primary medical care in rural Colorado.

The objectives of this study include conducting an analysis of access to primary medical care in rural Colorado through simultaneous consideration of primary care physician-to-population and distance-to-nearest provider indices. Analyses examined the potential development and implications of excessively large, perhaps unmanageable patient caseloads that might result from every rural Coloradoan's exclusive use of the nearest generalist physician as a regular source of care. Using American Medical Association Physician Masterfile data for 1995 and coordinates for latitude and longitude from U.S. Census files (Census of Population and Housing, 1990), the authors calculated distance to the nearest primary care physician for residents of each of the 1,317 block groups in Colorado's 52 rural counties. Caseloads for each generalist physician were computed assuming the population used the nearest provider for care. Straight-line mileage to primary medical care was modest for rural Coloradoans--a median distance of 2.5 miles. Almost two-thirds (65 percent) of the population resided within 5 miles, and virtually all residents (99 percent) were within 30 miles of a generalist physician. However, had everyone traveled the shortest possible distance to care, demand for service from many of the 343 primary care doctors in rural regions of the state would have been overwhelming. The results of simultaneous application of distance-to-care and provider-to-population techniques unrestricted by geographic boundaries depict access to primary medical care and corresponding consumer difficulty more fully than in previous studies. Further combination of methods of needs assessment such as those used in this analysis may better inform the future efforts of organizations mandated to address health care underservice in rural areas.

Unmanageable Patients

Unmanageable Patients

Expand the community care system: deinstitutionalization can work.

The author argues that most of the mentally ill should be treated in the community, where they can develop the skills necessary to function in society. The state hospitals should be used only to treat the most unmanageable patients. The author blames the presently inadequate community care system on insufficient funding and on the tendency of states to divide newly available funds between community services and state hospitals so that neither system is adequate. But whereas community care's problems can be resolved through greater commitment of funds and other measures, the author contends, the shortcomings of the state system are built-in and intractable. He examines and refutes the arguments supporting a return to the state hospital system.

Psychotropic Drugs In Addiction

To the Editor.— I feel moved to take exception to Dr. Blackwell's article, Psychotropic Drugs in Use Today, when he states the lack of abuse of diazepam (225:1637, 1973). Anyone like myself, who runs a drug treatment program, especially with methadone maintenance, knows of addictive abuse of these products. I would judge at least 30% of my patients have abused diazepam and a number of them had to be gradually withdrawn from dosage of 40 to 80 mg daily. They suffered severe withdrawal symptoms. Because of the central nervous system depressant action, diazepam also potentiates the depressant effect of methadone and makes for a very unmanageable patient. I have seen this same depressant effect on patients other than addicts. We have all seen suicides in people robbed of their own defense mechanisms, after having their anxiety removed by diazepam. Consequently, unprotected against their depression, they succeed in their suicidal motives.