The Psychiatry Bootcamp at a psychiatric hospital was developed to address the unique and diverse challenges faced by new trainees, including Foundation Year Doctors, General Practitioner Specialty Trainees, Core Psychiatry trainees and Broad-Based Trainees, during their rotations in psychiatry in the Highlands, Scotland. The aim was to enhance their core skills and confidence levels, ensuring they are well-prepared for their first on-call shift. This initiative seeks to complement the existing induction program, specifically targeting areas of acute medical and psychiatric emergencies and care, that are critical for on-call duties.

Since its launch in 2022, the Psychiatry Bootcamp has been conducted quarterly, aligning with new doctor rotations. Held at the Medical Education Centre/Psychiatry Hospital, this one-day intensive training accommodates an average of 10 participants per session. The program, delivered by consultants, specialist nurses, and senior trainees, comprises tutorials, practical skills sessions, and simulated scenarios, focusing on key areas like the Mental Health Act, psychiatric risk assessment, wound management, resuscitation guidelines, and rapid tranquilisation.

A pre-test is administered to gauge participants' baseline knowledge and skills. Feedback is also collected immediately after the session and 3–4 months later. This ongoing feedback, systematically gathered since 2022, has been pivotal in continuously refining the curriculum and teaching methods, ensuring they remain up-to-date and effective.

The bootcamp demonstrated notable success in enhancing the preparedness of new psychiatry trainees for on-call duties. Post-course evaluations revealed an improvement in participants' confidence levels when managing psychiatric emergencies and various on-call situations. Through the practical and interactive nature of the training, trainees reported a deeper understanding of acute psychiatric care and an increased ability to apply theoretical knowledge in real-life scenarios. The hands-on experience with simulated scenarios was particularly effective in bridging the gap between classroom learning and clinical practice. Trainees expressed greater comfort in handling challenging situations, such as rapid tranquilisation and emergency detention under the Mental Health Act, which were previously areas of concern.

The Psychiatry Bootcamp represents a targeted and effective approach to preparing new psychiatry trainees for the demands of on-call duties. By focusing on key areas of need and employing a variety of teaching methods tailored to enhance practical skills and confidence, the bootcamp successfully addresses the gap between theoretical knowledge and clinical application. Preliminary feedback underscores the value of such programs in psychiatric education, suggesting that this model could be beneficial for similar settings seeking to improve trainee preparedness and overall patient care quality.

The Quality Improvement Project (QIP) for the Café of Royal College of Psychiatrists (RCPsych) Portfolio (CoRP) was initiated to address the challenges faced by UK postgraduate psychiatric trainees in utilizing the RCPsych Portfolio effectively. The primary objective of this project is to enhance trainees' confidence and competence in using the portfolio. Additionally, CoRP aims to establish a robust, sustainable ecosystem of peer coaching and mentorship to support continuous learning and development among trainees.

The CoRP employs a unique, multi-faceted approach, leveraging a scalable coaching and mentoring model. Firstly, the program focuses on increasing its visibility among trainee groups through targeted communication and marketing efforts. Secondly, CoRP provides on-demand sessions to cater to the varied schedules and job plans of trainees, offering flexibility and accessibility. The sessions offer a mix of coaching, mentorship, and guidance, tailored to the specific needs and learning styles of each trainee. Furthermore, the project fosters an environment where trainees can learn from peers and experienced professionals, enhancing the learning experience and promoting a culture of collaborative learning.

The implementation of the CoRP has led to significant improvements in trainees' confidence in using the RCPsych Portfolio. This outcome is evidenced by the data collected from pre- and post-session surveys, which show a marked increase in trainees' self-reported confidence levels. The project has successfully conducted a series of sessions that focus on various aspects of portfolio management and learning. These sessions have been well-received, with positive feedback from participants indicating that the program meets its intended objectives. However, the project acknowledges the need for long-term data to understand its impact on the Annual Review of Competency Progression (ARCP) outcomes and to assess its sustainability over time.

The CoRP has demonstrated immediate, positive effects in enhancing the skills of psychiatric trainees in using the portfolio. Its strengths lie in the scalability of the model and the incorporation of coaching and mentorship principles, which have proven effective in addressing the needs of trainees. However, the project recognizes that further evaluation is needed to establish a clear correlation between improved portfolio skills and ARCP outcomes. To this end, future plans include the continuous expansion and repetition of the program every six months to accommodate new trainees. Additionally, ongoing evaluation will be conducted to measure the program's long-term effectiveness and sustainability. This will ensure that CoRP continues to evolve and adapt to the changing needs of psychiatric trainees, ultimately contributing to their professional development and success in their field.

This audit evaluates the adherence of nursing and medical staff to local protocols for managing distress in older adults (aged >65 years) using non-pharmacological approaches and rapid tranquilisation (RT) in a psychiatric hospital's dementia ward, an acute medical unit, and a geriatric ward in a general hospital. We hypothesize that operational differences between these wards significantly influence the management of older adult patients.

Conducted from September 17 to October 8, 2022, in hospitals in Inverness, Scotland, this study reviewed 322 case notes and drug charts from patients who underwent RT in three wards: the Old Age Psychiatric Ward, Acute Medical Unit (AMU), and Geriatric Ward. Focus groups and informal discussions with ward nurses and junior doctors were organized to understand their perspectives on handling distress in dementia patients, with an emphasis on de-escalation techniques.

Data focused on key parameters:

• • Patient Diagnosis and Legal Status.

• • Administration Details: including initiation time, de-escalation techniques, consultation with senior doctors, and details of drugs administered (route, drug, and dosage).

Staff nurses in all wards prioritized non-pharmacological de-escalation techniques, such as recognizing early signs of agitation, employing distraction and calming tactics, and acknowledging the importance of personal space, even in the face of staffing challenges and high patient loads. These measures were consistently employed prior to considering RT, adhering to the local protocol. Physical restraint was employed only in scenarios where there was a risk to the patient or others, executed by personnel trained in managing violence and aggression.

Conversations with junior doctors, particularly in the AMU, revealed a limited understanding of the RT protocol, suggesting a need for enhanced training and awareness. Overall, the study indicates that while RT is regarded as a last resort after the failure of psychological and behavioral approaches, there is a clear necessity for further education and training to ensure the safe and effective administration of RT.

This audit demonstrates that despite the varying environments and pressures in the three wards, adherence to the local protocol for managing distress in older adults is largely effective, with a strong preference for non-pharmacological methods. The findings highlight the need for ongoing education and reinforcement of RT protocols, particularly among junior doctors, to ensure patient safety and adherence to best practices. The results suggest that with proper support and training, the use of RT can be a carefully controlled and beneficial tool in managing distress in older adult patients.

This study aims to evaluate dietary history documentation by junior doctors in a psychiatric hospital setting in Scotland. With emerging evidence in nutrition psychiatry highlighting diet's impact on mental health, especially ultra-processed foods, this aspect often receives insufficient attention in clinical assessments. The audit benchmarks current documentation against UK Public Health nutritional guidelines and UK Parenteral & Enteral Nutrition Guidelines on Malnutrition, assessing adequacy and consistency across psychiatric diagnoses.

This audit conducted a systematic review of medical records in psychiatric wards, focusing on patients newly admitted over six months. The data collection examined admission sheets by junior doctors, covering patient identifiers, admission time, diagnosis, doctor's grade, and comprehensive details on dietary habits, eating behaviours, BMI, and substance use. The review incorporated a dietitian's input to align dietary assessments with UK Public Health Nutritional expectations and the prevention of Malnutrition Guidelines. The goal was to assess the regularity, quantity, variety, and documented changes in patients' dietary behaviours, screening for potential nutrient deficits, impacts of psychotropic medications, and eating disorder psychopathology.

The results showed significant deficiency in the detail and consistency of dietary history documentation across all wards, regardless of the doctors' grade or the patients' psychiatric diagnoses. Most entries were inadequately documented or entirely missing. A particular discrepancy was noted in documenting dietary habits in patients with low BMI or those on metabolic altering antipsychotics, which should necessitate health behavior change dietary interventions. Furthermore, even in severe psychiatric conditions, there was a gap in dietary documentation indicating a widespread oversight in recognising the potential relevance of nutrition in the overall health and treatment planning of psychiatric patients, regardless of the severity or type of their condition.

The audit reveals a gap in psychiatric patient care concerning detailed dietary relevance history documentation. While Scotland's wards routinely use the Malnutrition Universal Screening Tool (MUST) for identifying malnutrition, this tool often overlooks key dietary elements like variety, quantity, and regularity, which are vital for linking diet content to mental health. This oversight is significant given the burgeoning field of nutritional psychiatry. Our findings suggest the necessity for systemic changes to improve dietary history documentation in psychiatric settings. This includes a more structured and systematic approach, integrating insights into the harmful effects of ultra-processed foods on mental health, to provide holistic care.

To improve the quality of care received by service users of Electroconvulsive Therapy (ECT) treatment in Lincolnshire Partnership Foundation Trust (LPFT) by measuring the compliance of the local ECT clinic in Lincolnshire in accordance with National Institute of clinical excellence guidance and ECT accreditation services standards.

Pre-audit work up includes consultations with ECT clinic lead and stake holders to ensure ethical and governance standard are met. This audit is conducted with the permission of trust quality and safety team.

Sample population is identified from ECT clinic registry, Lincoln. A total of 10 patients who received ECT treatment between January 2023 and August 2023 are included regardless whether the necessary information is available on the clinical system or not, to minimise selection bias. Retrospective data collection by using Rio electronic case records. Descriptive analysis of data using Microsoft Excel and evaluation of results is based on 3 key domains such as indication, consent process and monitoring.

A total of 10 service users, comprising 30% males and 70% females, underwent treatment in both inpatient (80%) and outpatient (20%) settings, primarily for severe depressive illness. In 70% of cases, a pre-ECT assessment was documented to evaluate potential risks and benefits. The consent procedure was completed by a psychiatrist in 70% of instances. However, ongoing consent was not consistently reviewed at each ECT treatment.

Baseline monitoring using the Clinical Global Impression and Comprehensive Psychopathological Rating Scale was conducted in 20% of cases, with no follow-up assessments performed after each treatment. The Montgomery–Åsberg Depression Rating Scale was employed at baseline for 40% of patients, yet there was no evidence of weekly monitoring. While the Montreal Cognitive Assessment was administered to all patients at baseline, it was not conducted after every four treatments.

Post-ECT follow-up data revealed that less than a quarter of patients underwent clinician reviews. Validated rating scales were utilized in no more than a fifth of patients at both one week and two months after treatment.

The findings suggest the need for improved documentation of the entire consent process and in regularly assessing the ongoing validity of consent. Moreover, there is a need for stronger monitoring at baseline, during, and after ECT treatment. It is recommended to revise the local ECT record pathway by December 2023, with a follow-up re-audit scheduled for March 2024 to evaluate the effectiveness of the implemented changes.

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.

9 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.

Learning 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.

We 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.

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.

The 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.

The 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.

With 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.

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.

Royal 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.

The 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.

There 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.

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.

Case 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.

Thematic 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.

Seclusion 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.

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.

A 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.

Subject 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.

Firm 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.

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).

All 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.

Total 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.

The 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.

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.

We 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.

There 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.

While 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.

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.

Data 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. 1. Ruthven Ward, New Craigs Psychiatric Hospital

2. 2. Acute Medical Unit (AMU), Raigmore Hospital

3. 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. 1. Patient Diagnosis and Legal status

2. 2. Administration

3. • Date and time started

4. • If de-escalation techniques were used

5. • If discussed with a senior doctor

6. • 1st and/or 2nd line of drugs administered (route, drug and dosage)

7. • If Haloperidol given and if ECG was done

Data collection showed the following:

1. 1. Ruthven Ward- all 32 patients did not receive RT.

2. 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. 3. Geriatric Ward – all 10 patients did not receive RT.

Focus 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.

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.

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.

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.

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.

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.

We aimed to look into phenomenology, predictors of reversibility, and its impact on the quality of life of DIMD patients.

We 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.

Fourteen 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.

DIP is the commonest and often reversible drug-induced movement disorder. Levosulpiride is notorious for causing DIMD in the elderly, requiring strict pharmacovigilance.