The use of semaglutide in patients with renal failure- a retrospective cohort study.

OBJECTIVE: Semaglutide, a glucagon-like peptide-1 receptor agonist is approved for weight loss and diabetes treatment, but limited literature exists regarding semaglutide use in patients with advanced chronic kidney disease (CKD). Therefore, this project assessed the safety and efficacy of semaglutide among patients with eGFR (estimated glomerular filtration rate) 15-29 mL/min/1.73m2 (CKD stage 4), eGFR<15 mL/min/1.73m2 (CKD stage 5) or on dialysis. METHODS: This is a retrospective Electronic Medical Record based analysis of consecutive patients with advanced CKD (defined as CKD 4 or greater) who were started on semaglutide (injectable or oral). Data was collected between Jan 2018 and Jan 2023. Investigators verified CKD diagnosis and manually extracted data. Data were analyzed using Fisher's exact test, paired T-test, linear mixed effects models and Wilcoxon signed rank test. RESULTS: Seventy-six patients with CKD 4 or greater who initiated semaglutide were included. Most patients had a history of T2DM (96.0%), and most were male (53.9%). The mean age was 66.8 y (SD 11.5) with the mean BMI was 36.2 (SD 7.5). The initial doses were 3 mg orally and 0.25 mg by injection. Maximum prescribed dose was 1mg (injectable) in 28 (45.2%) patients and 14 mg (orally) in 2 (14.2%) patients. Patients received semaglutide for a median duration of 17.4 (IQR 0.43, 48.8) months. Forty-eight (63.1%) patients reported no adverse effects associated with the therapy. Mean weight decreased from 106.2(SD 24.2) to 101.3 (SD 27.3) kg (p<0.001). Eight patients (16%) with type 2 diabetes (T2DM) discontinued insulin after starting semaglutide. Mean HbA1c decreased from 8.0 % (SD 1.7) to 7.1 % (SD 1.3) (p<0.001). Adverse effects were the primary reason for semaglutide discontinuation (37.0%), with nausea, vomiting, and abdominal pain being the most common complaints. CONCLUSIONS: Based on this retrospective study semaglutide appears to be tolerated by most individuals with CKD 4 or greater despite associated gastrointestinal side effects similar to those observed in patients with better kidney function and leads to an improvement of glycemic control and insulin discontinuation in patients with T2DM. Modest weight loss (approximately 4.6 % of the total body weight) was observed on the prescribed doses. Larger prospective randomized studies are needed to comprehensively assess the risks and benefits of semaglutide in patients with CKD 4 or greater and obesity.

Therapeutic Content of Mobile Phone Applications for Substance Use Disorders: An Umbrella Review.

Mobile phone applications (MPAs) for substance use disorder (SUD) treatment are increasingly used by patients. Although pilot studies have shown promising results, multiple previous systematic reviews noted insufficient evidence for MPA use in SUD treatment-many of the previously published reviews evaluated different trials. Subsequently, we aimed to conduct an umbrella review of previously published reviews investigating the efficacy of MPAs for SUD treatment, excluding nicotine/tobacco because umbrella reviews have been done in this population and the nicotine/tobacco MPA approach often differs from SUD-focused MPAs. No previous reviews have included a statistical meta-analysis of clinical trials to quantify an estimated overall effect. Seven reviews met inclusion criteria, and 17 unique studies with available data were taken from those reviews for the meta-analysis. Overall, reviews reported a lack of evidence for recommending MPAs for SUD treatment. However, MPA-delivered recovery support services, cognitive behavioral therapy, and contingency management were identified across multiple reviews as having promising evidence for SUD treatment. Hedges g effect size for an MPA reduction in substance use-related outcomes relative to the control arm was insignificant (0.137; 95% CI, -0.056 to 0.330; P=.16). In subgroup analysis, contingency management (1.29; 95% CI, 1.088-1.482; τ 2=0; k=2) and cognitive behavioral therapy (0.02; 95% CI, 0.001-0.030; τ 2=0; k=2) were significant. Although contingency management's effect was large, both trials were small (samples of 40 and 30). This review includes an adapted framework for the American Psychiatric Association's MPA guidelines that clinicians can implement to review MPAs critically with patients.

Opioid Maintenance Therapy: A Review of Methadone, Buprenorphine, and Naltrexone Treatments for Opioid Use Disorder.

The rates of opioid use and opioid related deaths are escalating in the United States. Despite this, evidence-based treatments for Opioid Use Disorder are underutilized. There are three medications FDA approved for treatment of Opioid Use Disorder: Methadone, Buprenorphine, and Naltrexone. This article reviews the history, criteria, and mechanisms associated with Opioid Use Disorder. Pertinent pharmacology considerations, treatment strategies, efficacy, safety, and challenges of Methadone, Buprenorphine, and Naltrexone are outlined. Lastly, a practical decision making algorithm is discussed to address pertinent psychiatric and medical comorbidities when prescribing pharmacology for Opioid Use Disorder.

The Frequency and Impact of Adverse Childhood Experiences on Mood, Alcohol Relapse, and Outcomes in Liver Transplantation: A Retrospective Cohort Study.

INTRODUCTION: Adverse Childhood Experiences (ACE) are associated with the development of negative health behaviors and medical illness. ACE's association with poor health outcomes has been well documented in the general population; however, this relationship remains less clear in liver transplant (LT) recipients. The aims of this study therefore were to determine the prevalence of ACE and the influence of ACE on LT outcomes. METHODS: A retrospective electronic medical record review of all LT recipients over 11 years at an academic liver transplant center. Demographic, diagnostic, and disease characteristics were extracted and compared for a history of ACE. Associations between a history of ACE and extracted variables were statistically tested using Student's t-test and Chi-square tests or Fisher's Exact Test where appropriate. Graft and patient survival were tested using log-rank tests. RESULTS: Of 1,172 LT recipients, 24.1% endorsed a history of ACE. Females (p = 0.017) and recipients with lower level of education (p < 0.001) had a higher frequency of ACE. Those with a history of ACE had a higher prevalence of HCV (p < 0.001) and higher pre-transplant BMI (P<0.001). Recipients with a history of ACE had higher prevalence of mood (p < 0.001), anxiety (p < 0.001), PTSD (p < 0.001), alcohol use (p < 0.001), and cannabis use (p < 0.001) disorders as well has higher PHQ-9 (p < 0.001) and GAD-7 (p < 0.001) scores pre and post-transplant. Those with ACE had higher incidence of recorded relapse to alcohol by 3 years post-transplant (p = 0.027). Mean lab values, graft survival, and patient survival were not significantly different between those with and without a history of ACE except for total bilirubin at 6 months (p = 0.021). CONCLUSION: One quarter of LT recipients have experienced ACE. ACE was associated with a history of a psychiatric diagnoses, substance use disorders, elevated PHQ-9 and GAD-7 scores, and a higher prevalence of relapse to alcohol use after transplant. This population may benefit from increased/improved access to appropriate mental health and substance use services and support in the peri and post transplant period.

Weight Loss Surgery Increases Kidney Transplant Rates in Patients With Renal Failure and Obesity.

OBJECTIVE: To describe the outcomes of kidney transplant (KT) candidates with obesity undergoing sleeve gastrectomy (SG) to meet the criteria for KT. METHODS: Retrospective analysis was conducted of electronic medical records of KT candidates with obesity (body mass index >35 kg/m2) who underwent SG in our institution. Weight loss, adverse health events, and the listing and transplant rates were abstracted and compared with the nonsurgical cohort. RESULTS: The SG was performed in 54 patients; 50 patients did not have surgery. Baseline demographic characteristics were comparable at the time of evaluation. Mean body mass index ± SD of the SG group was 41.7±3.6 kg/m2 at baseline (vs 41.5±4.3 kg/m2 for nonsurgical controls); at 2 and 12 months after SG, it was 36.4±4.1 kg/m2 and 32.6±4.0 kg/m2 (P<.01 for both). In the median follow-up time of 15.5 months (interquartile range, 6.4 to 23.9 months), SG was followed by active listing (37/54 people), and 20 of 54 received KT during a median follow-up time of 20.9 months (interquartile range, 14.7 to 28.3 months) after SG. In contrast, 14 of 50 patients in the nonsurgical cohort were listed, and 5 received a KT (P<.01). Three patients (5.6%) experienced surgical complications. There was no difference in overall hospitalization rates and adverse health outcomes, but the SG cohort experienced a higher risk of clinically significant functional decline. CONCLUSION: In KT candidates with obesity, SG appears to be effective, with 37% of patients undergoing KT during the next 18 months (P<.01). Further research is needed to confirm and to improve the safety and efficacy of SG for patients with obesity seeking a KT.

Management of Patients With Kidney Disease Undergoing Bariatric Surgery: A Multidisciplinary Approach.

Bariatric surgery is increasingly recognized as a safe and effective treatment for obesity in patients with chronic kidney disease (CKD), including stages 4, 5, and 5D (on dialysis). Among the available surgical methods, sleeve gastrectomy (SG) is the most commonly performed weight loss procedure and is mainly done to facilitate kidney transplantation (KT). However, many KT candidates treated with SG remain on the transplant waiting list for months to years, with some never receiving a transplant. Therefore, appropriate candidates for SG must be selected, and post-SG management should address the unique needs of this population, with a focus on sustaining the metabolic benefits of surgery while minimizing potential side effects related to rapid weight loss which may inadvertently lead to muscle and bone catabolism. Multidisciplinary post-SG care in this population may lead to overall better health on the transplant waiting list, resulting in a higher percentage of post-SG patients ultimately receiving KT. To tailor the effective treatment for these patients, clinicians should acknowledge that patients with CKD stage 4-5D have different nutritional needs and are metabolically and psychosocially distinct from the general bariatric surgery population. Sarcopenia is highly prevalent and may be exacerbated by muscle catabolism following SG if not adequately addressed. Blood pressure, glucose, and bone metabolism are all affected by the CKD stage 4-5D, and therefore require distinct diagnostic and management approaches. Long-standing chronic disease, associated comorbidities, and low adherence to medical therapies require ongoing comprehensive psychosocial assessment and support. This paper aims to review and consolidate the existing literature concerning the intersection of CKD stage 4-5D and the consequences of SG. We also suggest future clinical outcome studies examining novel treatment approaches for this medically complex population.

Clinical Characterization, Course, and Treatment of Othello Syndrome: A Case Series and Systematic Review of the Literature.

BACKGROUND: Othello syndrome (OS) is a condition characterized by a delusion of jealousy that one's spouse is having extramarital affairs. As in the eponymous Shakespearean tragedy, there is an unfortunate risk of violence. For patients with these symptoms, consultation-liaison psychiatrists may be asked to assist with evaluating the differential diagnosis, assessing safety, and developing treatment options. OBJECTIVE: This study's objective was to solidify current knowledge of the clinical presentations and management of OS through a systematic review of the literature and description of 2 new cases. METHODS: We conducted a literature search from the start of relevant databases through August 2023 to identify English language case reports of adults (≥18 years) with OS that described clinical evaluations, biological treatments, and outcomes. We extracted demographics, proposed etiologies, treatment choices and responses, duration of delusions, comorbid psychiatric symptoms, neuro-radiographic findings, and presence of physical violence. We reported clinical findings for 2 new cases. RESULTS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we screened 705 abstracts and conducted full-text reviews of 118 articles to identify 73 cases published from 1983 to 2023 meeting inclusion criteria. The mean age was 58.2 years with male predominance (M:F = 1.88). Etiologies included primary psychiatric disorders (16, 22%), other medical conditions (38, 52%), and medications or other substances (19, 26%). Delusional disorder, cerebrovascular accident, and dopaminergic agonists were the most common etiologies, respectively, in these groups. Antipsychotics were the most common treatment (57, 78%). Symptom remission was reported in 51 (70%) cases. The average duration of OS was 39.5 months. Of 32 cases reporting brain imaging insults, 12 of 20 (60%) showed right-sided lesions, and 8 of 20 (40%) showed left-sided lesions, with 9 of 32 (28%) located in the frontal lobes. The most commonly co-existing psychiatric symptom was depression (14, 19%). Violence was reported in 25 cases (34%). Our 2 new cases were consistent with these findings. CONCLUSIONS: OS may be a manifestation of several neuropsychiatric conditions, primarily delusional disorder, cerebrovascular accident, Alzheimer's dementia, and the use of dopaminergic agonists. One-third of cases include violent behaviors. It appears to respond to antipsychotic medications, but treatment is delayed more than 3 years on average. Available data have not localized OS to a specific brain region.

Clinical Utility and Impact of Phosphatidylethanol Testing in Liver Transplantation Evaluations.

BACKGROUND: Phosphatidylethanol (PEth) is a serum biomarker that can detect alcohol use within the last 28 days with excellent sensitivity and specificity. Urinary ethyl glucuronide (uEtG) is commonly used in transplant settings to screen for alcohol use; however, it has several limitations relevant to liver transplantation. Transplant centers are beginning to regularly utilize PEth as part of the screening process for high-risk liver transplantation candidates although the clinical utility of uniform pre-transplant PEth testing is unclear. METHODS: This was a retrospective chart review of all patients evaluated for liver transplantation from December 1, 2019, through May 31, 2022, at a large academic tertiary referral center utilizing uniform serum PEth and uEtG screening. Information regarding the patients' transplantation status, age, sex, race, Model for End-Stage Liver Disease score, and PEth levels was obtained. In those with a positive PEth, we examined if the result would have been detected with uEtG, identified a discrepancy from the documented patient report of last use, led to a change in the Psychosocial Assessment of Candidate for Transplantation score, or influenced the transplant selection committee's decision. RESULTS: Our sample included 865 individuals (mean age = 55.20, 61.27% male and 82.54% white) with calculated Model for End-Stage Liver Disease-Sodium scores ranging from 6.43 to 50.65 (mean: 18.09; median: 16.46). Forty-eight patients were found to have a positive PEth (PEth range 20-1833); 75% of the sample had alcohol-associated liver disease. In 23 of 48 (47.91%) cases, the positive PEth identified alcohol use missed by a concomitant uEtG screen. A positive PEth test identified a discrepancy from patients' self-report in 29 (60.42%) cases and influenced the selection committee's decision in 28 cases (58.33%). CONCLUSION: Uniform pretransplant PEth screening of liver transplant candidates at the time of initial evaluation identified alcohol use that would have been missed by uEtG testing, identified discrepancies from the patient's self-report, and influenced clinical decision-making in a significant number of cases. These findings support the use of uniform PEth screening in liver transplantation evaluations.

Consultation-Liaison Case Conference: Psychiatric Care of Patients Who Undergo Bariatric Surgery.

We present the case of a 42-year-old female with major depressive disorder who received a Roux-en-Y gastric bypass and subsequently decompensated in her depression symptoms and began newly engaging in problematic alcohol use. Top experts in the consultation-liaison field, specifically bariatric surgery psychiatry, provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. Key teaching points include the presurgical psychosocial assessment, pertinent perioperative psychopharmacology, and problematic alcohol use after bariatric surgery.

A 10-Year Follow-up Survey of Psychiatry Resident Education in Consultation-Liaison Psychiatry.

BACKGROUND: In 2010, the Academy of Consultation-Liaison (then Academy of Psychosomatic Medicine) surveyed US residency programs to understand training in consultation-liaison (CL) psychiatry, leading to recommendations in 2014. Since then, residency training in CL has evolved in the context of competing training demands, increased prioritization of electives, and reactions to coronavirus 2019. OBJECTIVE: To determine the current state of residency training in CL across the United States, including the structure of core and elective resident rotations in CL, attending physician staffing, presence of fellows and other trainees, didactic curriculum, and impact of coronavirus 2019. METHODS: Members of the Academy of Consultation-Liaison Residency Education Subcommittee designed and piloted an 81-question survey tool that was sent to program directors of 269 US general psychiatry training programs for voluntary completion. RESULTS: One hundred three of 269 programs responded to the survey, yielding a response rate of 38.3%. Responding programs were larger and more likely to have a CL fellowship than nonresponding programs. Of the 103 responding programs, 82.5% have more than the minimally required time on CL, with 46.6% reporting an increase in total CL time in the past decade. Since 2010, 18.4% of responding programs changed the placement of the CL rotation, with 43.7% now adherent to the 2014 Academy of Psychosomatic Medicine recommendation to include core CL training in the second half of residency. Thirty-five percent of responding programs require residents to rotate on more than 1 CL service, and 19.4% have a required outpatient CL component. Faculty full-time equivalent varies widely. Of all services included, 33.8% report that all CL faculty are board-certified in CL psychiatry, whereas 18.7% have no board-certified faculty. Of the 103 responding programs, 36.9% offer a CL fellowship, but 31.1% report no residency graduates pursuing CL fellowships in the past 5 years. Of the included programs, 77.7% have a formal CL curriculum for residents, with 34.0% reporting a separate didactic series during the CL rotation. CONCLUSIONS: Among the responding programs, the amount of time spent on core CL rotations has increased in the past decade, but programs have also shifted CL training earlier in the course of residency. Residency programs are increasingly challenged to provide an optimal CL experience, and updated guidance from Academy of Consultation-Liaison may be appreciated.

To treat or not to treat? High-potency benzodiazepine use in a case of comorbid hallucinogen persisting perception disorder and alcohol use disorder.

Hallucinogen persisting perception disorder (HPPD) is characterized by visual disturbances that resemble psychedelic intoxication and linger after use has ceased. The most common substances precipitating HPPD, lysergic acid diethylamide (LSD) and psilocybin, are posited to do so via damage to serotonergic neurons involved in vision. Mr. N is a 37-year-old with a history of alcohol, cannabis, LSD, cocaine, and nicotine use disorders who described visual distortions that resolved when he drank heavily or received benzodiazepines for withdrawal. He did not appear psychotic. Over 20 years after his last LSD use, he continued to experience illusions of halos around objects, moving walls, and figures appearing cartoonish. He understood that his perceptual disturbances were not reality based. During hospitalization for suicidal ideation, laboratory tests, head computed tomography (CT), and electroencephalogram (EEG) studies offered no explanation for his visual disturbances other than HPPD. The visual distortions remitted with scheduled clonazepam treatment, although chemical dependency treatment programs were hesitant to accept him while on a benzodiazepine. This case emphasizes the importance of diagnostic clarification when patients present with perceptual disturbances that do not fit typical psychotic presentations. Our discussion will distinguish misperceptions from hallucinations and review the pathophysiology of HPPD. Last, we will discuss management strategies for patients with co-occurring HPPD and substance use disorders. It is necessary to discern the correct cause of visual disturbances in order to provide proper treatment. The risks and benefits of long-term benzodiazepine use must be weighed when deciding whether to prescribe them for patients with comorbid HPPD and alcohol use disorder. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Neuropsychiatric Sequelae of Thyroid Dysfunction: Evaluation and Management.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion CNS Disord 2023;25(6):23f03570. Author affiliations are listed at the end of this article.

Psychosocial considerations in the combined bariatric surgery and organ transplantation population: a review of the overlapping pathologies and outcomes.

PURPOSE OF REVIEW: This review highlights the salient data of the psychosocial concerns that influence outcomes of bariatric surgery and organ transplantation. RECENT FINDINGS: Bariatric surgery has emerged as an important intervention with data supporting substantial and sustained weight loss, enhanced quality of life, remission of obesity-related medical comorbidities, and improved long-term patient and graft survival in transplant patients. Depression, suicide, anxiety, posttraumatic stress disorder, alcohol use, adherence, and psychopharmacology considerations can influence outcomes of both these surgeries. SUMMARY: Obesity is increasingly prevalent among patients pursuing transplantation surgery, and it is often a factor in why a patient needs a transplant. However, obesity can be a barrier to receiving a transplant, with many centers implementing BMI criteria for surgery. Furthermore, obesity and obesity-related comorbidities after transplant can cause poor outcomes. In this context, many transplant centers have created programs that incorporate interventions (such as bariatric surgery) that target obesity in transplant candidates. A presurgery psychosocial assessment is an integral (and required) part of the process towards receiving a bariatric surgery and/or a transplantation surgery. When conducting a dual (bariatric and transplantation surgery) psychosocial assessment, it is prudent to understand the overlap and differentiation of specific psychosocial components that influence outcomes in these procedures.

Case Report: Right Insular Stroke Causing Simultaneous Onset of a Functional Vestibular Disorder and Psychiatric Disorder-Persistent Postural-Perceptual Dizziness and Post-stroke Depression.

Introduction: Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder that can be precipitated by acquired brain injuries. Poststroke depression (PSD) is the most common psychiatric sequela of stroke, affecting 33% of stroke survivors. Pathophysiologic mechanisms of PPPD and PSD are not fully understood. Case Report: A 40-year-old woman developed new, debilitating chronic dizziness exacerbated by her own motion and exposure to visual motion stimuli plus prolonged depressive symptoms, both beginning within days after a localized right insular stroke. A collaborative evaluation by specialists in neurology, otorhinolaryngology, optometry, and psychiatry concluded that the insular stroke caused simultaneous onset of PPPD and PSD. Discussion: Prior case reports described short-lived vertigo following insular strokes, but no long-term vestibular symptoms without ongoing nystagmus or gait ataxia. In this case, chronic dizziness and motion sensitivity continued in the absence of focal neurologic deficits, invoking the possibility that changes in functioning of brain networks subserving spatial orientation persisted despite otherwise adequate recovery from the stroke, a mechanism previously proposed for PPPD. This case also reinforced prior work implicating pathways through the insula in PSD. Co-occurrence of PPPD and PSD offers insights into simultaneous functions of the insula in multiple networks in human brain.

Expanding Access to Social Support in Primary Care via Telemedicine: A Pilot Study.

The coronavirus pandemic quickly exposed the need for efficient and widespread implementation of telehealth services. Additionally, it further unveiled the impact of social and environmental barriers to healthcare in underserved, rural populations. This in-practice pilot study tested the utility of a geographically centralized social worker providing services between a patient and a primary care provider via telecommunication at two high volume rural outpatient family practice clinics. Outcome measures included patient and provider satisfaction. Twenty-two telehealth social work encounters occurred spanning both adult and pediatric patients. Data collected from patients, primary care providers, and social work staff revealed positive feedback. The data from our small pilot study demonstrated that social work triage delivered via a tablet was an acceptable and valued resource in busy primary care practices.

Family history of obesity and the influence on physical activity and dietary adherence after bariatric surgery.

BACKGROUND: The causes of obesity are multifactorial, with genetic, environmental, behavioural and societal contributions. These factors also affect adherence to diet and exercise after bariatric surgery. The objective of this study was to evaluate changes in perceived obesity-related stigma, exercise and dietary adherence perioperatively as well as what demographic factors most influence the magnitude of these changes. METHODS: Validated questionnaires regarding perception of stigma and adherence to diet and exercise regimens were administered to 104 bariatric surgery patients preoperatively and postoperatively at three, six and 12 months. Scoring was compared for improvement, and concomitant factors were analysed for effect on magnitude of improvement. RESULTS: Our study found overall improvement in perception of stigma as well as adherence to diet and exercise regimens. Those with a family history of obesity had less robust improvement compared to those without a family history of obesity. Those who were Caucasian also did not have as robust of an improvement in their scores. CONCLUSIONS: Patient perception of obesity-related stigma and adherence to diet and exercise regimens improve after bariatric surgery. However, a patient with a family history of obesity and/or a Caucasian ethnicity may have a less robust improvement in these facets.

Teaching Psychopharmacology in the Medically Ill: A Problem-Based Learning Card Game for Consultation-Liaison Psychiatry Didactics.

INTRODUCTION: Our educational report discusses a unique card game that provides an engaging, and competitive strategy for teaching psychopharmacology in the medically ill. It engages the players and helps them learn how to justify medical decisions in the context of complicated medical comorbidity. METHODS: We describe a problem-based learning approach where learners are presented with randomized diagnoses and complications and are then forced to make prescription decisions for treatment from a limited and randomized supply of medication cards. Each round is facilitated by the teacher, who engages the teams and/or individual players in discussions regarding the rationale and justification of the medication decisions. These treatment plans are scored according to the appropriateness of the medication choice and the process is repeated. DISCUSSION: The game is flexible regarding players' levels of education and has been played by medical students, psychiatry residents, and fellows throughout their years of training. Overall feedback has been positive from facilitators and trainees and the game has been a valuable source of engaging learners in the process of making complex medication decisions in the medically ill.