Trends in Second Generation Antipsychotic Prescribing for Adolescents from 2013-2021

Objectives: To examine temporal trends of FDA-approved and off-label second-generation antipsychotic (SGA) prescribing for adolescents over time through the Covid-19 pandemic. Method(s): This is a new-user, retrospective longitudinal panel study using electronic health record data from a large, integrated health care system. Outpatient prescription orders for a new SGA (index date) for adolescents (age 10-17 years) during 2013-2021 were analyzed. Prescription orders were linked to diagnoses at time of encounter to examine prescribing behavior. A one-year lookback period was used for baseline inclusion and exclusion criteria, including one-year "washout" of SGAs and continuous insurance enrollment. FDA-approved use was determined by two outpatient diagnoses (one baseline diagnosis and the prescription order diagnosis) for autism, psychotic disorders, bipolar disorders, or Tourette's;the remaining proportion was considered potentially off-label. We report crude annual prescribing rates per 1,000 youths. Result(s): There were 8,145 unique patients with new SGA prescription orders, of which 5,828 (71.6%) had linked diagnoses available. Calendar year 2013 had the highest prescribing rate prior to Covid-19 onset (2.1 per 1,000) but then declined through 2016 (1.7 per 1,000). Prescribing rates in 2020 (2.0 per 1,000) and 2021 (2.2 per 1,000) were higher than those between 2017-2019. Across all study years, SGA prescriptions were mostly off-label and ordered for aripiprazole, quetiapine, or risperidone. The proportion of off-label indications was highest in 2013 (80.1%) and lowest (69.1%) in 2019. Off-label proportions increased again in 2020 (76.1%) and in 2021 (74.1%). At baseline, patients frequently had other psychotropic prescriptions (e.g., antidepressants 63.3%, stimulants 22.9%, and sedatives/hypnotics 20.7%). Conclusion(s): A general decline in SGA prescribing rates among adolescents was observed from 2013 to 2019, but then increased following Covid-19 onset. Despite known safety risks, off-label use of SGAs remains prominent. Future studies are needed to better understand prescribing outside of pediatric professional society guidelines.Copyright © 2023

Sexual Health Implications Associated with Psychotropic Medication Usage in Adolescents during the Covid-19 Pandemic: Analysis of a Federated Research Network

INTRODUCTION AND OBJECTIVE: Psychotropic medications have a significant impact on sexual health. Long-term usage is strongly associated with dyspareunia, decreased libido, hypogonadism and erectile dysfunction. We hypothesized that the prescription rates for psychotropic medications increased in adolescent patients during the COVID-19 pandemic because of the unprecedented stress levels on youth in isolation. Therefore, we evaluated the prescription rates of psychotropic medications as well as concurrent use of PDE5i in adolescent patients during the COVID-19 pandemic compared to the pre-pandemic era. METHOD(S): We utilized data generated from TriNetX Research Network to conduct a retrospective matched cohort study. Adolescent patients aged 10-19 presenting for outpatient evaluation were placed into two cohorts: 1) outpatient evaluation before and 2) during the COVID-19 pandemic. Patients with prior psychiatric diagnoses and those with prior use of psychotropic medications were excluded. The outcomes of interest were new prescriptions within 90 days of outpatient evaluation. Propensity score matching was performed using logistic regression to build cohorts of equal size. RESULT(S): A total of 1,612,283 adolescents pre-COVID-19 and 1,008,161 adolescents presenting during the COVID-19 pandemic for outpatient evaluations were identified. After propensity matching, a total of 1,005,408 adolescents were included in each cohort each withan average age of 14.7 +/- 2.84 and 52% female and 48% male. Prescribing of antipsychotics and benzodiazepines were more frequent during the pandemic for adolescents (RR: 1.58, 95% CI 1.01-2.2). However, they were less likely to receive antidepressants (Risk Ratio (RR): 0.6, 95% Confidence Interval (CI) 0.57-0.63), anxiolytics (RR: 0.78, 95% CI 0.75-0.81), stimulants (RR: 0.26, 95% CI 0.25-0.27), as well as mood stabilizers (RR: 0.44, 95% CI 0.39-0.49). Erectile dysfunction requiring oral PDE5i in this cohort was more frequent during the pandemic for adolescents (RR: 1.53, 95% CI 1.05-2.01). CONCLUSION(S): The rates of antipsychotic and benzodiazepine prescriptions increased during the COVID-19 global pandemic compared to preceding years. This coincided with a statistically significant increase in the prescription of PDE5i for erectile dysfunction. Adolescents may face an increased risk of sexual dysfunction as both their illness and the medications they are prescribed both have a positive association with sexual dysfunction. Clinicians must be cognizant of the fact that adolescents may face an increased risk of medication related sexual dysfunction.

Exploring the views of care home staff on the use of antipsychotics for people with dementia amid the COVID-19 pandemic: A qualitative study

Introduction: There was an increase in antipsychotic prescribing for people with dementia during the COVID-19 pandemic (1). To explain this increase, the current study was conducted to explore the views of staff working in care homes for the elderly during the pandemic on the use of antipsychotics for residents with Behavioural and Psychological Symptoms of Dementia (BPSD). Aim(s): The aim was to explore the use of antipsychotics for people with BPSD during the COVID-19 pandemic by interviewing staff in care homes about their experiences during that time. Method(s): Semi-structured interviews were conducted online with staff working in ten UK elderly care settings using convenience sampling. Participants mainly onsite care home staff were recruited through online networks, for example, Twitter, and support groups such as CHAIN and NIHR clinical research network. Interviews were conducted between May 2021-March 2022, were audio recorded, transcribed verbatim, and analysed inductively using thematic analysis in NVivo version 12. Result(s): Ten interviews were completed with managers (n=2), care staff (n=6) and nurses (n=2) in nursing homes (n=7) and residential homes (n=3) (all were female). The first theme 'Challenges experienced in care provision' entails challenges experienced in the care environment;residents were confined to their rooms, activities were suspended, staff were absent and stressed, and family visits were barred. The reduced human contact affected residents' sense of self, mental and physical wellbeing, and in turn, their behaviours. The second theme 'Prescribing process' refers to doctors prescribing medicines in response to staff raising concerns. The third theme 'Attitude toward antipsychotics' denotes participants' positive and negative beliefs about antipsychotics. The positive beliefs included antipsychotics being the right choice and beneficial, an increased need and continued use of antipsychotics, use of a combination of medications and weighing the risks and benefits of antipsychotics. The negative beliefs included reports of adverse effects and short-term benefits of antipsychotics, antipsychotics not always beneficial, benefits in deprescribing, dislike for antipsychotics and belief antipsychotics are the last resort. Some expressed the need for antipsychotics had not increased but been driven by health professionals involved. The fourth theme 'Other psychotropic medication' alluded to other commonly used psychotropic medications and associated risks and benefits. The fifth theme 'Measures implemented within care settings' represented strategies implemented to avert the initiation or bolster antipsychotic deprescribing such as non-pharmacological approaches, nurses' assessment of residents before requesting antipsychotics, multidisciplinary consultation, and medication review. Conclusion(s): This is the first study that reports care home staff views on antipsychotic use for residents with dementia during the pandemic. The limitations include that only views of female respondents were obtained and the limited sample size. Care homes faced enormous challenges in the provision of care services to residents with dementia during the pandemic. The multitude of difficulties experienced in care homes due to lack of preparedness may have influenced staff to have positive views of antipsychotics and their use as an option during the pandemic. It's important to acknowledge and address these difficulties for example through education and training interventions to help with future preparedness.

Prevalence of adverse drug reactions associated with emergency department visits and risk factors for hospitalization

Objective: Adverse drug reactions increase morbidity and mortality, prolong hospital stay and increase healthcare costs. The primary objective of this study was to determine the prevalence of emergency department visits for adverse drug reactions and to describe their characteristics. The secondary objective was to determine the predictor variables of hospitalization for adverse drug reactions associated with emergency department visits. Method(s): Observational and retrospective study of adverse drug reactions registered in an emergency department, carried out from November 15th to December 15th, 2021. The demographic and clinical characteristics of the patients, the drugs involved and the adverse drug reactions were described. Logistic regression was performed to identify factors related to hospitalization for adverse drug reactions. Result(s): 10,799 patients visited the emergency department and 216 (2%) patients with adverse drug reactions were included. The mean age was 70 +/- 17.5 (18-98) years and 47.7% of the patients were male. A total of 54.6% of patients required hospitalization and 1.6% died from adverse drug reactions. The total number of drugs involved was 315 with 149 different drugs. The pharmacological group corresponding to the nervous system constituted the most representative group (n = 81). High-risk medications, such as antithrombotic agents (n = 53), were the subgroup of medications that caused the most emergency department visits and hospitalization. Acenocumarol (n = 20) was the main drug involved. Gastrointestinal (n = 62) disorders were the most common. Diarrhea (n = 16) was the most frequent adverse drug reaction, while gastrointestinal bleeding (n = 13) caused the highest number of hospitalizations. Charlson comorbidity index behaved as an independent risk factor for hospitalization (aOR 3.24, 95% CI: 1.47-7.13, p = 0.003, in Charlson comorbidity index 4-6;and aOR 20.07, 95% CI: 6.87-58.64, p = 0.000, in Charlson comorbidity index >= 10). Conclusion(s): The prevalence of emergency department visits for adverse drug reactions continues to be a non-negligible health problem. High-risk drugs such as antithrombotic agents were the main therapeutic subgroup involved. Charlson comorbidity index was an independent factor in hospitalization, while gastrointestinal bleeding was the adverse drug reaction with the highest number of hospital admissions.Copyright © 2022 Sociedad Espanola de Farmacia Hospitalaria (S.E.F.H)

Neuropsychiatric Side Effects of Steroids during Treatment for Pediatric Acute Lymphoblastic Leukemia: A Comprehensive Narrative Review

Background/Purpose: Pediatric Acute Lymphoblastic Leukemia (ALL) affects ~4000 young Americans each year. Steroids are essential to curative ALL treatment yet have significant neuropsychiatric side effects that decrease quality of life for patients and families. However, incidence and predisposing risk factors are not well understood. This review aims to describe the current literature on neuropsychiatric side effects of steroids in Pediatric ALL. Method(s): A precise search in PubMed and Embase was cultivated using controlled vocabulary terms (MeSH, Emtree) and keywords for the following concepts: pediatrics, steroids, side effects, cancer, and neurobehavioral manifestations. Keywords and controlled vocabulary for each subject were arranged logically and combined with other concepts by Boolean Logic, using the Boolean operator AND, resulting in 642 precise results exploring neurobehavioral side effects of steroids in children with cancer. Results (2010 to date of search) were imported into Covidence systematic review software, and reviewed by SB and AM. Result(s): Twenty-three articles met inclusion criteria. There is marked variability in research methodology and no standard measurement of neuropsychiatric symptoms. Commonly reported symptoms include mood swings, irritability, depression, anxiety, aggression, insomnia, mania, and psychosis with prevalence between 5% and 75%. Heterogeneous research methodology and descriptions of psychiatric symptoms make it difficult to determine risk factors, though dexamethasone, family psychiatric history, and younger age are consistently associated with greater risk of behavioral dysregulation. Genetic predisposition (Bcl1 polymorphism, SNPs in GR gene) may increase susceptibility to developing depression during treatment. Data suggest variable efficacy of antipsychotics, benzodiazepines, hydrocortisone, and potassium-chloride. Conclusions and Implications: Existing data about neuropsychiatric side effects of steroids in pediatric ALL is extremely heterogeneous, creating challenges for standardized assessment and treatment. The burden of these symptoms necessitates further research to identify and treat vulnerable patients. Standard measurement of these symptoms could be a first step in eventually alleviating this source of distress.

Covid-associated psychosis - A challenge for expert opinion.

Discussed is the case of a 41-year-old pilot with no relevant psychiatric history who presented with headache, fatigue, and lack of drive in the context of a confirmed mild COVID infection. At the same time he suffered from a paranoid symptomatology persisting for several weeks. After remission the patient remained stable also after discontinuation of neuroleptic medication. CCT, NMR, CSF were normal. The interrelationship between COVID and acute psychosis is discussed.Copyright © 2023 Georg Thieme Verlag. All rights reserved.

The Issue of Post-COVID Syndrome in Children and Adolescents: Approaches to Terminology, Pathogenesis, Clinical Manifestations, Diagnosis, and Treatment.

The article discusses the issues of terminology, epidemiology, etiopathogenesis, clinical manifestations, approaches to the diagnosis and treatment of post-covid syndrome (PCS). It has been shown that the incidence of PCS in people who had COVID-19 is 10-35%;there are no generally accepted approaches to defining the term PCS. Clinical manifestations of PCS include more than 50 symptoms that occur in both children and adults, regardless of their place of residence. The damage caused by metabolites of the systemic inflammatory response of the central nervous system with the formation of a syndrome of autonomic dysfunction, cognitive impairment, and affective disorders is of critical importance in the genesis of PCS. Antipsychotics, antidepressants, and benzodiazepine drugs are used in the correction of PCS. However, they have limitations, in particular - when used in children with comorbid disorders. The use of aminoacetic acid (glycine), which has a wide range of safety, anxiolytic, anti-inflammatory, and nootropic effects in the correction of PCS, can become an effective therapeutic strategy.Copyright © Team of Authors, 2022.

Virtual Schooling and Pediatric Mental Health During the COVID-19 Pandemic

Introduction: The first six months of the COVID-19 pandemic saw a nearly 50% increase in pediatric mental health emergencies. Specific factors contributing to this rise remain poorly characterized. One frequently cited contributor is pandemic-related interruptions of in-person schooling. Early studies indicate that students have experienced significantly greater psychological distress during such disruptions. We set out to investigate what correlation, if any, exists between school modality (ranging from exclusively virtual to exclusively in-person) and pediatric mental health status. Method(s): This is a retrospective, descriptive study combining patient chart review and parental telephone survey, exploring the prevalence and severity of mental illness among inpatients at a single urban, academic, midwestern tertiary care center. The study population included all patients ages 6-18 admitted to the study site during the 2015-19 and 2020- 21 school years who received Psychiatry and/or Psychology consults and/or were admitted to the inpatient psychiatry unit. Parents/guardians of participants from 2020-21 were surveyed regarding their child' educational experiences. We describe and compare participants between school years prior to and during the pandemic using descriptive demographic data and clinical data highlighting monthly admission rates and proxies for illness severity. We then assess for any correlation between these measures and recent virtual schooling. Result(s): Total mental health-related admissions rose from an average of 1070 during pre-pandemic school years to 1111 in 2020-21. Patients admitted in 2020-21 were more likely to be female, non-white, and from ZIP codes with higher median income. Primary diagnosis was more likely to be a mood or eating disorder. Patients were less likely to present primarily for suicidal ideation or self-harm. Proxies of illness severity, including utilization of PRN antipsychotics/benzodiazepines and readmission rates, rose in 2020-21. 255 of 800 (31.9%) families responded to the telephone survey. Respondents were more likely to have a child who was female and slightly younger compared to non-respondents. 98% of respondents reported some virtual schooling for their child, with 77% reporting virtual schooling for the majority of the three months prior to their child' first hospital admission. 61% indicated their child was exclusively in virtual school. No significant relationships were observed between virtual schooling and any outcome measures relating to mental health. Conclusion(s): Pediatric mental health emergencies and hospitalizations have grown and evolved since the start of the COVID-19 pandemic. This study characterizes some of the changes in patient demographics and experience with virtual schooling prior to and following the pandemic. Our results do not support any correlation between virtual schooling and mental illness requiring emergent care or hospitalization. However, this study has many significant limitations. Respondents were not representative of all admitted patients, and survey data were gathered for only one-third of families whose children were admitted at one site. Very few respondents remained in school in person throughout the pandemic, complicating efforts to make meaningful comparisons. Future work should attempt to capture a broader subject pool and obtain prospective data regarding the effects of school modality on mental health.

Possible autoimmune pediatric encephalitis following COVID-19 infection with focal cerebral dysfunction in a young female: A case report

Introduction: Post-COVID-19 autoimmune encephalitis is a rare manifestation following COVID-19. Most cases have not demonstrated solid evidence regarding their pathogenesis. Some believe it to be an immune process. Case presentation: In this case report, we present a case of a young female who presented to our emergency department with visual, auditory, and olfactory hallucinations after successfully treating COVID-19 two weeks prior to this visit. On examination, her vital signs were stable, but she was agitated, distressed, and hallucinating. Neurological examinations were normal. Laboratory investigations, including autoimmune profiles, were all negative. Magnetic resonance imaging of the brain showed non-specific changes in the bilateral frontal area. Electroencephalography (EEG) showed lateralized rhythmic delta activity (LRDA) arising more from the right occipital lobes. Autoimmune psychosis was suspected due to psychosis, abnormal imaging, and abnormal EEG findings. She was given corticosteroids and antipsychotic medication. Her symptoms improved within ten days. On follow-up, she remained well without any return of psychosis. Conclusion(s): Possible autoimmune pediatric encephalitis following COVID-19 is a rare entity that has scarcely been reported. The majority of the cases were reported to have been related to stress following the infection. To establish the correct diagnosis, an extensive workup, including an autoimmune profile, lumbar puncture, magnetic resonance imaging, and electroencephalography, is recommended.Copyright © 2022 The Author(s)

Clinico-Epidemiological Profile of Cutaneous Adverse Drug Reactions at Rural Tertiary Care Centre

Background: Cutaneous adverse drug reactions (CADRs), also known as toxidermia, are skin manifestations resulting from systemic drug administration and it constituted 10%-30% among all reported adverse drug reactions (ADRs). These reactions range from mild morbilliform drug rash to much more severe reactions. Material(s) and Method(s): A retrospective observational study was conducted at dermatology outpatient department of rural based tertiary care center for a duration of 03 years from August 2019 to July 2022, a total of 211 patients who had been clinically diagnosed or were suspected to have drug reactions were studied. Result(s): In this observation there was male preponderance (59.72%) and majority of patients were in their 3rd and 4th decade (40.28%) with maculopapular drug rash (33.17%) being most common clinical profile of CADRs, followed by urticaria (23.70%). Less frequently seen CADRs were acneiform eruptions (21), hair Loss (9), photodermatitis (9), generalised pruritus (7), erythroderma (2), pityriasis rosea (2), Stevens Johnson Syndrome-Toxic Epidermal Necrolysis (SJS-TEN) (4), lichenoid drug eruptions (3), Vasculitis (1) and pustular drug eruption (1). The most common group of drugs causing CADRs were antibiotics (40.28%), followed by NSAIDs (28.43%). Conclusion(s): Cutaneous Adverse Drug Reactions (CADRs) are price we pay for the benefits of modern drug therapy;knowledge of these reactions is important for treating physician as prompt recognition and treatment can prove lifesaving.Copyright © 2022 Academic Medicine and Pharmacy

EVALUATION OF THE EFFECT OF THE COVID-19 PANDEMIC ON THE TREATMENT OF RADIATION ONCOLOGY PATIENTS

Background: Patients undergoing cancer treatment and people with a history of cancer constitute a high-risk patient group in the COVID-19 pandemic. In this study, we aimed to evaluate the life effect of the COVID-19 pandemic on the treatment processes of cancer patients receiving radiotherapy at our hospital's Radiation Oncology Clinic. Methods: Sociodemographic data, COVID-19 pandemic awareness, vaccination and disease transmission of the Radiation Oncology Clinic's patients were administered with a written questionnaire that includes the effects of the pandemic on the treatment between 1st and 30th June of 2021. Results: 7 (13.2%) of the patients had COVID-19 infection during the treatment processes, the in-home index was 4 (57%) due to contact with the case (p<0.001). 4 of the patients (7.5%) stated that they had experienced disruptions in their treatment processes caused by the health institution and 4 of the patients (7.5%) stated that they had experienced disruptions in their treatment processes caused by personal anxiety and anxiety during the pandemic process. 8 patients (15%) stated that they had concerns that they would receive incomplete treatment due to the pandemic process, while one patient (1.9%) stated that they had received psychological support and psychiatric medication due to this anxiety and fear. 9 patients (17%) stated that the covid-19 pandemic had a negative effect on oncological disease treatment processes. Conclusion: It is important that the treatment and follow-up of cancer patients, who are a at-risk group for COVID-19 infection, should continue without interruption, accompanied by up-to-date national and international guidelines.

Hyperactive delirium in an 11-year-old boy with juvenile neuronal ceroid lipofuscinosis and a SARS-CoV-2 infection

An 11-year-old boy with juvenile neuronal ceroid lipofuscinosis (JNCL) is admitted because of acute agitation and hallucinations. Upon admission, the patient takes lorazepam, which does not induce the expected rest. A PCR-test had a positive result for SARS-CoV-2. Juvenile neuronal ceroid lipofuscinosis (JNCL) is a rare neurodegenerative disease in children and adolescents. Hallucinations are a known symptom in the course of the disease. In the case discussed in this article, however, the pronounced hallucinations fit within a broader clinical picture of a hyperactive delirium. A delirium is by definition provoked by a physical cause. In the presented case, JNCL was an existing risk factor for a delirium, the SARS-CoV-2 infection and lorazepam were presumably the triggering factors. Recent literature shows that an asymptomatic or mildly symptomatic SARS-CoV-2 infection can also trigger a delirium. Treatment consists of treating the physical cause (if possible), supportive measures for the patient and context, as well as medication. The antipsychotics risperidone and haloperidol are recommended. Within the context of JNCL, cautious initiation of a second-generation antipsychotic, such as risperidone, along with great alertness to possible side effects, such as extrapyramidal symptoms and neuroleptic malignant syndrome, are advised. For the young patient in the discussed case risperidone was started, supplemented with olanzapine as rescue medication. The medication had a good effect and no side effects were observed.

A Case of Cotard Syndrome and Neurosyphilis

BACKGROUND: Cotard syndrome is a rare neuropsychiatric condition in which individuals have delusions of being deceased or losing their organs. It is often seen in patients with severe depression and is associated with catatonia.1 Neurosyphilis is a severe sequelae of untreated treponema pallidum infection in which the paretic form of this disorder commonly has a psychiatric presentation. 2 We present a rare case of Cotard syndrome in a patient with neurosyphilis with successful treatment. OBJECTIVE: To understand Cotard syndrome and underlying neuropsychiatric conditions, and characterize the diagnosis and management of psychiatric symptoms in a patient with neurosyphilis. METHODS: Review of a case using electronic medical records and relevant literature. Key terms searched: 'Cotard syndrome,' 'neurosyphilis,' 'COVID-19 infection' using Medscape and Google Scholar. RESULTS: We present a 49-year-old male with a history of alcohol use disorder in remission, depression, and history of COVID-19 (asymptomatic) 6 months prior. The patient presented to the emergency department for recent changes in behavior. He was agitated, threatening, and required chemical and physical restraint. Evaluation was notable for illogical thought processes with somatic delusions. He repeatedly stated, 'I am already dead, my organs have died,' and had an episode of catatonia. All tests including drug screen and COVID-19 were negative. Rapid plasma regain (RPR) titer was 1:64. Neurology and Infectious Disease were consulted. Lumbar puncture revealed positive venereal disease research laboratory (VDRL) titer of 1:4. The patient was diagnosed with neurosyphilis and major depressive disorder with psychosis with Cotard syndrome. He was treated with intravenous (IV) penicillin G and was discharged on oral mirtazapine 30 mg and olanzapine 20 mg nightly at bedtime, oral donepezil 5 mg daily, thiamine, and folate. CONCLUSIONS: Cotard syndrome is often seen in depression with psychotic features.1 Neurosyphilis can present with depression, anxiety, psychosis, and dementia. Early identification is the key for successful treatment. This is a unique case of neurosyphilis with features of Cotard syndrome in a patient with a history of depression with treatment noncompliance. Studies show that quetiapine and risperidone improve psychosis in neurosyphilis.5 In this case, neurosyphilis was successfully treated with IV penicillin G for 2 weeks. The patient was also tried on antipsychotics and mood stabilizers ' specifically aripiprazole, valproic acid, and haloperidol ' and was eventually stabilized on oral olanzapine 20 mg taken nightly at bedtime. Our differential diagnosis also included COVID-19 delirium with Cotard syndrome, which was ruled out due to a negative COVID test. To our knowledge, there are 2 cases of COVID-19 delirium with Cotard syndrome.6 We present this case to inform clinicians of rare manifestations of neurosyphilis in patients with comorbid psychiatric illness and to advance research into treatment options for psychosis in neurosyphilis.

COVID-19 VACCINATION INTENTION among TUNISIAN HEALTH CARE WORKERS

Background: Health care workers (HCW) are the soldiers in the forefront of the fght against the coronavirus (COVID-19) pandemic. It is therefore a priority target group in the COVID-19 vaccination process. Objectives: Our purpose was to assess the COVID-19 vaccination intentions of Tunisian HCW and the reason for fear in case of hesitancy. Methods: We conducted an anonymous online questionnaire in the months of May and June 2021among HCW via social networks. The data collected included demographic characteristics, vaccination intentions, and reasons of hesitancy. Results: Five-hundred HCW were included in the study. Participants were divided as follows: 74% doctors (15% seniors, 37% juniors, 22% interns), and 26% nurses. The mean age was 34 ± 5 years [24-58]. Seventy-three percent of participants were female. A history of chronic illness was noted 150 HCW (30%). A psychiatric disease was noted in 105 participants (21%): anxiety disorder (62%), depression (33%), and bipolar disorder (5%). A treatment was prescribed in 63% of cases: anxiolytics (84.2%), antidepressants (16.6%), and neuroleptics (10%). Psychotherapy was prescribed in 47% of cases. A personal and family history of COVID-19 infection was noted in 50.4 and 55% of cases, respectively. The infection was mild in 91.2% of cases. Four-hundred and five HCW (81%) had the intention to get vaccinated against COVID-19. Twenty participants (4%) refused the vaccine, and 75 (15%) were still hesitant. Vaccination hesitancy was linked to concerns about the safety of a rapidly-developed vaccine in 92% of cases: adverse reactions (95.8%), tolerance (75%), and efficacy (25%). Sixteen percent of hesitant respondents expressed concerns about the involvement of policy in vaccine development. Vaccines to avoid according to participants were: Astra Zeneca (62%), Synovac (26%), Sputnik (8%), and Pfzer (4%). Conclusion: The intention to be vaccinated against COVID-19 reached 81% among Tunisian HCW. Acceptance of the vaccine, even among medically informed individuals, is based on a personal perception of the risks and benefts of vaccine safety. Hence the need for campaigns targeting both the general population and the HCW.

Incidence, Risk Factor and Outcome of Delirium in Intensive Care Unit (COVID vs Non-COVID ICU): An Observational Study

Aim and background: Delirium is the disturbance of consciousness characterised by acute onset, rapid fluctuations in mental status, and impaired cognitive functioning. The patient's ability to receive, process, store, and recall information is impaired in delirium. Objective: To study the incidence of delirium in patients in COVID and non-COVID ICU. To also study various risk factors associated with delirium. Materials and methods: After ethical committee approval and written informed consent, this study was carried out over a period of 1 year (August 2020 to July 2021). Each patient meeting the inclusion criteria was evaluated on the RAAS score within 24 hours of admission, then screened for delirium according to CAM-ICU worksheet every 6th hourly after admission in MICU. 50 patients were studied each in COVID and non-COVID ICU. Patients found to have delirium after the first assessment were classified as new cases. Various risk factors were evaluated prospectively. Results: Incidence of delirium in non-COVID ICU was 29%, while in COVID ICU was 37%. Delirium is present in a patient who has risk factors including smoking, higher severity of illness, oversedation, and mechanical ventilation. Antipsychotics can be used for patients who develop delirium. Conclusion: Delirium is a preventable issue in ICU patients that can be managed by preventing the risk factors that will decrease overall length of stay in ICU.

Management of depression: A daily challenge in psychiatric emergencies

Depression is the most common psychiatric disorder in the general population, and emergency room visits for depression have been increasing for several years. In addition, the Covid-19 pandemic may lead to an explosion of psychiatric emergency room visits for this reason, with an overall prevalence of anxiety and depression that appears to be increasing since 2020. The Centre Psychiatrique d'Orientation et d'Accueil is a regional psychiatric emergency service located in Paris which records approximately 10,000 consultations per year. Among these consultations, the main symptoms are those of depression (depressive ideations, anxiety) and nearly 40 % are diagnosed with mood disorders, including depression. The management of the patient in the emergency room is based on a global evaluation, which should not be limited to the psychiatric interview. In the best case, and if compatible with the organization of the service, an initial evaluation by the nursing reception staff determines the context of the arrival of the patient, the reason and the degree of urgency of the consultation can thus be assessed from the outset. The request for care can come from the patient themself, but also from family and friends who are worried about a decline in the patient's previous condition. The consultation may also be triggered by the intervention of emergency services, particularly in the case of attempted suicide or agitation. The context of arrival, the environment, and the patient's entourage must be taken into account in order to achieve an optimal orientation. Particular attention must be paid to the first episodes (elimination of a differential diagnosis, screening for a possible bipolar disorder). The existence of an external causal factor or a comorbid personality disorder should not trivialize the consultation and lead to a faulty diagnosis of a characterized depressive episode. Drug treatment in the emergency room is usually symptomatic (anxiolytic treatment with benzodiazepines or neuroleptics, depending on the situation), and outpatient referral should always be preferred. Therapeutic adaptations can then be considered. The decision to hospitalize must always be justified, and consent for care must be rigorously evaluated. It is almost always necessary to take the patient's entourage into account as well as the potential support of the patient by the entourage. All these elements must be recorded in the file. Suicide risk assessment must be systematic for all patients consulting psychiatric emergencies, and the use of the RUD (Risk, Urgency, Dangerousness) grid can be useful. Any decision to release a patient with suicidal tendencies must be made strictly following certain conditions:a rapid psychiatric re-evaluation of the crisis, with for example the proposal of a post-emergency consultation, a supportive entourage, accepted symptomatic treatment. The registration of the suicidal patient in a monitoring system such as VigilanS can also be beneficial and reduce the risk of recidivism.

AN UNUSUAL CASE OF DISSEMINATED TUBERCULOSIS FOLLOWINGANTIPSYCHOTIC THERAPY: AN AUTOPSY-BASED CASE REPORT

Tuberculosis (TB) is a communicable bacterial infection caused by Mycobacterium tuberculosis. It is the second leading fatal infectious disease after COVID-19. Tuberculosis also stands at 13th position, with respect to the leading cause of death. In 2020, around 86% of new tuberculosis cases were reported in 30 countries, of which two-thirds of cases were recorded in eight countries alone, with India leading the chart. Tuberculosis in a mentally ill patient is a common entity because of its common comorbidities, but prolonged antipsychotic drug therapy is rare. Here we discuss a case of a 36 years old female who was brought dead to casualty. She was apparently alright 10 days back and then developed symptoms like fever, breathlessness, and cough. She had severe anorexia and cachexia for the past few months. She has been under antipsychotic medication for schizophrenia. On autopsy, there were multiple whitish nodules present all over the intestine and various abdominal organs. We identified disseminated tuberculosis, and we analyzed histopathology and microbiology of tissues. We reported Ziehl-Neelsen staining negative for TB. Culture reported positive for Mycobacterium tuberculosis. Histopathology study tissues showed caseous necrotizing granulomas. As seen in some literature, tuberculosis can be seen in mentally ill patients, whereas literature showing the association between tuberculosis and antipsychotic drugs is less. This article highlights the association between such occurrence of tuberculosis while undertaking antipsychotic drug therapy.