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A tale of excess: the curious case of the woman with 1447 emergency visits
- M. Sagué Vilavella, A. Giménez Palomo, A. Àvila-Parcet, T. Fernández Plaza, L. Navarro Cortés, G. Oretega Hernández, M. Pons Cabrera, L. Tardón Senabre, M. Vázquez
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S286
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Introduction
Frequent attenders to emergency services are challenging and costly. We report the case of a woman in her mid-twenties who stands out for a total of 1447 emergency visits.
ObjectivesOur primary objective was to describe the emergency visits of our patient. Secondary objectives were to assess her use of other healthcare services and to calculate her health expenditure.
MethodsThis is a clinical case report. We reviewed the patient’s electronic medical records for sociodemographic and clinical data. We obtained detailed information of psychiatric ED visits (length, most frequent times and days) regarding the second most-visited hospital. We assessed the efficacy of hospitalizations in reducing ED visits with a paired samples t Test, comparing the number of visits 30 days pre- and post-hospitalization. We estimated the health expenditure using the regional public health system prices, including three direct costs: emergency visits, hospitalizations and ambulance transportation. We obtained written informed consent from the patient’s legal guardian.
ResultsA 26-year-old woman from Barcelona (Catalonia, Spain), diagnosed with mild intellectual disability, made 1447 emergency visits between 2009 and 2021 (figure 1). 946 visits (65%) took place in psychiatric emergency departments (EDs), whilst 353 (24%) in non-psychiatric EDs and 148 (10%) in urgent primary care. She attended 24 hospitals (ranking number one the closest to the patient’s home, with 387 visits) and seven primary care centers, distributed across 17 cities in Catalonia. Most visits were self-referred, being the main presenting problems anxiety and instrumental suicidal behaviour. Saturday was her favorite day for hospital visits (24,1%), while she seeked care on Tuesdays much less often (4.5%). She made 73.5% of consultations between 1pm and 6pm, with a median length per visit of 2.8 hours (range 0.33-20.9 hours). Regarding other therapeutic approaches, she attended day hospitals, psychiatric rehabilitation programs and family therapy, among others (figure 2), for which she showed low adherence and scarce benefit. She had ten acute hospitalizations, interventions that did not reduce ED visits (t=-0.9835, p=0.36). Health expenditure reached 410.035€.
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ConclusionsThe most common definition of frequent attendance is a patient who has five or more visits per year. Many times, but not always, repeat visits are also inappropriate. The case we report is a grotesque example of both frequent and inappropriate attendance, which has been resistant to all kinds of interventions and has quality-of-care, financial and ethical implications. As of today, it is still a pending case. Maybe it is worth considering residential treatment?
Disclosure of InterestNone Declared
Bioenergetic changes and mitochondrial dysfunction in mania versus euthymia in bipolar disorder type I
- A. Giménez-Palomo, M. Guitart-Mampel, G. Garrabou, X. Alsina-Restoy, A. Meseguer, L. Colomer, G. Roqué, F. J. García-García, E. Tobías, J. Moisés, M. Valentí, E. Vieta, I. Pacchiarotti
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S692-S693
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Introduction
Current evidence has hypothesized the involvement of mitochondrial dysfunction during the acute episodes of BD compared to symptomatic remission. So far, no studies have compared mitochondrial and bioenergetic functions both in-vivo (respiratory parameters) and ex-vivo (cellular respiration) in different phases of the disease in the same individuals.
ObjectivesThis multidisciplinary pilot study aims at assessing bioenergetic and mitochondrial intra-individual differences between manic and euthymic states.
MethodsFour patients with a manic episode admitted to our acute psychiatric ward were recruited. Bioenergetic parameters were measured at admission (T0) and after symptomatic remission (T1).
At admission (T0) and before discharge (T1), HAMD and YMRS total scores were obtained. For the assessment of cellular respiration, polymorphonuclear cells were obtained by a Ficoll density gradient centrifugation procedure. To determine oxygen consumption (at T0 and T1), a million of living peripheral blood mononuclear cells (PBMC) were used. High-resolution respirometry was performed at 37°C by polarographic oxygen sensors in a two-chamber Oxygraph-2k system.
Specific oxygen uptakes (Routine: basal oxygen consumption; Proton Leak: oxygen consumption not coupled to ATP synthesis; and ETC: maximal capacity of the electron transport chain) rates were obtained using mitochondrial chain inhibitors and uncouplers. Oxygen consumption was normalized for protein concentration. Results are expressed as picomoles of oxygen per millilitre (pmol O2/s*μg prot).
Also, a constant work rate exercise test was performed on a cycle ergometer and basal and effort respiratory variables were measured.
Statistical analysis was performed with the SPSS v. 25.0 and GraphPad. Results were expressed as means and SD. Nonparametric tests (Mann–Whitney, Pearson) were used to determine differences (significant at p value <0.05).
ResultsOne patient was a man and three patients were women, with a mean age of 28 years old. HAMD initial and final mean scores were 11.0 and 7.0, and mean YMRS scores were 21.5 and 7.0 respectively.
Results from mitochondrial oxygen consumption revealed that mean basal oxygen consumption tended to be higher in T1 (0.98±0.45) than in T0, and maximal respiratory capacity was significantly increased in T1 (2.26±0.33; p=0.028) compared to T0.
Mean lactate levels and pH levels were similar in T0 and T1. Scales scores were not correlated to different pH or lactate changes after the effort task. Higher initial oxygen consumption was significantly correlated to higher maximal capacity (p<0.05) in T0 and T1.
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ConclusionsOur preliminary results suggest that mania could imply lower oxygen consumption capacity, which should be confirmed in future studies. A bigger study is planned to determine changes in bioenergetic patterns and capacity for aerobic response in manic and depressive episodes.
Disclosure of InterestNone Declared
Changing trends of suicide mortality from 2011 to 2019: an analysis of 38 European Countries
- G. Fico, A. Gimenez-Palomo, R. Andra Bursan, C. R. Ionescu, F. Kraxner, P. Rolland, S. Gomes-Rodrigues, M. Batković, E. Metaj, S. Tanyeri Kayahan, A. Mamikonyan, P. Paribello, A. K. Sikora, C. M. Platsa, M. Spasic Stojakovic, A. H. Halt, M. Az, N. Ovelian, K. Melamud, M. Janusz, K. Hinkov, C. Gramaglia, J. Beezhold, J. L. Castroman, C. Hanon, D. Eraslan, E. Olie
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S85-S86
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Introduction
Suicide is a serious public health problem since it accounts for nearly 900,000 deaths each year worldwide. Globally in 2019, 10.7 persons out of 100,000 died by suicide. Psychiatric disorders are related to an overwhelming proportion of these cases. In the last years, several specific interventions and action plans for suicide prevention have been implemented in a number of European countries.
ObjectivesOur aim was to analyze recent epidemiologic trends of suicide mortality rates in Europe.
MethodsAnnual national statistics of suicide mortality rates derived from Eurostat public databases from 2011 to 2019 were analyzed for 38 European countries. The suicide mortality rate was estimated per year/100,000 population. Linear regression models were used to study temporal trends of suicidal mortality. Analyses were performed using RStudio.
ResultsAvailable data show a statistically significant reduction in suicide mortality rates from 2011 to 2019 in 15 European countries, and a significant increase for Turkey (ES=0.32, SD=0.06, p=0.037) (Fig 1). The greatest significant decrease was reported in Lithuania (ES=-1.42, SD=0.02, p=0.02), followed by Hungary (ES=-1.13, SD=0.11, p=0.0007), Latvia (ES=-0.76, SD=0.11, p=0.007), and Poland (ES=-0.73, SD=0.10, p=0.001). Italy reported the lowest significant reduction in suicide mortality rates (ES=-0.13, SD=0.018, p=0.003). The remaining 16 countries showed no significant changes in suicide mortality trends.
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ConclusionsIn the last years, Europe registered an overall reduction in reported suicide rates. However, more recent data (i.e., suicide rates after COVID-19 pandemic, age and sex-related effect on suicide rates) should be analyzed and used to implement future recommendations. Current and future suicide prevention strategies aim to contribute to a greater reduction of suicide rates in the different European countries.
Disclosure of InterestNone Declared
Neutropenia induced by Valproic Acid: A case report
- N. Baldaquí, G. Anmella, S. Madero, F. Gutierrez, E. Pujal, L. Colomer, A. Giménez-Palomo
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- Journal:
- European Psychiatry / Volume 65 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 01 September 2022, pp. S731-S732
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Introduction
Valproic acid (VPA) is considered a well-tolerated antiepileptic drug used in Bipolar Disorder as a mood stabilizer. Nevertheless, VPA has been related to several adverse effects. Neutropenia is included as a potential adverse effect, although in clinical practice it is not often measured with regularity.
ObjectivesTo report a case of a patient with Bipolar Disorder type 2 and Personality Disorder Cluster B treated with VPA with a neutropenia caused by VPA.
MethodsA 61-year-old woman assists to the outpatient psychiatric unit in order to a pharmacological treatment adjustment. A blood test is performed showing a decrease in the levels of neutrophiles in comparison with previous tests. Psychiatric history is revised finding and association between the prescription of VPA and the reduction of neutrophile levels. When this drug was removed, neutrophile levels had increased again up to normal levels.
ResultsDue to the relationship between neutropenia and VPA treatment, we decided to discontinue this drug. At the beginning the patient doesn’t agree with the withdrawal of VPA treatment due to its effectiveness in her mood stabilization. Psychoeducation sessions are performed in order to explain risk and benefits of potentials treatment alternatives versus maintaining the same prescription. Finally the patient accepts the switch of the mood stabilizer treatment to oxcarbazepine with a good tolerability and effectiveness.
ConclusionsPeriodical blood test monitoring is needed in order to study adverse effects as neutropenia in patients with VPA treatment.
DisclosureThe author has received support from Janssen-Cilag, Otsuka-Lundbeck, Italfármaco, Angelini Pharma and Casen Recordati; and declares no support related to the subject of this article.
Emergency Psychiatry before and during COVID-19 pandemia
- A. Giménez-Palomo, M. Sagué, G. Fico, M. Gómez-Ramiro, M. Vázquez
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- European Psychiatry / Volume 65 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 01 September 2022, p. S277
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Introduction
The COVID-19 pandemic had a significant impact worldwide. Consultations in the Emergency Service of the Hospital Clínic of Barcelona varied in terms of reasons for consultations, psychopathology, and other aspects, before and after the pandemic.
ObjectivesTo examine changes in the profile of patients admitted before and during the COVID-19 pandemic to our Psychiatric Emergency Service.
MethodsAll children, adolescent and adult psychiatric inpatients admitted from December 4th 2019 to March 31st 2021 to the Psychiatric Emergency Service of Hospital Clínic of Barcelona, Spain, were retrospectively included for analysis and divided into two groups –groups 1 or 2- including the first one all patients who attended before lockdown and the second group those who attended during the pandemic.
ResultsA total of 1991 patients were included -1224 in the first group and 767 in the second group. The majority of patients were male (52.08%), with a mean age of 41.21 years (SD 16.53). A proportion significantly higher of men was found in the second group (p<0.05). The proportion of patients consulting with substance use disorders was significantly higher in the second group (p<0.05). Patients from the second group presented a significantly higher proportion of admissions in an acute psychiatric ward (p<0.05), and also a significantly higher proportion of consultations of patients with dementia (p<0.05).
ConclusionsThe COVID-19 pandemic lead to a significant reduction in the overall consultations, with a higher proportion of severe cases. The lack of availability of caregivers and telework might have influenced the increase in consultations of patients with dementia.
DisclosureAG has received travel and financial support from Janssen, Otsuka-Lundbeck and Angelini, and research support from Instituto de Salud Carlos III, and declares no support related with the subject of this presentation.
Bipolar disorders and suicide: stumbling twice with the same stone?
- M. Sagué-Vilavella, G. Fico, G. Anmella, A. Giménez-Palomo, M. Gómez-Ramiro, M. Pons Cabrera, S. Madero, E. Vieta, A. Murru
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- European Psychiatry / Volume 65 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 01 September 2022, pp. S222-S223
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Introduction
Suicide is the most terrible outcome of bipolar disorders (BD). It impacts families and healthcare professionals deeply. Family history of suicide (FHS) is one of its main risk factors, whereas lithium treatment and absence of substance use disorders (SUD) are two of its few modifiable protective factors.
ObjectivesTo explore the relationship between FHS and clinical characteristics in BD. We hypothesized that FHS would be associated with less SUD, higher rates of lithium treatment and shorter duration of untreated illness (DUI).
MethodsCross-sectional analysis of subjects with BD followed-up in a specialised outpatient unit (Barcelona, October’08-March’18). We described data with measures of frequency, central tendency and dispersion, and we used χ², Fisher’s test and t-tests for comparisons.
ResultsThe sample consisted of 83 subjects, 56.6% males, mean age 41.9 years (SD 12.7). 74.7% (n=62) had a diagnosis of BD-I and 25.3% (n=21) of BD-II. 11 subjects (13.3%) had FHS. Those with FHS did not show significant differences in sociodemographic data, DUI (58.5+/-60.4 vs 38.19+/-84.9 months, p=0.341), lithium use (72.7% vs 73.6%, p=0.95) or SUD (27.3% vs 23.6%, p=0.79). There were differences in terms of lifetime suicide attempts (54.5% vs 20.8%, p=0.026), family history of mental disorders (100% vs 69.4%, n=0.032).
ConclusionsContrary to our hypothesis, FHS was not associated with the modifiable protective factors against suicide (namely, less SUD and more lithium prescription). Similarly, we did not find an association with earlier access to mental health services at symptom onset (DUP as proxy). Therefore, our results suggest FHS does not modify attitudes towards prevention.
DisclosureNo significant relationships.
Clinical profile of patients admitted in an acute psychiatric ward before and during the COVID-19 lockdown
- A. Giménez Palomo, N. Baldaquí, L. Colomer, F. Gutiérrez, E. Pujal, P. Barrio, M. Bioque, E. Vieta, I. Pacchiarotti
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- Journal:
- European Psychiatry / Volume 64 / Issue S1 / April 2021
- Published online by Cambridge University Press:
- 13 August 2021, p. S102
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Introduction
The COVID-19 pandemic entailed several changes in health and medical assistance, economy, and lifestyle. In the Acute Psychiatric Ward of the Hospital Clínic of Barcelona, the implementation of restrictive measures was necessary in order to ensure patients’ safety.
ObjectivesTo compare clinical profiles and course of hospitalization of patients admitted before and during the COVID-19 lockdown in our Acute Psychiatric Ward.
MethodsAll patients admitted from January 7th to February 25th and from March 19th to May 7th of 2020 in the Acute Psychiatric Hospitalization Unit of Hospital Clínic of Barcelona, Spain, were retrospectively included for analysis and divided into two groups according to the period when they were admitted. Statistical analyses were performed using SPSS, 23.0 version.
ResultsA total of 117 inpatients were included (73 admitted before lockdown and 44 during lockdown), being 50.4% male, with a mean age of 42.4 (SD 15.73). Patients from the first group presented a significantly higher proportion of antidepressants prescription at discharge (p<0.05) and more substance use disorders (p<0.05). Regarding the lockdown group, 51% of patients manifested COVID-19-related stress. Time of hospitalization was significantly lower in the lockdown group (p<0.05), even though a significantly higher proportion of patients were discharged at home (p<0.05) compared with the first group.
ConclusionsThe situation of lockdown led to a series of changes in our unit and also in the profile of patients admitted, having shorter admissions, lower prescription of antidepressants, and often COVID-related stress. These differences should be considered in future situations in which restrictive measures may be necessary.
DisclosureNo significant relationships.
Dissociative disorder following preeclampsia: A case report
- A. Giménez Palomo, M.L. Imaz, I. Pacchiarotti, A. Roca, E. Solé, L. Garcia-Esteve
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- European Psychiatry / Volume 64 / Issue S1 / April 2021
- Published online by Cambridge University Press:
- 13 August 2021, p. S650
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Introduction
Preeclampsia is a new-onset hypertension with new-onset proteinuria after 20 weeks gestation. Scarce evidence regarding psychiatric effects of preeclampsia is available.
ObjectivesTo describe a case of a pregnant 24 year-old patient with a premature cesarean section in context of severe preeclampsia and dissociative symptoms.
MethodsPatient referred to a third-level hospital for cesarean section due to a severe preeclampsia at week 32, in whom magnesium sulfate, labetalol perfusion and betamethasone are started. In the puerperium period only labetalol up to 300 mg/6h is maintained.
ResultsDue to the appearance of pulsating headache and photophobia, a computerized tomography is conducted, showing bilateral insular and occipital hypodensity related to vasogenic edema. High blood pressure is maintained (177/121 mmHg) despite antihypertensive treatment. A magnetic resonance imaging and an ophthalmologic exam do not show significant abnormalities and blood pressure is stabilized with treatment. However, the patient refers new-onset auditory imperative hallucinations and suicide thoughts, being referred to our Acute Psychiatric Ward for clinical assessment and intervention. Treatment with risperidone 2 mg is started. The day after her admission, she does not refer psychotic symptoms, explaining depersonalization symptoms in the previous 5 days, seeing herself having to choose a knife to commit suicide. After discharge, she maintains reiterative dreams in which she falls down from a building, not presenting dissociative symptoms during the day.
ConclusionsFurther evidence regarding psychiatric effects of preeclampsia is needed in order to study the consequences of edema and pharmacological treatment. Blood pressure and psychiatric symptoms monitoring after preeclampsia should also be considered.
DisclosureNo significant relationships.
Neonatal and infant outcomes of clozapine exposure in pregnancy: A consecutive case series
- M.L. Imaz, S. Lera, B. Sureda, A. Roca, S. Andres, A. Giménez Palomo, E. Solé, A. Torres, L. Garcia-Esteve
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- Journal:
- European Psychiatry / Volume 64 / Issue S1 / April 2021
- Published online by Cambridge University Press:
- 13 August 2021, p. S479
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Introduction
Clozapine is a second-generation antipsychotic agent approved for treatment-resistant schizophrenia and risk reduction of recurrent suicidal behavior in schizophrenia and schizoaffective disorder. Given the known negative consequences of relapse of severe mental disorders for both mother and infant, the maintenance of clozapine during pregnancy is recommended.1 Studies of pregnancy regarding to clozapine have demonstrated a heterogenous range of neonatal and infant complications.2
ObjectivesTo evaluate neonatal and infants outcomes of clozapine exposure in pregnancy.
MethodsWe report three cases of infants exposed to clozapine politherapy throughout pregnancy. The dose range for all women on clozapine was 200-600 mg/day. Infants were evaluated between 4-6 months of chronological age with the Bayley-III infant development scale (BSID-III)3 and with the Alarme Détresse Bébé Scale (ADBB)4 for the detection of early-signs of withdrawal.
ResultsWomen remained stable during pregnancy but presented obesity and gestational diabetes. Clozapine Newborn were born to term by caesarean section due to breech presentation (N=2) or instrumental delivery due to loss of fetal well-being (N=1). They presented normal weight (3500-3800 gr). Two presented Apgarmin1-5 9/10 and one Apgarmin1-5 6/8 which showed lethargy and low alertness during the first weeks of life. All showed normal capacity for sociability, reciprocity and development of language and communication. However, one baby had scores in the low normal zone for cognition and another for motor skills.
ConclusionsThe infant’s risks of clozapine exposure during pregnancy should be discussed with women and weighed against those associated with other treatments and/or with untreated severe mental illness.