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Firm Size, Capital Investment, and Debt Financing over Industry Business Cycles
- Praveen Kumar, Vijay Yerramilli
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- Journal of Financial and Quantitative Analysis , First View
- Published online by Cambridge University Press:
- 06 November 2023, pp. 1-27
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We find that capital investment and net debt issuance of large firms are, on average, more sensitive to industry business cycles than those of small firms, in stark contrast to the effect of size on investment sensitivity to macroeconomic cycles. We theoretically examine the role of firm size on firms’ responses to industry shocks. Consistent with our theoretical predictions, we find that large firms exhibit greater sensitivity to industry cycles than small firms in their investment and net debt issuance only in industries with low cyclical variability of markups and production growth, high fixed cost intensity, high market-to-book, and high markups.
Rewilding Medical Education
- Praveen Kumar, Johanna Thonning, Ananya Santosh, Nicholas Barnes
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- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S28
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Access to a healthy environment offers broad health benefits and has been declared a human right (UNHCR, 2021). However, despite the release of position statements by royal colleges on the climate and ecological emergency, there appears to have been limited opportunities for dissemination and sharing of knowledge, understanding and opportunities for action for many doctors and medical students in the North of Scotland. Hence, this project was aimed to create awareness on the importance of nature connectedness and explore its association with good physical and mental health and well-being. It was also so the medical students can understand the relationship between nature connectedness and the experiences in nature through active observation and hands-on engagement activities alongside acknowledging already active allies providing practical environmental volunteering activities.
Methods9 Medical students, 3 Core Psychiatry Trainees, 1 Psychologist and 1 Child and Adolescent Psychiatrist met at Trees for Life, Dundreggan. We were introduced to 2.5 hours of mindful grounding techniques, mindful eating, connecting with nature through art along with sensory exercises such as tree hugging and trust building activities by Nature for Health. We interacted in group work to design nature-based activities that can be used in clinical practice to improve mental well-being in people living with OCD, depression, ADHD, trauma and eco-anxiety.
ResultsLearning experience amidst nature was well received by participants who also gained positive effects on their own personal well-being. The project successfully brought the participants together to access, care for and enjoy green spaces whilst learning about allied programs available in the community. The participants also learnt how nature can aid mental health recovery and well-being, whilst giving people a chance to do their bit towards the fight against climate change.
ConclusionWe suggest to incorporate teachings on climate change in medical education with consideration on using green spaces as delivery sites to enhance nature connectedness (local green social prescribing opportunities such as Green Walking, Green Gym, conservation volunteering, city farms, forest schools by The Conservation Volunteers, The Wildlife Trusts and the ‘Rewild and Recover’ programme from Trees of Life). We also suggest to promote our future healthcare professionals to collaborate with other groups linking nature restoration to human health and well-being. Awareness on benefits of nature connectedness should become one of the most important aspects of medical education in this century to foster a generation of healthcare professionals with pro-nature attitudes and active engagements with the natural world.
ID (Intellectual Disability) Crisis Resolution! Novel Approaches in NHS Highland
- Praveen Kumar, Ashwin Bantwal
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- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, pp. S136-S137
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Like most health and social services, community ID teams are under increasing pressure to manage burgeoning caseloads. This evaluation was for the Red People Meeting video conferencing (VC) from its conception during the pandemic 2020 with particular reference to it's simple format to structure meetings for their effectiveness and promotion of team communication and well-being.
MethodsThe Red people meetings is held every Mon – Fri between 11am and 12pm through an invite sent via e-mail or diary invite. A RED STATUS is identified by a support worker who poses:
• Serious risk of harm to self or others
• Serious concerns related to Physical / Health / Perceived challenging behaviours.
• Individual requiring hospitalisation
Meeting Attendees (over TEAMS): Chaired by the Head of Service or Lead ID Nurses. With attendance of ID Consultant Psychiatrist, OT Team, Moving Home Manager, ID Nurse, Social Worker. Attendance depending on individual need include Clinical Psychology, AHPs, Social Work Team Manager, Social Worker, Police, GP, Housing, MHO, District Nurses, etc
Individuals identified as RED and are at risk of admission or an inappropriate alternative solution will likely require significantly longer discussions and a full plan to reduce the risk of harm.
Evaluation data were gathered via qualitative feedback from the multi-disciplinary team (MDT). Number of patients admitted among cases discussed from January 2020 until September 2022 (Total 248) was noted.
ResultsThe MDT team were generally satisfied with the assistance they received and were able to be provided solution focused remedies with immediate feedback. In particular, they were satisfied with the accessibility in having a collaborated approach with addressing the challenges to request priority of interventions from NHS Highland ID staff and provision of timely advice and guidance to support providers. Out of the 248 People With Intellectual Disability (PWID) discussed from January 2020 to Sept 2022, only two required admission with the rest successfully being managed in the community.
ConclusionWith its easy accessibility and quick response via video conferencing, ‘Red people’ meeting can be used as a platform to discuss PWID and / or autism who have been classified with a RED status identifying the immediate support required, providing expert advice and guidance, enabling a quick prioritised response from professionals and provision of safe and timely discharge from hospital.
It is evident that further research needs to be undertaken into the contemporary and future practice of community ID teams in the management of crisis settings.
RCPsych MTI Scheme; Cultural Differences in Psychiatry Training Among MTI Fellows From Low and Middle-Income Countries in the UK
- Razrin Razak, Praveen Kumar
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- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S142
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The Royal College of Psychiatrists’ Medical Training Initiative is a scheme aimed at psychiatrists from lower and middle-income countries to work and train in the National Health Service (NHS) UK for up to 2 years before returning to their home countries. They came from various countries and cultural backgrounds, however, there is a lack of study being done on how these cultural differences and experiences are impacting the newly recruited MTI fellows while working in the UK at a CT3 level. In this study, we distributed a brief questionnaire to the 2022 Rcpsych MTI trainees cohort to explore the sociocultural differences between working in the NHS and their home countries and surveyed the things that could be improved within the MTI scheme.
MethodsRoyal College of Psychiatrists MTI Fellows from various backgrounds and countries participated in a survey between December 2022 and January 2023. The survey consisted of open-ended and closed-ended questions about the differences in psychiatric practices from their home countries alongside cross cultural differences while working in the NHS.
ResultsThe response rate was 55% from five different countries; Egypt, Malaysia, Nigeria, Sudan, and Turkey. The majority of the participants have worked in the UK under the MTI scheme for more than 3 months and reported that English is not a widely spoken language in their countries of origin. 72.8% of respondents find it easy to incorporate their skills and knowledge in the UK despite the linguistic, cultural and mental health act differences while 72.7% of the fellows reported that psychiatric patients' presentations are similar between their home countries and the UK. There is also a bigger mental health stigma reported in their home countries. It appears based on experiences in their home countries, culture indeed plays a major role in mental illness and treatment. Besides that, 72.8% of respondents are satisfied with the MTI scheme while 81.9% of them would recommend this scheme to others. Some of the respondents recommended for introductory course about the mental health system in the UK and the mental health act before starting the scheme.
ConclusionThere are cultural and linguistic differences impacting the experiences of newly recruited MTI fellows in the UK. There is room for improvement to bridge the sociocultural gaps for the MTI Fellows to improve their experience and service provision.
Audit of Seclusion Practice in an Inpatient Adult Intellectual Disability (ID) Psychiatry Unit
- Praveen Kumar, Catriona Graves, Sheena Jones
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- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S99
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To investigate if current practice regarding the use of seclusion in an adult ID assessment and treatment unit was in keeping with the newly developed NHS Highland Seclusion Policy.
MethodsCase notes were reviewed for all patients who had had a period of seclusion between 20 September and October 2022.
Data were collected regarding the following:
• Administration of seclusion (date; time started; medication used prior; reason for administration & duration);
• 15 min interval monitoring (record of patient's mental & physical state including presentation, behaviour, conscious levels, respirations & appearance)
• Review at 2 and 4 hours (including plans on how to end seclusion)
• Documented Datix submitted and Monitoring of improvements.
ResultsThematic analysis showed that the most common reason for the use of seclusion was due to increasing agitation and aggression.
Data collection showed that the following information was missing from case records:
• Use of anxiolytic before seclusion;
• Under the 15 minute interval recording - respiration rate & appearance was missed most of the times;
• Review at 2 hours: Plans to end seclusion was often missed; Review at 4 hours: on most occasions the duty consultant was not informed. They could give valuable insight and plans on stopping seclusion if it has prolonged more than 4 hours.
• Datix was not sent every time seclusion commenced and this is needed as it would further provide to better identify and manage patients needing it.
ConclusionSeclusion places people at risk. It is vital to ensure that there is robust monitoring of the patient's mental and physical state to reduce the risks associated with seclusion and, in particular, when medication which may lead to respiratory depression has been used. Seclusion should be used for the shortest time possible - explicit consideration of when and how to end seclusion provides an opportunity to limit the length of this highly restrictive intervention and minimise the impact on the person.
The results of the audit were shared with the staff team via the Seclusion Policy Short Life Working Group and will allow subsequent drafts of the service protocol to reflect good clinical practice. Results were also shared via the internal teaching programme and at the Clinical Governance forum. An additional session will also be provided during the induction plan for new trainees. Finally, a reaudit will be done to assess changes in seclusion practice.
Full Remission of Obsessive Compulsive Disorder (OCD) Symptoms in Huntington's Disease (HD) Using Fluoxetine
- Mithun Devasia, Praveen Kumar, Abdurazak Kottelassal
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- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S125
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HD is an autosomal, dominantly inherited, neurodegenerative disorder which can present with cognitive, motor and behavioural symptoms. Recent studies suggest that obsessive compulsive disorder (OCD) symptoms, although not common, may precede or coincide with symptoms in patients with HD. We present a case of an adolescent boy presenting with symptoms of OCD, for 4 months duration, in background of three years diagnosis of HD.
MethodsA 15-year-old boy from South India, presented with recurrent, intrusive thoughts of sexual content, consistent with obsessions and some instances of compulsions in the form of avoiding to do deviant sexual act like fetishism, and having excessive worries about an act he had done earlier for 3 months duration (supported by high scores on Yale-Brown Obsessive Compulsive Scale; Y-BOCS). Patient had normal birth and development and had no past history of psychiatry disorder, however there was family history of HD in multiple first and second-degree relatives. He was on treatment for movement symptoms of HD, diagnosed 3 years back and was on Tetrabenazine for 2 years. Initial psychiatric assessment found the symptoms to be consistent with OCD due to Huntington's disease, according to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The patient was admitted to the mental health unit and was started on Fluoxetine, titrated to a dose of 20mg daily for symptoms of OCD.
ResultsSubject showed an excellent response to fluoxetine with complete remission of OCD symptoms within 4 weeks of treatment. The relationship between OCD and HD has been little-investigated, despite the fact that both diseases are associated with striatal dysfunction and that the number of case reports of obsessive-compulsive symptoms either preceding the clinical onset of HD or during later stages of the disease is increasing. For example, Dewhurst et al. reported “obsessional features” in 7 of 102 patients at onset of HD.
ConclusionFirm conclusions to explain this result cannot be drawn. However, a hypothetical involvement of the serotonergic system, suggested by the excess of OCD, seems supported by the response of said subject to fluoxetine. It may be worth further exploring the value of the psychiatric picture in selecting the appropriate treatment for at least some cases of HD. Anecdotal evidence suggest that SSRIs alone or in combination with atypical antipsychotics like olanzapine may be useful for these patients. However, these hypotheses need further testing.
Going somewhere…?
- Praveen Kumar, Robert Ashmore, Ashwin Bantwal
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- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S166
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Challenging behaviours often results in exclusion from communities and is associated with worse outcomes for patients with Intellectual Disability (ID). Due to substantial cut backs in local community service provisions across Highland for people with ID, placements have dwindled and recent trends indicate a high demand for “crisis” inpatient admission for PWID with co-morbid mental health and/or pervasive developmental disorders. This project aims to thematically analyse the admission trends to the Intellectual Disability Assessment and Treatment Unit (IDATU) in NHS Highland over a 5 year period (2018-2022).
MethodsAll patients admitted to and discharged from the IDATU over a 5 year (2018-2022) period were identified. Their case notes were reviewed and details on the primary reason for admission were manually gleaned from the admission clerking document. Data were also gathered for demographics, diagnosed mental disorder, legal status and length of admission.
ResultsTotal 18 new admissions were identified. All had established ID and/or co-morbid mental illness, autism, & other organic conditions. The average age was 30.2 years. 81% of admissions were formal. Length of admission varied from 1 to 814 days.
Allowing for some overlap, admission themes mainly fell into 3 categories: challenging behaviour related- Aggression, Abscond, Self-Neglect, Suicidal (50%), Decline in mental/Physical health- Psychosis, Confusion, Weight Loss (16.7%) and manageability- Vulnerability, Breakdown of social situations (33.3%).
Several themes were identified amongst the stated reasons for admission in case notes. A pattern emerged whereby these fell into 3 different headings as shown by the table here.
ConclusionThe above three themes identified are not surprising. A combination of behaviours grouped as “challenging” and also felt to be “unmanageable” were cited as primary reasons for admission.
Notwithstanding the dwindling of community resources and workforce attrition within the ID Service in recent years, the actual numbers admitted to IDATU was roughly down by 50% comparing a 5 year analysis done from 2012-2017 (34 Vs 18).
Robust scrutiny/tightening of IDATU admission criteria, along with other new service initiatives may have helped mitigate against any inappropriate use of IDATU beds.
Given the established and well researched risk of institutionalisation, it is of interest to us that our findings suggest that the services employed by the State to reduce this risk were already involved in a large proportion of cases. It is our recommendation that future service development planning should focus, incentive, invest and expand robust community ID services and resources within Highland.
Re-Audit of Blood Monitoring of Lithium in Outpatients of Working Age Under Dudley Mental Health Services
- Peter Bridgewater, Praveen Kumar
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- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S151
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Lithium remains the first line mood stabilising therapy recommended by NICE for Bipolar Disorder and an important treatment option for augmentation of the treatment of Depression. Lithium has a strict monitoring requirement due to long term impact on Renal, Thyroid function and risk of toxicity due to a narrow therapeutic range. This Re-Audit aimed to assess improvement in Lithium Blood monitoring in working age adults in Dudley following an initial 2021 audit.
MethodsWe used the standards set by NICE CG185- Bipolar Disorder Assessment and Management. We agreed a standard of 3 monthly monitoring of lithium levels due to the number of indications for 3 monthly monitoring to ensure safest practice. We also agreed to standards for 6 monthly monitoring of Urea and Electrolytes (U&Es) and Thyroid Function Tests (TFTs). An additional standard was agreed that at every outpatient review Lithium blood results should be reviewed and documented. A sample of 40 patients was gathered from the 8 outpatient sector teams. We used Rio notes system for demographic, diagnosis and clinical information and blood results systems EMIS and ICE for blood results over a period of November 2021- November 2022.
ResultsThere was a noted minor improvement to compliance with 3 monthly monitoring, overall increasing from 10% to 17.5%, but this result is still poor. The number of patients who had 4 or more Lithium blood tests over the 12 month period was more of a positive increase, to 32.5% from 17.5% in the previous audit cycle. There was also an improvement in the mean number of lithium blood tests per patient from 2.67 to 3.3. For U&Es 90% of patients were monitored 6 monthly while for TFTs 85% of patients were monitored 6 monthly. There was a slight reduction in documentation of blood results at clinic review, reducing to 62.5% from 67.5% in the initial audit.
ConclusionWhile the progress is positive, the results are still far below where the trust would like to be. We considered whether frequency of outpatient review, poor awareness of 3 monthly monitoring standards and a lack of formal system to remind or ensure patients are monitored appropriately. It was agreed that measures to ensure compliance such as a lithium blood monitoring clinic may be useful to improve compliance with monitoring.
Comparison of Management (Non-Pharmalogical Approaches and Rapid Tranquilisation) of Older Adults (≫65 Years) With Dementia Between the Dementia Ward, Acute Medical Unit and the Geriatric Ward in a Rural Health Board
- Adam Wild, Praveen Kumar, Fiona Howells, Hamed Emara, Phoebe Williams
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- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S187
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To investigate if current practices by nursing and medical staff in the dementia ward (New Craigs Psychiatric Hospital), acute medical unit and geriatric ward (Raigmore General Hospital) followed the local protocol for managing distress of non-pharmalogical approach and rapid tranquilisation (RT) in older adults (aged >65years). We believe the split between the general and psychiatric hospitals and the different time pressures experienced in these 3 wards will influence the management and RT of their older adult patients.
MethodsData were collected from 17/09/2022 to 8/10/2022 from case notes and drug charts of older adult patients that received rapid tranquilisation from 3 wards:
1. Ruthven Ward, New Craigs Psychiatric Hospital
2. Acute Medical Unit (AMU), Raigmore Hospital
3. Ward 2C (Geriatrics), Raigmore Hospital
Focus groups and informal discussions were made with the ward nurses and junior doctors to understand their point of view on managing distressing behaviours in patients with dementia using de-escalation techniques.
A table was collated using Microsoft Excel. The parameters used were:
1. Patient Diagnosis and Legal status
2. Administration
• Date and time started
• If de-escalation techniques were used
• If discussed with a senior doctor
• 1st and/or 2nd line of drugs administered (route, drug and dosage)
• If Haloperidol given and if ECG was done
ResultsData collection showed the following:
1. Ruthven Ward- all 32 patients did not receive RT.
2. AMU- only 1 out of 280 patients received 4 subsequent RT in 5 hours including 3x haloperidol (total 3mg) and 2mg of Midazolam despite an ECG showing prolonged QT interval. The latter prescribed after consultation with a senior doctor.
3. Geriatric Ward – all 10 patients did not receive RT.
ConclusionFocus groups and informal discussions with staff nurses from all three wards concluded that in spite of the stressful environment posed by issues of understaffing and high patient load, de-escalation techniques (recognition of early signs of agitation, distraction and calming techniques, recognising the importance of personal space) were prioritised before moving on to RT as per local protocol. Restraining was often used if patient was at risk to self or others by staff trained in violence and aggression management.
Informal discussions with junior doctors rotating in and out of AMU showed limited awareness of the RT protocol. In general, it was evident that RT was a last resort when psychological and behavioural approaches failed but that further education was required to administer RT safely.
Reduced kinetic model of polyatomic gases
- Praveen Kumar Kolluru, Mohammad Atif, Santosh Ansumali
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- Journal of Fluid Mechanics / Volume 963 / 25 May 2023
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- 12 May 2023, A7
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Kinetic models of polyatomic gas typically account for the internal degrees of freedom at the level of the two-particle distribution function. However, close to the hydrodynamic limit, the internal (rotational) degrees of freedom tend to be well represented just by rotational kinetic energy density. We account for the rotational energy by augmenting the ellipsoidal statistical Bhatnagar–Gross–Krook (ES–BGK) model, an extension of the BGK model, at the level of the single-particle distribution function with an advection–diffusion–relaxation equation for the rotational energy. This reduced model respects the $H$ theorem and recovers the compressible hydrodynamics for polyatomic gases as its macroscopic limit. As required for a polyatomic gas model, this extension of the ES–BGK model not only has the correct specific heat ratio but also allows for three independent tunable transport coefficients: thermal conductivity, shear viscosity and bulk viscosity. We illustrate the effectiveness of the model via a lattice Boltzmann method implementation.
Large-eddy simulation of tripping effects on the flow over a 6 : 1 prolate spheroid at angle of attack
- Marc Plasseraud, Praveen Kumar, Krishnan Mahesh
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- Journal of Fluid Mechanics / Volume 960 / 10 April 2023
- Published online by Cambridge University Press:
- 30 March 2023, A3
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Large-eddy simulation is used to simulate the flow around a 6 : 1 prolate spheroid at $10^\circ$ and $20^\circ$ angles of attack, and Reynolds number $4.2 \times 10^6$. Flows with and without trip are compared to understand the relative effect of the trip on the state of the boundary layer and separation. For the tripped case, the geometry of the trip is resolved to better predict its effect on the downstream flow. The simulations employ overset grids that allow adequate resolution of the trips without significant increase in the overall computational cost. Results suggest that while the trip accelerates transition to turbulence at $10^\circ$, it does not induce a fully developed turbulent boundary layer as intended at $20^\circ$. Rather, the influence of the trip is localized, and the near-wall flow converges towards a solution similar to that of the non-tripped case upstream of separation. This is due to two distinct phenomena: directly downstream of the trip, favourable pressure gradient and streamline curvature effects suppress the disturbance on the windward side. Further along the spheroid, the boundary layer receives a small fraction of the initial perturbation due to spanwise and wall-normal streamline curvatures inducing a secondary flow that advects the low-momentum trip wake to the leeward side. The locations of transition and separation are insensitive to the presence of the trip. The simulation results are used to construct a regime map that identifies different regions characterized by distinct boundary layer properties and flow features. The present results underscore the difficulty associated with tripping smooth bodies at angle of attack, and the importance of accounting for transition in simulations of such flows, even on tripped geometries.
Pregnancy in Eisenmenger syndrome: a case series from a tertiary care hospital of Northern India
- Bharti Sharma, Pooja Sikka, Seema Chopra, Ramandeep Bansal, Vanita Suri, Neelam Aggarwal, Subhas C. Saha, Rajesh Vijayvergiya, Ishwar Bhukal, Praveen Kumar
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- Cardiology in the Young / Volume 33 / Issue 11 / November 2023
- Published online by Cambridge University Press:
- 05 January 2023, pp. 2185-2189
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Background:
Despite advances in medical care, we still come across pregnancy in Eisenmenger syndrome. Eisenmenger syndrome represents the severe end of the spectrum for disease in pulmonary artery hypertension associated with CHD. Due to very high maternal and perinatal morbidity and mortality, pregnancy is contraindicated among these women. Current guidelines also recommend that the women who become pregnant should opt for early termination of pregnancy. Here, we present a case series of 11 women of Eisenmenger syndrome and their pregnancy outcome.
Methods:It was a retrospective analysis of 12 pregnancies among 11 women with Eisenmenger syndrome who were managed in a tertiary care referral centre of Northern India.
Results:The mean age of these women was 28 ± 4 years (range 22 to 36 years). Almost 80% of them (9/11) were diagnosed with Eisenmenger syndrome during pregnancy. The commonest cardiac lesion was Ventricular Septal defect (54.5%) followed by Atrial Septal defect (27.3%) and Patent Ductus arteriosus (9.1%). Only three women opted for medical termination of pregnancy, rest eight continued the pregnancy or presented late. Pregnancy complications found include pre-eclampsia (50%), abruption (22%), and fetal growth retardation (62.5%). There were three maternal deaths (mortality rate 27%) in postpartum period.
Conclusion:This case series highlights the delay in diagnosis and treatment of CHD despite improvement in medical care. Women with Eisenmenger syndrome require effective contraception, preconceptional counselling, early termination of pregnancy, and multidisciplinary care.
Phenomenology, quality of life, and predictors of reversibility in patients with drug-induced movement disorders: a prospective study
- Rohit Anand, Shweta Pandey, Ravindra Kumar Garg, Hardeep Singh Malhotra, Shrikant Shrivastava, Sujita Kumar Kar, Sumit Rungta, Rajesh Verma, Praveen Kumar Sharma, Neeraj Kumar, Ravi Uniyal, Imran Rizvi
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- CNS Spectrums / Volume 28 / Issue 5 / October 2023
- Published online by Cambridge University Press:
- 19 December 2022, pp. 534-536
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Background
Drug-induced movement disorders (DIMDs) form an important subgroup of secondary movement disorders, which despite conferring a significant iatrogenic burden, tend to be under-recognized and inappropriately managed.
ObjectiveWe aimed to look into phenomenology, predictors of reversibility, and its impact on the quality of life of DIMD patients.
MethodsWe conducted the study in the Department of Neurology at a tertiary-care centre in India. The institutional ethics-committee approved the study. We assessed 55-consecutive DIMD patients at presentation to our movement disorder clinic. Subsequently, they followed up to evaluate improvement in severity-scales (UPDRS, UDRS, BARS, AIMS) and quality of life (EuroQol-5D-5L). Wilcoxan-signed-rank test compared the scales at presentation and follow-up. Binary-logistic-regrerssion revealed the independent predictors of reversibility.
ResultsFourteen patients (25.45%) had acute-subacute DIMD and 41 (74.55%) had tardive DIMD. Tardive-DIMD occurred more commonly in the elderly (age 50.73±16.92 years, p<0.001). Drug-induced-Parkinsonism (DIP) was the most common MD, followed by tardivedyskinesia. Risperidone and levosulpiride were the commonest culprit drugs. Patients in both the groups showed a statistically significant response to drug-dose reduction /withdrawal based on follow-up assessment on clinical-rating-scales and quality of life scores (EQ-5D-5L). DIMD was reversible in 71.42% of acute-subacute DIMD and 24.40% of patients with chronic DIMD (p=0.001). Binary-logistic-regression analysis showed acute-subacute DIMDs and DIP as independent predictors of reversibility.
ConclusionDIP is the commonest and often reversible drug-induced movement disorder. Levosulpiride is notorious for causing DIMD in the elderly, requiring strict pharmacovigilance.
Parametric optimization of FDM using the ANN-based whale optimization algorithm
- Praveen Kumar, Pardeep Gupta, Indraj Singh
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Surface roughness (SR) is one of the major parameters used to govern the quality of the fused deposition modeling (FDM)-printed products, and the FDM process parameters can be easily regulated in order to obtain a good surface finish. The surface quality of the product produced by the FDM is generally affected by the staircase effect that needs to be managed. Also, the production time (PT) to fabricate the product and volume percentage error (VPE) should be minimized to make the FDM process more efficient. The aim of this paper is to accomplish these three objectives with the use of the parametric optimization technique integrating the artificial neural network (ANN) and the whale optimization algorithm (WOA). The FDM parameters which have been taken into consideration are layer thickness, nozzle temperature, printing speed, and raster width. Experimentation has been conducted on printed samples to examine the impact of the input parameters on SR, VPE, and PT according to Taguchi's L27 orthogonal array. The ANN model has been built up using the experimental data, which was further used as an objective function in the WOA with an aim to minimize output responses. The robustness of the proposed method has been validated on the optimal combinations of FDM process parameters.
Cardiovascular risk factors among older adults with cognitive impairment in primary care
- Vikas Dhikav, Bhargavi Jadeja, Praveen Kumar Anand
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- International Psychogeriatrics / Volume 33 / Issue 8 / August 2021
- Published online by Cambridge University Press:
- 09 August 2021, pp. 837-838
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Impact of online group studying for the MRCPsych A exam amongst international doctors logging-in from 7 countries
- Praveen Kumar, Sara Mohsen, Oksana Zinchenko, Philip Verde, Kathleen Breslin, Alice Judge, Sridevi Shanmugam
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S265
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Aims
Recently, global-remote group studying has been made possible via digital video conferencing platforms. In preparation for the December 2020 MRCPsych part A exam, a study group was formed comprising 30 International Medical Gaduates (IMG) logging-in from different countries via 3 hour Zoom-study sessions hosted daily from 28th September until 12th December 2020 (1800-2100 GMT time). This study demonstrates the impact of online group study in preparation for the MRCPsych A exam for s via data collected through questionnaires.
MethodThe data of the study were collected through the questionnaires given to the group study members containing a total of 17 questions, 5 of which were open-ended.
The participants totalled 30 International Doctors who responded to an advertisement to form an online study group on Facebook. They logged-in for the sessions from seven different countries: Malaysia, India, Bangladesh, Ireland, Nigeria, Saudi Arabia, and the United Kingdom. The participants represented different working grades incuding experiences in psychiatry ranging from 0 to 5 years.
Data were analysed using percentage. The answers given to the open-ended questions were each examined using descriptive interpretation methods.
ResultThematic analysis demonstrated that online group study made learning faster and easier. 96.6% support using online study sessions for future exams citing that they fostered cooperation, respect for diverse opinions and motivation for regular studying. 93.1% and partly 6.9% found the experience enjoyable and enabled the cultivation of different ideas. Indeed, 89.7% relied on it as a big part of their preparation with 26 saying it contributed to their passing of the exam success.
Almost three quarter of participants in the group also forged friendships and a sense of trust. It also became a platform for expressing opinions comfortably and developing communication and interpersonal skills.
Different working hours and time zones represented a challenge with most linking in at odd hours. Cultural differences were ultimately accepted including aspects of delivery of information which made a few participants appear abrupt.
ConclusionWith the ease in which social media connects us on a global scale, online study groups connecting IMGs from various backgrounds and diverse cultures not only makes exam preparations stimulating and easier to pass but also fosters interpersonal skills and connections that would be an asset in the long run.
COVID-19 antibody seroprevalence in residential psychiatric inpatients
- Sheena Shah, Arshad Hussain, Sabreena Qadri, Fazle Roub, Insha Rauf, Praveen Kumar
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S102
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While other mental health care outpatient facilities were moved to COVID-centers in March 2020 during the COVID-19 pandemic, the Institute of Mental Health and Neurosciences in Kashmir remained the only functional outpatient facility in the region. It is the only mental health care hospital in the country with a residential facility for psychiatric inpatients catering to the whole population of Jammu and Kashmir, India. The Mental Health Care Act 2017 that neccesitated “halfway homes” is yet to be implemented in the state leaving it's inpatients entirely under the institution's care. This study is to investigate the seroprevalence of antibodies to SARS-COVID-19 virus in the 34 residential inpatients in separate male (23 patients) and female (11 patients) wards. This was done as an audit to strategies and measures taken by the institute in protecting it's inpatients.
Method3 to 5 ml of peripheral venous blood samples were collected and plasma extracted and analysed using the CE-IVD Roche Cobas Elecsys AntiSARS-CoV-2, Electrochemiluminescence Immunoassay (ECLIA) for the qualitative detection of total Immunoglobulins (IgG, IgM and IgA; Pan Ig) generated against SARS-CoV-2 (Roche Diagnostics, Indianapolis, IN, USA). The test was performed according to the manufacturer's instructions.
ResultOut of the 34 inpatients, 2 male inpatients tested positive for antibodies against SARS-CoV-2 (seroprevalence of 5.88%). In comparison, based on a report conducted by the government's Department of Community Medicine and Biochemistry on the 28th of October 2020, out of 2,361 participants in the community, 959 tested positive (seroprevalence of 40.6%).
One of the inpatients that tested positive was re-admitted after testing negative via RT-PCR. The second patient was admitted after being found homeless. He was tested negative on day 1 via RAT and on day 5 via RT-PCR. We believe both of them aquired the infection in the community.
ConclusionThis audit shows that the strategies implemented by the institute were effective in the prevention of the spread of COVID-19. Practical implementations of what works and improvisations are the proven methods of decreasing the mortality and morbidity in vulnerable populations while continuously providing vital mental health services.
Does my patient have sex ? - Mental health professionals’ understanding of sexual health issues among their patients
- Nalin Hettiarachchi, Praveen Kumar, vikramraj balasundaram
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S256
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To assess the level of understanding and difficulties encountered when obtaining sexual health details of their patients among mental health clinicians.
BackgroundPeople with mental health problems, especially those treated with psychiatric medication experience greater rates of sexual difficulties than those in the general population. Mental health practitioners need to examine personal beliefs and attitudes about sexuality among people with mental health problems. Providing information about sexuality and sexual practice benefits and enhances the quality of life of people with mental health problems. Therefore taking a sexual history should be an integral part of psychiatric assessment.
MethodAn online survey consisted of 17 questions to cover 3 areas of objectives mentioned above was created using Survey Monkey. A link to the survey was emailed to all the clinicians who perform psychiatric assessments. Response collection and data analysis was performed by the trust IT team.
ResultTotal of 54 clinicians participated in the survey representing nurses, junior, middle grade doctors and consultants. Almost all stated that mental health patients have capacity to make appropriate decisions about their sexual behaviour patterns. 43% thought people with mental health problems don't have similar patterns of sexual behaviour compared to people without mental health problems. 11% stated that people with mental health problems do not experience greater rates of sexual difficulties than those in the general population. Nearly a third did not believe that telling patients about potential sexual side effects may lead to poor compliance. Nearly 70% stated taking a sexual history should be an integral part of psychiatric assessment. 44% reported lack of knowledge and skills when talking about sexual health and 33% avoided asking about sexual health due to lack of knowledge. Half of the clinicians avoided asking about sexual health due to the fear of embarrassing or causing distress to patients while 16% avoided asking about sexual health due to self-embarrassment. 65% talk about sexual health issues only if patients brought them up.
During last 3 clinical encounters majority never asked about sexual difficulties, high risk behaviour and drug side-effects related to sexual difficulties. A significant proportion of clinicians never asked about contraception from their female clients.
ConclusionSurvey revealed majority of mental health clinicians lack understanding and skills about sexual health issues highlighting the importance of raising awareness among clinicians about sexual health issues.
Acute mania with psychotic symptom in post COVID-19 patient
- Sridevi Shanmugam, Praveen Kumar, Blaga Carr
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S50-S51
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COVID-19 is an on-going pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Recent evidence suggests that SARS-CoV-2 may be associated with various neuropsychiatric symptoms, including mania. We present a case of a middle aged man presenting with acute mania with psychotic symptoms 20 days post COVID infection in the absence of prior psychiatric illness. This report highlights the need for rigorous neuropsychiatric assessment in patient with symptoms of SARS-CoV-2 infection.
MethodA 52-year-old man of West African origin with past history of hypertension and no previous history of mental health illness presented with acute manic symptoms on background of two weeks of high fever, diarrhoea, mild headache, dry cough and anosmia. He was tested positive for SARS-CoV-2 infection on COVID PCR test. He was under self-isolation along with his family members who exhibited mild symptoms of SARS-CoV-2, none of them required hospital admission. He was initially fearful to seek medical attention but was brought in by family after exhibiting behaviour changes, obsession with toilet cleaning, reckless spending and getting aggressive approximately two weeks after the onset of acute upper respiratory symptoms. He presented elated in mood with pressure of speech and grandiose ideas. Investigations like neuroimaging and bloods were unremarkable. Initial psychiatric assessment found symptoms consistent with acute mania and he was detained under the Mental Health Act. During admission, he was sexually disinhibited and agitated on the ward requiring IM antipsychotics. He was treated with high dose of Olanzapine and Sodium valproate and his symptoms subsided within two weeks.
ResultThis case emphasises the manifestation of neuropsychiatric illness post COVID-19 without a background of psychiatric illness, hypoxemia and cerebral infarction.
Based on the CORONERVE Programme and latest retrospective Lancet cohort studies, the period between 14 and 90 days after diagnosis, 5.8% COVID-19 survivors had their first recorded diagnosis of psychiatric illness.
It is also important to consider other organic disease given the simultaneous diagnosis of COVID-19. Although it is not yet possible to confirm here due to the lack of a validated CSF-PCR assay, previous reports have implicated SARS-CoV-2 in the development of viral encephalitis, and this remains an important differential.
ConclusionClinicians should be alert to the possibility of patients with COVID-19 developing neuropsychiatric complications post SARS-CoV-2 infection, mandating the need for vigilant initial neuropsychiatric assessment and possibly follow-up care in 3 months.
Neurodiversity in the teaching of the mental state examination: a pilot study of interactive mind-mapping seminars for the new ScotGem (Scottish graduate-entry medicine) students during the COVID-19 pandemic
- Kathleen Breslin, Sara Mohsen, Praveen Kumar
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S10-S11
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Agility in educational delivery has been catalyzed in response to national restrictions mandated by the recent COVID-19 pandemic. Increased use of assistive technologies further aligns with the General Medical Council's aims that medical educators provide an 'accessible training experience'. The study examined medical students' receptiveness to different types of interactive teaching. Two undergraduate cohorts received teaching on the Mental State Examination, either socially-distanced delivered by traditional powerpoint or remotely by mind-mapping software on a tablet hand-held digital device. We required an effective program which would retain the popular interactive elements of Psychiatry teaching and promote inclusivity across students' diverse learning styles.
MethodTwo cohorts of Year 2 students from the Universities of Dundee and St Andrew's Scottish Graduate-Entry Medicine (scotGEM) course took part in an Introduction to Psychiatry seminar which involved a presentation of the Mental State Examination. One was conducted in a face-to-face setting via traditional PowerPoint. The second was conducted via remote-conferencing with mindmaps of key concepts drawn and screen-shared live to students as teaching progressed.
This was a qualitative study, with online links to questionnaires for 24 student participants across 5 domains. (1. The tutorial met my learning objectives, 2. The format was suitable for me, 3. The balance of theory and cases was suitable for me, 4. The tutorial was of appropriate length, 5. I was satisfied with the performance) Response options included: strongly disagree, disagree, neutral, agree, strongly agree. A section was also included with open-ended questions pooled for thematic analysis.
ResultResponse rate reached >60% with >80% respondents answering strongly agree across all domains. Thematic results demonstrated positive responses across both teaching sessions, with the interactive elements valued by students. Comments included: “great job was done with the delivery of the session considering it was online rather than in person”; “drawing element was fantastic”; “Good: interactivity of the session drawing and creativity element”.
ConclusionThe Mental State Examination (MSE) via live-drawn mind-maps allows salient clinical information to be conceptualised in non-linear diagramatic format. This paediological approach can offer further access points across wide range of learning styles. This pilot study demonstrated such interactive components of Psychiatry teaching continue to be well received and can be effectively delivered remotely. Such sessions also serve to promote inclusivity, linking those who are geographically distant in addition to the visual learner and the neurodiverse. We aim to incorporate these dynamic teaching sessions into our online induction programs and disseminate Intelligent Tutorials to our remote and rural learners throughout Scotland.