Drawing the Line Between Postacute Sequelae of COVID-19 and Functional Neurologic Disorders: A Daunting Clinical Overlap or Irrelevant Conundrum?

ABSTRACT: Coronavirus disease 2019 (COVID-19) is an acute infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in its multiple variants that classically presents with cough, fatigue, fever, headache, myalgias, and diarrhea. As vaccination becomes widely available and infection rates facilitate herd immunity across the globe, more attention has been given to long-term symptoms that may persist after the index infection, which include impairments in concentration, executive dysfunction, sensory disturbances, depression, anxiety, fatigue, and cough, among other symptoms classified under the umbrella term of postacute sequelae of SARS-CoV-2 infection (PASC).Functional neurologic disorder (FND), also known as conversion disorder and functional neurologic symptom disorder, refers to the presence of one or more symptoms of altered voluntary motor or sensory function that are incompatible with and not better explained by a known neurological or medical condition that causes significant distress and functional impairment. Although the diagnosis of FND may not require the identification of an underlying psychological stressor, being diagnosed with an FND can worsen stigma and shift attention and resources away from other medical concerns that should be concomitantly addressed.This review summarizes the literature on the overlapping nature and discrimination of PASC from FND in COVID-19 survivors. Based on this, we develop a treatment framework that targets unique domains of these complex overlapping presentations, following a multidisciplinary approach with an individualized treatment plan inclusive of physical and psychological interventions focused on functional rehabilitation.

Support Groups and Individual Mental Health Care via Video Conferencing for Frontline Clinicians During the COVID-19 Pandemic.

BACKGROUND: The current coronavirus disease 2019 (COVID-19) pandemic has put an enormous stress on the mental health of frontline health care workers. OBJECTIVE: Psychiatry departments in medical centers need to develop support systems to help our colleagues cope with this stress. METHODS: We developed recurring peer support groups via videoconferencing and telephone for physicians, resident physicians, and nursing staff, focusing on issues and emotions related to their frontline clinical work with COVID patients in our medical center which was designated as a COVID-only hospital by the state. These groups are led by attending psychiatrists and psychiatry residents. In addition, we also deployed a system of telehealth individual counseling by attending psychiatrists. RESULTS: Anxiety was high in the beginning of our weekly groups, dealing with fear of contracting COVID or spreading COVID to family members and the stress of social distancing. Later, the focus was also on the impairment of the traditional clinician-patient relationship by the characteristics of this disease and the associated moral challenges and trauma. Clinicians were helped to cope with these issues through group processes such as ventilation of feelings, peer support, consensual validation, peer-learning, and interventions by group facilitators. People with severe anxiety or desiring confidentiality were helped through individual interventions. CONCLUSIONS: Our experience suggests that this method of offering telehealth peer support groups and individual counseling is a useful model for other centers to adapt to emotionally support frontline clinical workers in this ongoing worldwide crisis.

Pantoprazole-Induced Delirium: Review of a Case and Associated Literature.

BACKGROUND: Proton pump inhibitors (PPIs) are frequently prescribed antiulcer agents in hospitals and are shown to be safer than H-2 blockers. We present a case report of PPI-induced delirium, regarding which not much has been written in the literature. CASE REPORT: We present a case of a 93-year-old woman with no known past psychiatric history, who was hospitalized for syncope workup and who developed delirium after a double dose of pantoprazole. DISCUSSION: Very few reports of PPI-induced delirium exist in the literature. In this case report, we attempt to highlight the mechanism of PPI induced delirium which in our case was most likely due to the primary effects of PPI and drug-drug interactions. Given the paucity of literature on this topic, we encourage further research into relationship between PPI and delirium and urge caution while using PPIs in geriatric population.

Can Religion Protect Against Suicide?

The vast majority of the world's population is affiliated with a religious belief structure, and each of the major faith traditions (in its true form) is strongly opposed to suicide. Ample literature supports the protective effect of religious affiliation on suicide rates. Proposed mechanisms for this protective effect include enhanced social network and social integration, the degree of religious commitment, and the degree to which a particular religion disapproves of suicide. We review the sociological data for these effects and the general objections to suicide held by the faith traditions. We explore how clinicians may use such knowledge with individual patients, including routinely taking a religious/spiritual history. The clinician who is aware of the common themes among the faith traditions in opposition to suicide is better prepared to address religious/spiritual matters, as appropriate, in crisis situations. The clinician who understands the patient's belief system is also better prepared to request consultation with religious professionals when indicated.

Caregiver's Health Locus of Control and Medication Adherence in Sickle Cell Disease.

ACKNOWLEDGEMENTS: The authors would like to thank Dr. Morisky for giving us permission to use the Morisky Medication Adherence Scale PURPOSE: To explore caregivers' Health Locus of Control's relationship to self-reported adherence to penicillin prophylaxis or hydroxyurea in children with sickle cell disease (SCD). PROCEDURE: A questionnaire-based study was conducted of caregivers of children with SCD who visited a comprehensive sickle cell center in an inner city hospital, who were either on penicillin prophylaxis or hydroxyurea or both. Multidimensional Health Locus of Control Scale (MHLC) and the Morisky Medication Adherence Scale (MMAS-8) questionnaires were used for the study. RESULTS: Caregivers of 43 children (27 on penicillin prophylaxis, 13 on hydroxyurea, and 3 on both) completed the MHLC and the MMAS-8. There was no significant difference in adherence between the penicillin and the hydroxyurea groups. The mean Powerful Others score of caregivers of the hydroxyurea only group (25.5+5.6) was higher than that of the penicillin only group (21.2+6.1, p=0.043). Regression analysis revealed an inverse relationship of Chance Locus of Control to adherence in the entire group (Beta = -0.306, R2=0.093, F[1,40]=4.12, p=0.049). CONCLUSION: Chance Locus of control may identify caregivers of children with SCD at risk for non-adherence to treatment.

Dengue-specific subviral nanoparticles: design, creation and characterization.

BACKGROUND: Dengue is today the most significant of arboviral diseases. Novel tools are necessary to effectively address the problem of dengue. Virus-like particles (VLP) offer a versatile nanoscale platform for developing tools with potential biomedical applications. From the perspective of a potentially useful dengue-specific tool, the dengue virus envelope protein domain III (EDIII), endowed with serotype-specificity, host receptor recognition and the capacity to elicit virus-neutralizing antibodies, is an attractive candidate. METHODS: We have developed a strategy to co-express and co-purify Hepatitis B virus surface (S) antigen in two forms: independently and as a fusion with EDIII. We characterized these physically and functionally. RESULTS: The two forms of the S antigen associate into VLPs. The ability of these to display EDIII in a functionally accessible manner is dependent upon the relative levels of the two forms of the S antigen. Mosaic VLPs containing the fused and un-fused components in 1:4 ratio displayed maximal functional competence. CONCLUSIONS: VLPs armed with EDIII may be potentially useful in diagnostic, therapeutic and prophylactic applications.

Management of agitation following aneurysmal subarachnoid hemorrhage: is there a role for Beta-blockers?

Introduction. Stroke is a leading cause of mortality and morbidity in the United States. About 20% of the stroke is hemorrhagic and about 50% of these is due to aneurysmal subarachnoid hemorrhage. A troublesome neuropsychiatric complication of subarachnoid hemorrhage is agitation/aggression. Case Presentation. A 45-year-old man with no prior psychiatric history, sustained subarachnoid hemorrhage. After initial stabilization for 2 days, he underwent craniotomy and clipping of anterior cerebral communicating artery aneurysm. Treatment was continued with labetalol, nimodipine, and levetiracetam. Beginning postoperative day 4, patient developed episodes of confusion and agitation/aggression. Switching of Levetiracetam to valproate did not show any improvement. Psychiatry team tried to manage him with intense nursing intervention and different medications like olanzapine, valproate, lorazepam, and haloperidol. However, patient continued to be agitated and aggressive. Switching from labetalol to metoprolol resulted in dramatic improvement within 3 days. Discussion. Antipsychotics and benzodiazepines are often not sufficiently effective in the control of agitation/aggression in patients with traumatic brain injury and similar conditions. Our case report and the literature review including a cochrane review suggests that beta-blockers may be helpful in this situation.

The incidence and influence of early traumatic life events in patients with panic disorder: a comparison with other psychiatric outpatients.

Early traumatic life events, including childhood physical and sexual abuse, has been associated with increased risk for panic disorder in adulthood. We examined the incidence and influence of early traumatic life events in outpatients with panic disorder (n = 101), compared to outpatients with other anxiety disorders (n = 58), major depression (n = 19), or chronic schizophrenia (n = 22). Data were obtained by means of Structured Clinical Interviews and self-report questionnaires. The incidence of childhood physical abuse ranged from 16 to 40% and for childhood sexual abuse from 13 to 43% with no significant differences among the four diagnostic groups. Across all outpatient groups a history of childhood physical or sexual abuse was positively correlated to clinical severity. Patients with panic disorder who reported childhood physical abuse were more likely to be diagnosed with comorbid depression, to have more comorbid Axis I disorders, to score higher on symptom checklists as well as reporting a greater history of suicide attempts in the past year (5% vs. 0%); or lifetime (36% vs. 15%). Similar findings were noted, but not as robustly, for patients with panic disorder who reported childhood sexual abuse. There is a high rate of adverse early childhood events across diagnostic groups in psychiatric outpatients and these events are likely to influence the severity of the disorder but are unlikely to be a unique risk factor for any one type of disorder.